8. Neurological Emergencies Flashcards
What is RICP, its presentation, DDx and Mx?
S+S = seizures, lethargy, irritability, vomiting, neck stiffness, tinnitus, dizziness, paraesthesia, headache, sun setting sign, forehead veins, focal neurology
DDx = comp of neurological injury, hydrocephalus (impaired absorption), brain tumour, intracranial infections, hepatic encephalopathy, impaired CNS venous outflow
Mx = head positioned midline, head end tilted 20-30 degrees, isotonic fluid at 60% maintenance, intubation + ventilation if GCS >9, mannitol, maintain normothermia/BP
What is status epilepticus, its causes and presentation?
Seizures lasting more than 5 minutes or more than 3 seizures in one hour
S+S = tonic-clonic, tonic, clonic or myoclonic seizures, LOC
Causes =
- Intake of substance accidental/intentional, meds
- Infection = bacterial meningitis, encephalitis (travel - malaria)
- Hypoglycaemia = DM (insulin over use, illness), new-borns, metabolic disorders
- Febrile convulsion (common 6m-6y, generalised tonic-clonic short, swift recovery, complex/atypical) - usually triggered by the initial rise in temp
SOL = AV malformation, bleed, hypotensive encephalopathy, tumour
- Electrolyte abnormalities = hypoCa, hyperNa, hypoNa, hypoMg, hypoGly (SAIDH, fluid loss, Ca metabolism)
- Epilepsy = not associated with fever, but at higher risk of seizure when ill
- Vascular = stroke (MRI, MR angiogram)
- Cerebral hypoxia = significant resp/cardio failure
- Hepatic encephalopathy, renal encephalopathy, metabolic encephalopathy (mitochondrial)
- Congenital brain abnormalities
- Jaundice - kernicterus
Outline the Mx of status epilepticus
Acute = A-E (airway, oxygen, glucose), call for senior help, if airway compromised call ITU/anaesthetist
IV access - (if cant get consider rectal, buccal, IO)
- Bloods (FBC, CRP, clotting, U+Es)
- Cultures
- VBG
- Pabrinex = vitamins B1, B2, B3, B6, C (if alcoholism or malnutrition)
1) buccal midazolam
2) IV/IO lorazepam (1st line - quicker, less resp depression) after 10m repeat lorazepam
- IM midazolam 10mg
3) Phenytoin infusion over 20m (whilst waiting for the phenytoin to be prepared: can give rectal paraldehyde) even if the seizure has stopped continue entire dose
- consider airway: nasopharyngeal
3) Transfer to ICU - anaesthetist involvement (trial IV midazolam, RSI: rapid sequence induction, intubate and muscle relaxant)
Sepsis = start sepsis 6 (cefotaxime, ceftriaxone) Meningitis = LP if can be performed quickly before Abx, if not then give Abx with no delay then LP later PICP = mannitol, furosemide
? cause = CT head, blood cultures, blood alcohol levels, examine for meningism, ?LP
Outline the aetiology of meningitis
0-3m = group B strep, e.coli, listeria
3m-6y = strep pneumonia, Neisseria meningitidis, H.influenza
6-60y = strep pneumonia, Neisseria meningitidis
> 60y = strep pneumonia, Neisseria meningitidis, listeria
Viral (2/3) = enterococcus, EBV, adenovirus, mumps
What are the signs and symptoms of meningitis?
Early:
- Headache
- Leg pains
- Cold hands/feet
- Abnormal skin colour
- Fever
Later:
- Meningism = stiff neck, photophobia
- Kernigs sign (pain + resistance on passive knee extension with hip fully flexed)
- Brudzinski’s sign = +ve when passive forward flexion of the neck causes involuntarily raising of knees or hips in flexion
- Decreased conscious level, coma
- Seizures
- Petechial rash - non-blanching
- Sepsis = slow cap refill, decreased BP, increased temp, increased pulse
- Bulging fontanelle
How would you investigate meningitis?
Bloods = FBC, U+Es, LTF, glucose, coag (on LP don’t want the pt to bleed), BM
Blood cultures, throat swabs, rectal swabs
LP (do not perform in RICP) = CSF for microscopy, biochem, culture, PCR
CT head
CXR
VBG
Ophthalmoscopy
How would you manage meningitis?
A-E assessment
Dexamethasone 4-10mg/6h IV = reduced RICP/inflam
Start Abx
- <3m = IV cefotaxime + oral amoxicillin
- 3m-50y = IV cefotaxime
- > 50y = IV cefotaxime + oral amoxicillin
Viral = 3w acyclovir
IV fluids
Isolate for 1st 24h
Careful monitoring
Household/close contacts = rifampicin or oral ciprofloxacin
Outline the pathophysiology of CES
Surgical emergency = compression of the corda equina (L2-5)
Peak onset between 40-50 years of age
Results in LMN signs and symptoms
Outline the aetiology of CES
Disc herniation = most common at L5/S1 and L4/L5 level
Trauma = vertebral fracture and subluxation
Neoplasm = either primary or metastatic (most common cancers that spread to spinal vertebrae are thyroid, breast, lung, renal and prostate)
Infection = discitis or Potts disease
Chronic spinal inflammation = ankylosing spondylitis
Iatrogenic = haematoma secondary to spinal anaesthesia
What are the symptoms of CES?
Reduced lower limb sensation (often bilateral)
Bladder or bowel dysfunction
Lower limb motor weakness
Severe back pain
Impotence
Perianal (the lower sacral dermatomes, termed “saddle” anaesthesia)
Lower limb anaesthesia
Loss of anal tone
Urinary retention
How would you investigate CES?
Whole spine MRI
Lower limb neurological exam
PR exam
Post-void bladder scan
How would you manage CES?
Urgent decompression
High-dose steroids (dexamethasone) = reduce any localised swelling
Malignancy = radiotherapy and/or chemotherapy can be used
What is GCA?
Chronic vasculitis of large/medium sized vessels - pts aged >50yrs
Most commonly causes inflam of arteries originating from the aortic arch
What are the signs and symptoms of GCA?
Headache - localised, unilateral, over the temple
Tongue/jaw claudication
Visual - amaurosis fugax, blindness, diplopia, blurring
Scalp tenderness - particularly over the temporal artery
POSSIBLE proximal weakness - GCA commonly presents alongside polymyalgia rheumatica (often affecting shoulders/hips)
How is a diagnosis of GCA made?
Presence of any 2 or more of the following in patients >50 years with:
- Raised ESR, CRP or PV
- New onset of localized headache
- Tenderness or decreased pulsation of temporal artery
- New visual symptoms
- Temporal A biopsy: granulomatous inflam with skip lesions
