Acute neurology Flashcards
DDX acute confusion/neuro presentation - VITM-D
DDx acute neurological deterioration:
* Vascular: stroke or TIA
* Inflammatory/Infective: Encephalitis, Meningitis
* Traumatic: SAH/EDH/SDH or TBI
* Metabolic: hypoglycaemia, hypo/hypernatraemia, severe acidosis, Addison’s, DKA
* Drugs: sedatives, recreational and non-recreational
Stroke red flags
Stroke most likely: hyperacute, risk factors known, focal neurological signs, no history of trauma, otherwise normal observations, Rosler 1 or more
ROSIER scale for likelihood of stroke
o LOC (-1)
o Seizure (-1)
o Unilateral face weakness (+1)
o UL arm weak (+1)
o UL leg weak (+1)
o Speech disturbance(+1)
o VF defect (+1)
ABCDE in stroke
TIME OF ONSET CRUCIAL (thrombolysis within 4.5h)
A
* May not be patent if bulbar involvement
B
* RR N/H/L – erratic if high ICP (bleed)
* SpO2 normal, low if hypoxic
C
* CVS exam (?AF)
* ECG, continuous cardiac monitor
* Cannula in; VBG, FBC, U&E, Clotting, lipids, glucose, cardiac markers (acute HF – hypovolaemic stroke)
* Ascultate carotids
D
* AVPU; GCS if P/U.
* Focal neurological exam - NIHSS score calculation
* Pupil dilation and reflexes checked
* Glucose
E
* Check for fractures eg if fall or overt haemorrage
Think of thrombolysis contraindications
Hyperacute stroke management (<4.5h)
- HEAD CT FIRST OF ALL
- Thrombolysis: Alteplase (r-TPA) 0.9mg/kg IV (10% as bolus, the rest over 1h)
- Aspirin ONLY 24h after thrombolysis (300mg PO OD)
- Consider thrombectomy if large stroke rather than thrombolysis
- Supportive care: Monitor on GCS, ventilation, swallowing assessment, monitor airway, monitor for malignanct MCA
- VTE prophylaxis: Heparin 5000iU SC OD // enoxaparin 40mg SC OD
Stroke >4.5h non-thrombolyasble non-thrombectomy candidate
- Check for haemorrage on CT (only stroke)
- Aspirin / Clopidogrel 300/300 (ONLY IF NO HAEMORRAGE)
o Continue aspirin 300 for 2 weeks
o Down to 75mg for Clopidogrel after first dose - Formal swallow assessment, GCS monitoring, nutrition, mobility, rehab
- Hemicraniectomy may be indicated if significant odema
- After A&E:
o Stroke: transfer to stroke ward
o TIA: be seen in specialist clinic within 24 hours - Considr further investigatons:
o Doppler of carotids and endartectomy;
o Bubble study for PFO
o 24h tape for AF
o Vasculitis and thrombophilia screen
ICH management
- IV mannitol to reduce ICP
- Control HTN and seizures
- Hyperventilation to lower ICP
- Immediate NS input - Evacuation of haematoma may be required
- REVERSE ANTICOAGULATION ASAP if anticoagulated
Head injury ABCDE
A
* Patent or may be collapsed if low GCS - consider adjuncts, avoid NPA if possible BSF
* C-SPINE!!!! - if unable to clear, apply collar
* If cardiac arrest: ALS protocol NOW
B
* High ICP: irregular breathing
* CXR ?PTX – trauma
* Rib fractures – severe pain
Consider hyperventilation for ICP if signs of high ICP (irregular pupils, extension posturing)
C
* High ICP: high BP, low HR [>Mannitol]
* (Cushing’s triad: hBP lHR iRR)
* Bloods: VBG, FBC, UE, LFT, Clot, G&S/XM, consider tox screen, CK
D
* AVPU
* P/U GCS formally REASSESS EVERY 15 mins!
* Pupil reactions and eye movement (CN6 palsy if high ICP)
* Glucose check
E/F
* Assess for fractures, and overt haemorrage
* ASK ABOUT ANTICOAGULANTS + reverse if needed
* CT if criteria met
Criteria for CT in head injury - within 1h
o GCS < 13 on initial assessment in the emergency department.
o GCS < 15 at 2 hours after the injury.
o Suspected open or depressed skull fracture.
o Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
o Post-traumatic seizure.
o Focal neurological deficit.
o More than 1 episode of vomiting.
Criteria for CT in head injury - within 8h
o Age 65 years or older.
o Any history of bleeding or clotting disorders.
o Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
o More than 30 minutes’ retrograde amnesia of events immediately before the head injury.
No CT in head injury
o In patients with normal neuro exam, no GCS impatient and negative CT scan (or CT scan not indicated) should be kept in for observations for 2h and then discharged under the care of responsible individual
o Patients should be provided written information for safety netting
Managing high ICP nonsurgically
a. Raise head of bed to 30 degrees
b. Analgesics and sedation; reduce metabolic demands
c. Hyperventialtion for a maximum of 30 minutes, close monitoring.
d. Mannitol or hypertonic saline: if severe TBI
e. High dose barbirutate: if ICP refractory to optimal treatment.
f. Monitor ICP in anyomne with GCS<9 at admission
g. Consider decompressive craniectomy, especially if:
Epidural haematoma with focal neurology or >30mm
SDH >10mm or >5mm midline shift
Contusions ior intraparenchymal if >20cm3
Posterior fossa haemorrage/compromising CSF flow
Status epilepticus definition
Prolonged seizure (lasting >30 min or numerous without recovery of consciousness for >30min. Start treating after 5 min)
Primary epilepsy
o Idiopathic generalized epilepsy
o Temporal lobe epilepsy
o Juvenile myoclonic epilepsy
Secondary epilepsy
o Tumors
o Infection (meningitis, encephaltitis, abscess)
o Inflammation (vasculitis and MS)
o Toxic/metabolic (glycaemia, hypocalcaemia, hyponatraemia, hypoxia, porphyria, liver failure)
o Drugs (withdrawal or use of alcohol or illicit drugs)
o Haem (stroke – haemoragic or infarction)
o Congenital: cortical dysplasia
o Malignant HTN or eclampsia
o Trauma
