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X Emergency Med Exam 2 > CNS Emergencies I > Flashcards

CNS Emergencies I Flashcards

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1
Q

When do you want to think about a possible CNS infection?

A

Fever, HA and neurologic signs/sxs

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2
Q

What might be seen in survivors of bacterial meningitis?

A

Neurologic sequela

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3
Q

How can bacteria get into CNS?

A

Bloodstream or contiguous spread (ex sinus infection)

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4
Q

Pathogenesis of bacterial meningitis

A

Inflammation damages BBB causing increased per so alterations in protein and glucose transport–progressive cerebral edema with increased ICP and decreased cerebral perfusion leads to neurologic damage

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5
Q

Etiology of bacterial meningitis from exposure during delivery (up to 4 wks old)

A

E coli, Group B strep

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6
Q

Etiology of bacterial meningitis from colonization from nasopharynx

A

Sinusitis, otitis media, mastoiditis–strep pneumo

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7
Q

Etiology of bacterial meningitis from crowded conditions

A

Military, college–N meningitides

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8
Q

Etiology of bacterial meningitis from head trauma

A

Staph species

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9
Q

Etiology of bacterial meningitis from post-neurosurgical procedures

A

Staph species, gram (-)

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10
Q

2 most common organisms of bacterial meningitis

A

N meningitides and s pneumoniae

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11
Q

Risk factors for s pneumoniae infection

A

Cochlear implants, fractures of face/skull

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12
Q

Who is listeria monocytogenes meningitis seen in?

A

Elderly and neonates

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13
Q

What meningitis do you worry about with breaks in the skin?

A

Coag neg staph or s. aureus

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14
Q

Which meningitis do you worry about with unvaccinated children and adults?

A

H. influenzae

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15
Q

How might bacterial meningitis present?

A

Progressively over a couple days or after febrile illness

Acutely with signs and sxs of sepsis (rapid progression over several hrs and cerebra edema)

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16
Q

Manifestations of bacterial meningitis

A

HA, photophobia, n/v/anorexia, focal neurologic deficits (weakness, cranial nerve palsies), seizures, AMS, nuchal rigidity, papilledema and increased ICP

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17
Q

Classic triad of bacterial meningitis

A

Fever
Nuchal rigidity
AMS

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18
Q

What organism produces a petechial rash and palpable purpura?

A

N meningitides

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19
Q

Tests for bacterial meningitis

A

Kernigs sign: won’t extend knee with hip flexed
Brudzinskis: flexion of hips with passive flexion of neck
Joint accentuation test: pt rotates his or her head 2 times per second and positive test is exacerbation of existing HA

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20
Q

Diagnostics for bacterial meningitis

A

Blood cultures x 2!!! (before abx)
Maybe CT
LP for CSF analysis
CBC with diff, CMP, ESR, CRP, serum and CSF glucose

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21
Q

Gold standard for bacterial meningitis diagnosis

A

CSF culture

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22
Q

CSF findings for bacterial meningitis

A 
Increased WBC (>1000 with mostly neutrophils)
Decreased glucose (<40)
Increased protein (100-500)
\+ gram stain and culture
Increased opening pressure
CSF/blood glucose
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23
Q

Recommendation to get a CT before LP

A 
With 1+ of following factors:
Immunocompromised
History of CNS disease
New onset seizure
Papilledema
Abnormal LOC
Focal neurological deficit
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24
Q

What might happen if there is increased ICP during an LP?

A

Mass lesion present can result in cerebral herniation

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25
Q

What do gram positive diplococci suggest?

A

Pneumococcal infection

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26
Q

What do gram negative diplococci suggest?

A

Meningococcal infection

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27
Q

What do gram negative coccobacilli suggest?

A

H influenzae infection

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28
Q

What do gram positive rods and coccobacilli suggest?

A

L monocytogenes infection

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29
Q

What is predictive of worse outcomes with bacterial meningitis?

A

AMS, seizures or hypotension

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30
Q

What is started immediately after blood cultures and LP

A

Empiric IV abx and dexamethasone (glucocorticoid) at same time or shortly before
(if waiting for LP til after CT, still start the abx after cultures)

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31
Q

Empiric tx for newborn meningitis and the causative organism

A

Ampicillin + cefotaxime OR gentamycin
(Group B strep, E coli, L monocytogenes)
**do not use Vanco when 4 wks and younger

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32
Q

Empiric tx for meningitis at 1-23 mos and the causative organism

A

Vanco + ceftriaxone OR cefotaxime + dexamethasone

Strep pneum, H flu, E coli, N meningitides

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33
Q

Empiric tx for meningitis at 2-20 yrs and the causative organism

A

Vanco + ceftriaxone OR cefotaxime + dexamethasone

S pneum or N meningitides

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34
Q

Empiric tx for meningitis when >50 YO and the causative organism

A

Ampicillin + Vanco + ceftriaxone OR cefotaxime + Dexamethasone
(Strep pneum, L monocytogenes, gram - bacilli, N meningitides)

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35
Q

Empiric tx for meningitis when immunocompromised and the causative organism

A

Ampicillin + Vanco + Cefepime OR meropenem + Dexamethasone

Strep pneum, L monocytogenes, gram - bacilli, N meningitides

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36
Q

What should be switched if there is a penicillin allergy?

A

Vanco + Moxifloxacin + Bactrim replace Ampicillin in >50YO and immunocompromised

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37
Q

Empiric tx for meningitis due to contiguous spread from basilar skull fracture and the causative organism

A

Ampicillin + cefotaxime OR gentamycin

Group A beta hemolytic strep, strep pneum or H flu

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38
Q

Empiric tx for meningitis due to contiguous spread from penetrating trauma and post-neurosurgery and the causative organism

A

Vanco + ceftazidime OR cefepime OR meropenem

s aureus, pseudomons, coag neg staph

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39
Q

What is the benefit of adding dexamethasone?

A

Decreased rate of hearing loss and neurologic sequelae and decreases morbidity and mortality in PNEUMOCOCCAL meningitis only

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40
Q

What must be added to the steroid if cultures are positive for S pneumoniae?

A

Rifampin (better CNS coverage)

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41
Q

Meningitis management algorithm for pt meeting criteria for CT before LP

A

Blood cultures STAT
Dexamethasone + empiric abx
CT of head
(if contraindication for LP like increased ICP then continue med regimen)
Perform LP if not contraindicated
CSF for gram stain, cultures, cell count, glucose, protein

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42
Q

Meningitis management algorithm for pt not meeting criteria for LP before CT

A 
Blood cultures
LP
Empiric abx + dexamethasone
CSF sent for gram stain, cultures, cell count, protein, glucose
Tailor tx based on results
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43
Q

Meningitis management algorithm for CSF gram stain positive

A

If gram positive diplococci, target abx therapy to strep pneum and continue dexamethasone and rifampin
All other bacteria, target abx and d/c dexamethasone

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44
Q

Meningitis management algorithm for gram stain neg but other CSF findings consistent with meningitis

A

Continue empiric tx and dexamethasone

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45
Q

Complications of bacterial meningitis

A

Septic shock
DIC
Acute respiratory distress syndrome
Possible neurologic long term complications (impaired mental status or cognition, sensorineural hearing loss)

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46
Q

Important vaccines to prevent bacterial meningitis

A

S pneum, N meningities, h flu

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47
Q

What is used for post exposure prophlyaxis for bacterial meningitis?

A

Cipro, rifampin or ceftriaxone (in pregnant pts)

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48
Q

What is aseptic meningitis?

A

Evidence of meningeal inflammation but bacterial cultures are neg–sometimes called viral meningitis

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49
Q

Presentation of aseptic meningitis

A

Similar to bacterial but usually less severe sxs so just supportive care

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50
Q

Most common cause of aseptic meningitis

A

Enterovirus (think with diarrhea too)

Other viral causes are coxsackie and echovirus (summer and autumn), HSV-2, VZV, mumps, HIV, west nile etc

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51
Q

Other infectious causes of aseptic meningitis

A

Mycobacteria
Fungi (crypto, cocci)
Spirochetes (treponema or borrelia)

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52
Q

Malignancy causing aseptic meningitis?

A

Uncommon but may see due to direct invasion of mets into meninges
Leukemia, lymphoma, melanoma, breast, lung or GI CA

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53
Q

Drug induced aseptic meningitis?

A

Uncommon but exclude other diagnoses
Must tell if delayed hypersensitivity rxn or direct irritation
NSAIDs! also abx like bactrim, chemo or pyridium

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54
Q

Clinical manifestations of aseptic meningitis

A

HA, fever, n/v, maybe photophobia or nuchal rigidity

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55
Q

What history clues are necessary for aseptic meningitis?

A 
Travel and expsoure hx
Sexual activity (HSV-2, syph, HIV)--look for genital lesions for HSV-2
56
Q

PE clue suggesting mumps as etiology of aseptic meningitis

A

Unvaccinated pt with parotitis

57
Q

PE clue suggesting HSV-2 as etiology of aseptic meningitis

A

Severe vesicular genital lesions

58
Q

PE clue suggesting enteroviral infection, HIV or syph as etiology of aseptic meningitis

A

Diffuse macpap exanthema in mildly ill pt

59
Q

PE clue suggesting primary HIV as etiology of aseptic meningitis

A

Oropharyngeal thrush and cervical LAD

60
Q

PE clue suggesting west nile virus as etiology of aseptic meningitis

A

Asymmetric flaccid paralysis

61
Q

Diagnostis for aseptic meningitis

A 
Blood cultures x2 before abx
CT (same criteria)
LP for CSF analysis
CBC with dif, CMP, ESR, CRP
Others based on suspicion
62
Q

CSF findings for aseptic meningitis

A 
WBC<500 and >50% lymphocytes if viral
Normal glucose (40-80)
Normal or mildly increased protein
- gram stain and culture
PCR (HSV, MMR, CMV, epstein barr)
Cultures
63
Q

Management for viral aseptic meningitis

A

Start empiric abx at presentation but d/c when r/o bacterial

Self limiting so just supportive (analgesics, antipyretics or acyclovir if severe or immunocompromised)

64
Q

Management for malignancy induced aseptic managment

A

Malignant cells within CSF

Oncology

65
Q

Management for drug induced aseptic meningitis

A

d/c offending med and then sxs resolver

66
Q

Management for uncommon causes of aseptic meningitis

A

Treat accordingly

Require ID and neuro involvement

67
Q

What distinguishes meningitis and encephalitis?

A

Presence of absence of normal brain function
Meningitis: preserve cerebral function and more common to have fever, HA, meningismus
Encephalitis: abnorm brain function due to inflammation of brain (AMS, seizures, motor/sensory deficits, personality changes, speech )

68
Q

What is the primary infection of encephalitis?

A

Due to direct viral invasion of CNS and can be cultured from brain tissue (neuronal involvement)

69
Q

What is post infectious encephalitis (acute disseminated encephalomyelitis ADEM)?

A

No virus is detected and neurons are spared but there is perivascular inflammation and demyelination
Occurs as initial infection is resolving

70
Q

Most common cause of encephalitis is US

A

West nile (arbovirus)

71
Q

Other causes of encephalitis

A

Influenza, Lyme, RMSF, syph, VZV/EBV/HIV/MMR (immunocompromised mostly)

72
Q

Most common cause of fatal encephalitis

A

HSV-1

73
Q

More common in meningitis or encephalitis: coxsackie

A

Meningitis

74
Q

More common in meningitis or encephalitis: west nile

A

Encephalitis

75
Q

More common in meningitis or encephalitis: HSV-1

A

Encephalitis

76
Q

More common in meningitis or encephalitis: HSV-2

A

Meningitis

77
Q

More common in meningitis or encephalitis: varicella

A

infrequent in both

78
Q

More common in meningitis or encephalitis: CMV

A

Encephalitis

79
Q

More common in meningitis or encephalitis: EBV

A

Infrequent in both

80
Q

More common in meningitis or encephalitis: HIV

A

Meningitis

81
Q

More common in meningitis or encephalitis: Influenza

A

Encephalitis

82
Q

More common in meningitis or encephalitis: mumps

A

Meningitis

83
Q

More common in meningitis or encephalitis: measles

A

Meningitis

84
Q

Manifestations of encephalitis

A

HA, fever, AMS, seizures, focal neuro deficits (hemiparesis, CN palsies, increased DTRs)

85
Q

What is rare in encephalitis?

A

Photophobia and nuchal rigidity (but can be seen in meningoencephalitis)

86
Q

Clues for HSV-1 on encephalitis PE

A

Ulcers or vesicles

87
Q

Clues for WNV on encephalitis PE

A

Flaccid paralysis and rash

88
Q

Clues for rabies on encephalitis PE

A

Hydrophobia, hyperactivity, pharyngeal spasms

89
Q

Clues for St louis virus on encephalitis PE

A

Tremors of tongue, lips, eyelids

90
Q

Diagnostics for encephalitis

A 
Blood cultures x 2
CBC with diff, CMP
PCR of CSF for HSV, enteroviruses, HBV
CSF tests (unless C/I)
Cultures
91
Q

What can indicated HSV-1 infection in CSF?

A

RBCs

92
Q

CSF analysis in viral encephalitis

A 
WBC<250
Glucose 40-80 (decreased in HSV tho!)
CSF/blood glucose .6
Protein elevated <150
Gram stain -
Increased lymphocytes
93
Q

Study of choice for encephalitis

A

MRI with contrast (might take a couple days to see the changes)

94
Q

Other diagnostics for encephalitis

A

CT with contrast if no MRI

Maybe EEG

95
Q

What suggests HSV on MRI?

A

Temporal lobe changes (illuminating contrast)

96
Q

What suggests bacterial/fungal/parasitic etiology of encephalitis on MRI?

A

Hydrocephalus

97
Q

When is serology ordered with encephalitis?

A

If pt not improving or no diagnosis based on CSF, culture or PCR
IgM testing for WNV, mumps, EBV

98
Q

Brain biopsy for encephalitis

A

Only if etiology unknown

Last resort!!

99
Q

Management for encephalitis

A

Acyclovir 10mg/kg IV Q8hrs–empiric ASAP
Seizure prophylaxis and control (carbazepime)
Diuretics if increased ICP (Mannitol or furosemide)

100
Q

Prognosis of encephalitis

A

Poor neuro recovery and increased mortality if inital diffuse cerebral edema or intractable seizures
Elevated initial ICP is not good
Monitor serial ICPs

101
Q

Causes of direct spread cerebral abscess

A

Usually single abscess
Otitis media, mastoiditis, meningitis, head/facial trauma, sinusitis, dental infection or S/P neurosurgical or spinal procedure

102
Q

How to determine etiology of cerebral abscess

A

Location of the abscess on MRI to determine direct spread

103
Q

What does inferior temporal lobe or cerebellum abscess suggest?

A

Subacute and chronic otitis media

Mastoiditis

104
Q

What do frontal lobe abscessed suggest?

A

Frontal or ethmoid sinusitis

Dental infection

105
Q

Causes of hematogenous spread cerebral abscesses

A

Usually multiple and has bacteremia
Chronic pulm infection, skin infection, pelvic infection, intraabd infection, bacterial endocarditis or after esophageal dilatation

106
Q

Most common cause of cerebral abscess

A

Bacterial:
Paranasal: strep or haemophilus
Odontogenic: strep or bacteriodes
Otogenic: strep, enterobacter, pseudomonas
Penetrating head trauma: staph, enterobacter
Neurosurgery: strep, staph, pseudomonas

107
Q

Most common cause of cerebral abscess when there is an immigrant from mexico

A

Parasite (cysticercosis due to taenia solium/pork tapeworm)

108
Q

Immunocompromised pathogens causing cerebral abscess

A

Toxoplasma, listeria moncytogenes or nocardia asteroides

109
Q

Fungal pathogens causing multiple abscesses and poor outcomes

A

Crypto, cocci, aspergillus, candida

110
Q

Manifestations of cerebral abscess

A 
Unilateral HA (unless multiple)
Sudden or gradual onset
Severe pain not relieved with OTC pain meds
Maybe fever or nuchal rigidity (more common in occipital lobe abscess)
AMS (severe cerebral edema)
Vomiting (increased ICP)
Focal neuro deficits
Seizures
Papilledema (late)
111
Q

Diagnostics for cerebral abscess

A

Blood cultures x2
CBC with diff, CMP
MRI (study of choice!!!)
CT guided aspiration or surgical excision for cultures (contrast!!)

112
Q

What will be seen on an MRI of a cerebral abscess?

A

Ring enhancing lesion
Early: lesion is poorly demarcated, localized edema, acute inflammation, no tissue necrosis
Late (>2 wks): necrosis and liquefaction, lesion surrounded by fibrotic capsule

113
Q

Management of cerebral abscess

A 
Empiric abx (based on gram stain) for 4-8 wks after find out pathogen on culture (IV)
Track progression on MRI every 4-6 wks
114
Q

Empiric tx of cerebral abscess due to oral, otogenic, sinus spread

A

Oral: Metro + Pen G

Otogenic or sinus: Metro + ceftriazone OR cefotaxime

115
Q

Empiric tx of cerebral abscess due to hematogenous spread

A

Vanco + Metro

116
Q

Empiric tx of cerebral abscess due to post op neurosurgery

A

Vanco + ceftazidime OR cefepime OR meropenem

117
Q

Empiric tx of cerebral abscess due to penetrating trauma

A

Vanco + ceftriaxone OR cefotaxime

118
Q

Empiric tx of cerebral abscess due to unknown source

A

Vanco + cetriaxone OR cefotazime + Metro

119
Q

Most common reasons for intracranial epidural abscess

A

Usually complication of neurosurgery or can be spread from osteomyelitis of skull from fetal monitoring probe (infections!! sinusitis, otitis)

120
Q

What is an intracranial epidural abscess?

A

Localized lesion with central collection of pus surrounded by wall of inflammatory tissue which may calcify (rarely spreads caudally due to tight attachment of dura at foramen magnum)

121
Q

Manifestations of intracranial epidural abscess

A

Fever, HA, lethargy, n/v
If secondary to sinusitis: purulent drainage from nose or ear
Compressing brain: increased ICP, papilledema, focal neuro changes

122
Q

Diagnostics of intracranial epidural abscess

A

CBC with diff, ESR
MRI with contrast
CT with contrast if can’t MRI
CT guided aspiration or open drainage for stains and cultures

123
Q

Management for intracranial epidural abscess

A

Drainage and abx
Burr holes or craniotomy (neurosurgical)
MRI every 4-6 wks after initiation of tx

124
Q

What to remember about abx with intracranial epidural abscess!!!

A

Empiric abx once sample of abscess fluid is obtained (so waiting 1-2 days before start!)
Can be earlier with immunocompromised pt or concerning findings

125
Q

Management of intracranial epidural abscess due to contiguous spread

A

Metro+ceftriaxone OR cefotaxime

126
Q

Abx for all other intracranial epidural abscesses

A

Vanco + Metro + ceftriaxone OR cefotaxime OR ceftazidime

127
Q

How does spinal epidural abscess happen?

A

Bacteria get access by hematogenous spread, direct extension (osteomyeltis) or direct inoculation into spinal canal (epidural cath)

128
Q

How does spinal epidural abscess spread?

A

Longitudinal extension so can go through whole spine! (more common in thoracolumbar area)

129
Q

Why do sxs occur with spinal epidural abscess?

A

Direct compression on spinal cord
Thrombosis of nearby vessels
Bacterial toxins or inflammation
Arterial blood supply interruption

130
Q

Major players in spinal epidural abscess

A

Staph aureus (mostly), gram - bacilli, streptococci, coag neg staph

131
Q

Risk factors of spinal epidural abscess

A

Immunocompromised (DM, alcoholism, HIV)
Direct inoculation (epidural cath, paraspinal injection, trauma)
Hematogenous (tattooing, acupuncture, bacteremia, IV drug use, hemodialysis)

132
Q

Classic triad of spinal epidural abscess

A

Fever, spinal pain and neurologic deficits (at or below abscess)

133
Q

Manifestations of spinal epidural abscess

A

May be non-specific at first
Absent fever may be seen (present multiple times before diagnosed!!)
Back pain focal and severe
Nerve root pain (shooting or electrical)
Motor weakness, sensory changes, bowel or bladder dysfunction
Paralysis that quickly becomes irreversible

134
Q

First line diagnostic for spinal epidural abscess

A

MRI with contrast ASAP (skip lesions on entire spine, want to see epidural soft tissue edema vs abscess)

135
Q

Other diagnostics for spinal epidural abscess

A

CBC with diff with ESR
CT with contrast is 2nd line
Ct guided extraction of pus fro abscess for culture

136
Q

Management of spinal epidural abscess

A

Blood cultures x2
Empiric abx after suspect (after cultures!!)–Vanco + cefotaxime OR ceftriaxone OR cefepime OR ceftazidime for 4-8 wks
Surgical decompression and drainage
Follow up MRI in 4-6 wks

137
Q

Prognosis of spinal epidural abscess

A

Can have death due to sepsis or complications but rare
Irreversible paraplegia can happen
Degree of neuro recovery related to duration of deficit

X Emergency Med Exam 2 (6 decks)

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