5- Neurology (Emergencies: Acute bulbar palsy, temporal arteritis, head trauma, status epilepticus) Flashcards
Acute bulbar palsy
Background
- Set of sign an symptoms linked to the impaired function of lower cranial nerves
- Damage to either:
o The LMN (neurones that connect the CNS (brain and spinal cord) to the muscles they innervate
o To the lower cranial nerves (9,10,11,12)
which cranial nerves are affected in acute bulbar palsy
Cranial nerves affected are those that arise straight from the brainstem
- CN IX (9) - glossopharyngeal
- CN X (10)- vagus
- CN XI (11)- accessory
- CN XII (12)- hypoglossal
how is acute bulbar palsy related to pseudobulbar palsy
Due to damage of UMN
- Similar presentation
- Atypical expression of emotion e.g. unusual outbursts of laughing or crying- lability
- Spastic and pointed tongue
- Exaggerated jaw jerk
- Can be classified as progressive (escalation of symptoms over time)or non progressive (rare)
causes of acute bulbar palsy
Causes
- Brainstem stroke
- Brainstem tumour
- Degenerative disease
o Motor neurone disease - Autoimmune conditions
o Guillain-Barre syndrome - Infection
o Diphtheria
o Poliomyelitis
Presentation of acute bulbar palsy
Wide variety of symptoms dependent on which CN is damaged
- Glossopharyngeal – reduced salivation, dysphagia and absent gag reflex
Other signs and symptoms associated with other CNS
- Chewing
- Nasal regurgitation
- Slurred speech
- Difficulty in handling secretions
- Aspiration of secretions
- Dysphonia
- Dysarthria
- Nasal speech which lacks modulation
- Difficult with all consonants
- Atrophic (wasting tongue)
- Drooling
- Weakness or jac and facial muscles
- Absent jaw jerk
Investigations for acute bulbar palsy
- Lumbar puncture to rule out MS
- MRI to diagnose stroke or tumour
management of acute bulbar palsy
- No treatment
- Intubation if airway obstruction
- Supportive treatment
o E.g. medication for drooling
o Feeding tubes
o SALT
summary of acute bulbar palsy
basilar skull fracture background
Skull base (Basilar) fractures
Background
- Traumatic head injury
- Fracture in base of skull e.g. around the foramen magnum (hole in the base of the skull where brains stem exits)
define basilar fracture
Defined as a fracture of one or more bones at the base of the skill (temporal occipital sphenoid frontal or ethmoid bones)
- Complex structure that forms the floor of the cranial cavity and separates the brain from the head and neck
- Composed of the temporal, occipital, sphenoid, frontal and ethmoid bones
- These bones have numerous foramina’s, that allow cranial nerves and blood vessels to pass from one region to another
basilar fractues are classified based on
- Based on location of fracture
o Anterior fossa
o Middle fossa
o Posterior fossa
Causes/ risk factors of basilar skull fracture
- Facial fractures often occur
- High force injury e.g. motor vehicle
- Penetrating injuries
- Falls
- Assaults
2 main presentations of basilar skull fracture
battle sign
panda eyes
battle sign
Bruising mastoid process (behind ears)
panda eyes
o Bruising around eyes
o Blood behind the ear drum
other presentation of basilar skull fracture
- battle sign
- panda eyes
- CSF leakage from nose or ears
- menigitis
- injury to cranial nerve e.g. facial or oculomotor
presentation of basilar skull fracture based on location
which type of basilar fracture can cause injury to the internal carotid
temporal bone fracture
Investigations basilar skull fracture
- Physical exam
- Glasgow coma scale (severe if <7)
- Neuro exam
- CT
Management basilar skull fracture
Admit to hospital
- Most heal by themselves
- Non-displaced fractures usually heal without intervention
- Surgery to manage
o CSF leak
o To relieve pressure on CN
o Repair blood vessels
temporal arteritis background
also known asGiant cell arteritis
- Vasculitis of large and medium sized arteries of head
- Superficial temporal artery commonly involved.
Risk factors temporal arteritis
- F>M
- > 50 years (most common >75 yrs)
- Polymyalgia rheumatica
- White
Presentation temporal arteritis
- Unilateral headache typically around temple and forehead
- Scalp tenderness when brushing hair
- Jaw claudication
- Blurred or double vision
- Associated: fever, muscle aches, fatigue, weight loss, lossof appetite, peripheral oedema
investigations for temporal arteritis
- Clinical presentation
- Raised ESR - Temporal artery biopsy
–> Multinucleated giant cells found
Additional tests
- FBC- normocytic anaemia and thrombocytosis
- LFT may show raised ALP
- CRP raised
- Duplex US may show hypoechoic halo sign
management of temporal arteritis
Initial
- Steroids -> to reduce risk of permanent slight loss
- 40-60mg per day
- Aspirin
- PPI – for steroid
- Referral to vascular surgeons, rheumatology, ophthalmology
Ongoing management
- Continue high dose steroids into symptom resolve and then wean
complication of temporal arteritis
Complications
- Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)
- Cerebrovascular accident (stroke)
- Relapse
- Aortitis – AA or aortic dissection
- Steroid related effects
Status epilepticus
Background
- Medical emergency- time is brain
- Seizure lasting more than 5 minutes or more than 2+ seizures without full recovery within 30 mins (new definition)
Management of status epileptics in the hospital:
Take an ABCDE approach:
- Secure the airway
- Give high-concentration oxygen
- Assess cardiac and respiratory function
- Check blood glucose levels (D- DON’T FORGET GLUCOSE)
- Gain intravenous access (insert a cannula)
- IV lorazepam 4mg, repeated after 10 minutes if the seizure continues
- If seizures persist: IV phenytoin or phenobarbital or valproate or levetiracetam ,
- If still no recovery call ITU – rapid sequence induction with Thiopental
status epilepticus medical options in the community:
- Buccal midazolam
- Rectal diazepam
summary status epilepticus case with A-E, management and investigations
