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Guide to Essentials in Emergency Medicine > Chapter 6: Neurology > Flashcards

Chapter 6: Neurology Flashcards

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1
Q

What are some causes of AMS?

A

1) Structural causes:
- traumatic: ICH
- non-traumatic: Stroke, tumour, SAH
2) Toxic-metabolic causes:
- Febrile: Cerebral abscess, Meningo-encephalitis, Heat Stroke, Septicemia, Cerebral malaria
- Non-febrile: Hypoglycemia, Dehydration, acid-base imbalance, electrolyte abnormalities, uremia, hepatic encephalopathy, resp and cardiac failure, drug overdose(opioids, BZD, DT, Wernicke’s), epilepsy

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2
Q

What is the initial mgmnt of AMS?

A

1) A-Positive airway control:
Open airway look for foreign bodies, insert OPA, if trauma can’t be ruled out, add C-spine to immobilize the spine. Definitive airway in a comatose patient is intubation or surgical airway.
2) B-Provide supp high-flow O2. Institute hypervent if the pt is thought to have raised ICP.
3) C-Insert peripheral large bore IV cannula and start slow infusion of crystalloids.

Continous vitals monitoring with ECG and do CBG to check bedside glucose.

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3
Q

What invg would you consider doing in a pt with AMS?

A

1) Bloods: FBC, U/E/Cr, ABG, +- toxicology screen, +-LFT/TFT
2) Radio: CT head (not required unless suspect pathology in the cranium), X-ray lateral C-spine film (if trauma can’t be excluded)
3) Others: ECG, Urinalysis

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4
Q

What is the AMS cocktail you would want to administer?

A

1) 50% Dextrose 40ml (if suspect hypogly)
2) Naloxone 0.8-2.0mg IV bolus
3) Thiamine 100mg IV bolus in malnourished or alcoholic patients
4) Flumazenil 0.5mg IV bolus (do not use empirically unless suspecting an overdose. If pt has been taking chronic BZD or TCA might cause fits)

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5
Q

What targetted symptoms and signs are you looking out for in AMS?

A

1) Head injury
2) Neck stiffness(meningitis and trauma if tender)
3) RR and pupil size(for drug overdose)
4) Focal neuro signs
5) Chronic organ failure signs (liver, resp, heart, renal)

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6
Q

What are some life-threatening causes of giddiness that must be ruled out first?

A

1) ACS
2) CCF
3) VBI
4) Hypovolemia due to blood loss
5) Gynecological issues like ectopic preg
6) Hypogly
7) Cardiac dysrhythmias
8) Anemia

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7
Q

What are some meds associated with giddiness?

A

1) Alcohol
2) OHGA
3) Anti-depressants
4) Anti-HTN
5) Anti-histamines
6) Antibiotics

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8
Q

What is the initial mgmnt and invg for all dizzy pts?

A

1) ABC and cardiac monitoring
2) Postural parameters should be taken (postural hypotension is >20mmHg drop in systolic upon standing)
3) Stat CBG for all DM pts
4) ECG and cardiac enzymes for those with CVS RFs or unstable vitals

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9
Q

What is the rx of vertiginous giddiness?

A

1) Symptomatic rx:
- IM/IV Prochlorperazine 12.5mg (Stemetil)
- PO Diazepam 2mg
2) IV hydration if vomiting is severe
3) Do Dix-Hallpike to pick up BPPV and if positive perform Epley’s to relieve the pt of symptoms
4) Make sure central vertigo is not missed by doing a neuro exam

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10
Q

What are the 6 important causes of headaches to not miss?

A

1) Hemorrhage
- SAH
- SDH
- EDH
- ICH
2) Meningo-encephalitis
3) Cardiac cephalgia
4) SOL
5) Glaucoma
6) Temporal arteritis

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11
Q

What are the red flags to look out for that will warrant emergent CT?

A
  • Severe ‘thunderclap’ headache, worst ever in life
  • Early morning headache worse on coughing
  • Fever or neck stiffness
  • Visual disturbances
  • AMS/Seizure
  • Neuro deficits
  • pt on anti-coagulation
  • HIV/AIDS pt
  • Current Malignancy
  • Head injury
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12
Q

What focused exam is indicated to rule out those causes?

A

1) Vital signs(BP/Temp)
2) Fundoscopy
3) Neuro exam
- Pupils, Visual Field, CN exam, Long tract exam, Cerebellar
4) Gait

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13
Q

What invg is indicated for secondary headaches?

A

1) Bloods: FBC, U/E/Cr, PT/PTT, GXM, ESR(if Temp arteritis suspected)
2) Imaging: CT head
3) Others: LP, ECG if indicated

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14
Q

What are the features suggestive of Migraine vs Cluster vs Tension-type Headache?

A

Migraine:
-Unilateral, Mod to severe intensity, Pulsating quality a/w N/V, photo/phonophobia
Cluster:
-Strictly unilateral, severe intensity and quality, a/w autonomic symptoms(conjunctival injection, lacrimation, rhinorrhea, facial sweating)
TTH:
-Bilateral, mild to mod intensity, tightening(helmet type),no a/w symptoms

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15
Q

What are some comfort signs suggestive of Migraine?

A
  • Positive Family history
  • Preceded by typical aura
  • Headache related to menstrual cycle
  • Normal physical/neuro findings
  • Headaches remaining stable over time
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16
Q

How do you treat migraine?

A

Aborting Meds:

1st Line:Paracet
2nd Line: NSAIDS and if Anti-emetics needed: IM Stemetil 12.5mg
(if no resolution)
3rd Line: Ergotamine 1-2mg and Cafergot 1 tab

Prophylatic Meds(those with>2 attacks a month, very severe attack+prolonged aura):

1) B Blockers(Atenolol)
2) CCBs(Flunarizine)
3) Anti-depressants(Amitriptyline)

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17
Q

How do you treat Primary Headaches?

A

1) Tension headache
-1st line:Paracet,Codeine phosphate 60mg/IM Declofenac 75mg
Prophylactic Rx: Amitriptyline 10-75mg

2) Cluster Headache
- 100% O2 for 10 mins and Sumatriptan

18
Q

Where do most SAH occur?

A

90% of SAH due to spontaneous cerebral aneurysms occur in the ant circulation which includes ant and post comm arteries and the MCA.

19
Q

What is the most common nerve involvement in SAH?

A

CN 3

20
Q

What PE signs are picked up in SAH?

A

1) LOC
2) Meningismus
3) Focal neuro deficit
4) Fundoscopic exam revealing subhyaloid and pre-retinal hemorrhage.

21
Q

Can you make a dx of migraine of a new onset headache in a pt>50 yrs?

A

NO

22
Q

What cx do you look out for in a pt with SAH?

A

1) Rebleeding -most sig acute cx
2) Cerebral salt wasting
3) Neurogenic pulmonary edema
4) Acute hydrocephalus
5) Seizures
6) Neurogenic cardiac disease

23
Q

What is Cushing’s reflex?

A

1) Bradycardia
2) Hypotension
3) Irregular respiratory rate

24
Q

What initial mgmnt and invg would you want to conduct in SAH?

A

1) ABC
2) Evaluate airway- need for intubation? Assess GCS regularly and document
3) Supp O2 high flow
4) Elevate bed to 30 degrees
5) Establish Peripheral IV line

Draw blood for invg:

1) Bloods: FBC, GXM 2 units, U/E/Cr, PT/aPTT
2) Imaging: Non-contrast CT head, CXR (look for neurogenic APO)
3) Others: LP(xanthochromia-presence of bilirubin in CSF) ECG

25
Q

What definitive mgmnt of SAH would you institute?

A

1) Non-opioid analgesia(IM declofenac)
2) Anti-emetics: Stemetil 12.5 mg
3) Anti-HTN: Labetolol 10mg IV(keep BP

26
Q

What clinical features must you look out for in meningitis?

A

2/4 of:(present in 95%)

1) Fever
2) Neck stiffness
3) AMS
4) Headache

Others: Rash, Seizures, Photophobia, Kernig’s sign, neuro deficits, N/V, hypotension and shock, papilloedema

27
Q

What is the risk stratification of meningitis pts?

A

3 basic Clinical features of:
AMS-1
Seizures-1
Hypotension-1

Low: 0 points
Mod: 1 point
High: 2/3 points

28
Q

What invg and work flow of pts with meningitis?

A

1) ABC-(contact precautions) and watch for septic shock
2) Bloods-FBC, U/E/Cr, Blood cultures, Lactate(in septic shock), DIVC(in meningococcemia) and ABG
3) GIVE ANTIBIOTICS NOW RIGHT AFTER BLOOD C/S
4) Imaging: CT scan in those with
-Neuro def
-New onset seizures
-LOC
-Raised ICP
-HIV
-Head injury
Others: LP (prior administration of antibiotics will not affect CSF culture) can be done prior to CT if those indications are not present.

Symptomatic Rx: Anti-pyretics/emetics

Therefore its Blood cultures–>Prophylatic Antibiotics–>CT head–>LP

29
Q

What prophylactic antibiotics are given in Meningitis?

A

In Immunocompetent:
IV Ceftriaxone
+IV Ampicillin(if above 60 yrs old)

30
Q

What is status epilepticus?

A

≥5 minutes of continuous seizures, or

≥2 discrete seizures between which there is incomplete recovery of consciousness

31
Q

What is the initial mgmnt of Status Epi?

A

Airway measures:
Open and maintain patent airway, pt in recovery position and Yanker Suction any vomitus seen
B-Supplemental high flow O2 and prepare intubation equip
C- Establish peripheral IV line

Drug Rx:
1st line: BZD(IV Diazepam 5mg slow bolus or if no IV line Rectal Diazepam 5mg Suppository. Or IV Lorazepam 4mg)
2nd Line: IV Phenytoin 18mg/kg with cardiac monioring
3rd Line: IV Propofol 50-200mg/hr
4th line: Sodium Valproate IV
5th Line: Phenobarbitone IV

Invg to do:

  • Bloods: Stat CBG, FBC, U/E/Cr, ionized Ca, Mg, PO4 or ABG, +-Toxi screen, +-anti-convulsant levels, +- Blood culture(if febrile)
  • Imaging: CT Brain if suspecting a structural cause
  • Others: ECG(in older pts for dysrhythmias), Urinalysis(+-Urine HCG(eclampsia)
32
Q

What is TIA?

A

A brief episode of neuro dysfunction caused by focal disturbance of retinal or cerebral ischemia without causing infarction and with symptoms lasting

33
Q

What kind of symptoms do TIAs cause?

A

1) Negative symptoms(loss of power/sensation) more than positive symptoms(aura, syncope etc)

34
Q

What kind of pts need to be admitted for further neuro evaluation in TIA?

A

1) Pts on Anticoagulation
2) Pts with recurrent TIA
3) Pts with identifiable cardioembolic source
4) High ABCD2 score

35
Q

What is ABCD2

A 
Age>60
BP>140/90
Clinical presentation(hemiparesis>speech probs)
Duration of symptoms (1hr)
DM

6-7 points high risk of another stroke within the first 2 days following a TIA

36
Q

What types of strokes are there?

A

Ischemic-Thrombotic(Normal BP, gradual onset), Embolic(sudden onset)
Hemorrhagic(sudden onset, N/V, Headache, decreased conscious level, HTN usually)

37
Q

What is the ddx of stroke?

A

1) Todd’s paralysis
2) Complicated migraine
3) HTN encephalopathy
4) Hypo/Hyper Gly
5) Brain SOL

38
Q

How will you manage a pt with stroke?

A

1) Supportive mgmnt
2) Stat CBG and ECG to check for abnormalities
3) Emergent CT scan in:
- IS pts who are candidates of thrombolytic rx
- suspected ICH
- suspected SAH
- Pts with risk of deterioration(eg. large cortical strokes)

39
Q

What is IV thrombolytic rx?

A

IV alteplase(rt-PA) should be given within 3-4.5hrs of onset of ischemic stroke. 0.9mg/kg over 1hr

40
Q

How about BP mgmnt in stroke?

A

-Hemorrhagic-Rx HTN but at a slow rate to prevent ischemia and reduction in CPP
-Ischemic Stroke- Do not need to rx HTN unless BP>220/120 which requires cautious lowering of BP during 1st 24hrs.
-Indicated if pt has
CCF
AD
AMI
And if pt is a candidate for rtPA then reduce to

Guide to Essentials in Emergency Medicine (10 decks)

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