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X Emergency Med Exam 2 > CNS Emergencies II > Flashcards

CNS Emergencies II Flashcards

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1
Q

What is increased intracranial pressure?

A

Abnormal increase in vol of any component (brain mostly, CSF or blood in constant space)

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2
Q

How might brain injury happen with increased intracranial pressure?

A 
Brainstem compression (herniation)
Reduction in cerebral perfusion pressure (CPP) which is needed to get O2 and nutrients to the brain
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3
Q

Management for increased intracranial pressure

A

Prompt recognition
Judicious use of invasive monitoring
Therapy aimed at reducing ICP and addressing cause

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4
Q

Presentation of ICP

A 
HA, n/v
Papilledema
Unilateral or bilateral fixed pupil
Loss of consciousness
Decorticate or decerebrate posturing
Cushings triad
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5
Q

What is Cushings triad?

A

Ominous finding

Bradycardia, HTN or respiratory depression

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6
Q

Max GCS for intubated pt

A

10

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7
Q

What does decorticate posturing suggest?

A

Destructive lesion in corticospinal tract from cortex to upper midbrain

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8
Q

What does decerebrate posturing suggest?

A

Damage to corticospinal tract at level of brainstem (pons or upper medulla)

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9
Q

Causes of intracranial HTN

A 
TBI/intracranial hemorrhage
CNS infection
Ischemic stroke
Neoplasm
Vasculitis
Hydrocephalus
Hypertensive encephalopathy
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10
Q

Diagnostics that might be ordered with ICP

A 
Type and cross
CBC, BMP
Osmolality
Toxicology
Blood alcohol level
Glucose
INR/PT/PTT
CT/MRI (brain, C/T/L, spine)
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11
Q

What can referral to neurosurgery do for ICP?

A

Decompressive craniectomy

Ventriculostomy

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12
Q

Resuscitation for increased ICP

A

Oxygenation (avoid hypoxia)–maintain O2 at >90% (or PAO2>60) and may need mechanical ventilation
BP (avoid hypotension and control HTN)
Maintain end organ perfusion

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13
Q

Other management for increased ICP

A 
Elevate head of bed to 30 degrees
Analgesia and sedation
Treat fever (maybe mechanical cooling or tylenol)
ICP monitors
IV fluids (normal saline)
Mannitol to decrease brain vol
Anti-seizure therapy
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14
Q

Things you might see with a skull fracture

A 
AMS
Cranial nerve or other neuro deficits
Scalp lacerations of contusions
Bony step off
Periorbital or retroauricular ecchymosis
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15
Q

Types of skull fractures

A

Linear
Depressed
Basilar

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16
Q

What is a linear skull fracture?

A

Single fracture but majority have minimal or no clinical significance

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17
Q

Sxs of linear skull fracture

A

No neuro sxs usually
Only small amt get significant intracranial hemorrhage
If on temporal bone- can disturb vasculature and get bleeding

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18
Q

What to do if CT shows no underlying brain injury and no neuro deficit with linear skull fracture?

A

Observe in ED for 4-6 hrs and then discharge home with supervision (admit if suspicious for brain injury)

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19
Q

What is a depressed skull fracture?

A

Segment of skull is driven below level of adjacent skull

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20
Q

What to worry about with depressed skull fracture

A

Often involves injury to brain parenchyma
High risk of CNS infection, seizures and death
Can be closed or open

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21
Q

What to do with open depressed fractures

A

Examine but not probe them

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22
Q

Management for depressed skull fracture

A

Get CT, admit to neurosurgery (Td tetanus if needed, prophylactic abs and anticonvulsants)

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23
Q

What might occur with a basilar skull fracture?

A

Dural tear resulting in communication b/w subarachnoid space, paraspinal sinus and middle ear

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24
Q

Presentation of basilar skull fracture

A

Clear/blood tinged rhinorrhea/otorrhea due to leakage of CSF
Retroauricular or mastoid ecchymosis (Battles-1-3 days after)
Raccon eyes (periorbital ecchymosis)
Maybe hemotympanum

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25
Q

Canadain head CT rule for basilar skull fractures

A

+Battle sign/racoon eyes, hemotympanum and otorrhea/rhinorrhea are predictive of significant injury

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26
Q

What to remember with basilar skull fracture

A

Can have CSF leak, infection or cranial nerve injury
Risk for intracranial hemorrhage
Can occur through temporal bone (epidural hematoma)

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27
Q

Management for basilar skull fracture

A

Admit for observation regardless and get neuro consult

Close monitoring

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28
Q

Penetrating injuries with skull fractures

A

Typically with significant brain injury and ICH

Consult neuro immediately and then give IV abx

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29
Q

Tangential skull fractures

A

Usually due to gun shot wound

Risk for ICH so get emergent CT

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30
Q

Imaging for skull fractures

A

Non contrast CT
MRI secondary for suspected vascular injury
If can’t get CT, get x-rays with 2 views (but hard to see depressed skull fractures and cannot rule out intracranial injury)
CT of cervical spine if positive findings of cervical spine or AMD (always assess!!)

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31
Q

What is a concussion?

A

Trauma induced alteration in mental status that may or may not have loss of consciousness (direct blow with impulsive force to head)

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32
Q

Brain contusion

A

Areas of bruising with localized ischemia, edema and mass effect
Direct external contact force, acceleration, deceleration trauma

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33
Q

Possible MOI for closed head injury

A

Coup or contrecoup (hit forward and back

Do a neuro exam with mental status testing if think so

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34
Q

Who needs urgent neuroimaging and neuro consulting?

A

GCS<15
Suspected open or depressed skull fracture
Signs of basilar
2+ episodes of vomiting
New neuro deficit
Presence of bleeding diathesis or use of antiocoag med
Seizure
>60 YO
Retrograde amnesia >30 min or longer before traumatic episode
High impact head injury
Intoxication, HA or abnormal behavior

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35
Q

When to admit with closed head injury?

A 
GCS<15
Abnormalities on head CT
Seizures
Underlying bleeding diathesis or oral anticoag
Other neuro deficit
Recurrent vomiting
No person at home to monitor
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36
Q

When to send home with closed head injury

A

GCS of 15
Normal exam and CT of head
No predisposition to bleeding
Someone to monitor them

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37
Q

What is a diffuse axonal injury?

A

Shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) leadin to severe intracranial hemorrhage
Axon disruptions, swelling and cell death

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38
Q

Presentation of diffuse axonal injury

A

Variable

Can be associated with posttraumatic coma (frequent cause of persistent vegetative state)

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39
Q

Management of diffuse axonal injury

A

No surgery

CT scan to demonstrate blurring of gray to white matter margin, cerebral hemorrhage or cerebral edema

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40
Q

Types of cerebral hemorrhage

A 
Intracranial hematoma which is external to brain parenchyma (epidural hematoma, subdural hematoma, subarachnoid hemorrhage/ bleeding into CSF)
Intracerebral hemorrhage (lesions within brain substance)
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41
Q

What is an epidural hemotoma?

A

Acute collection of blood b/w skull and dura mater

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42
Q

Presentation of epidural hemotoma

A

Usually adolescents/young adults
Associated with skull fracture and trauma!! (middle meningeal artery)
Brief LOC, then lucid interval and then rapid clinical deterioration

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43
Q

CT for epidural hemotoma

A

Lens-shaped or lenticular (bioconvex shaped)

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44
Q

What is a subdural hemotoma?

A

Collection of VENOUS blood between dura mater and arachnoid (tears bridging veins)
Usually with brain atrophy (elderly or alcoholics)

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45
Q

Presentation of subdural hemotoma

A

Usually due to fall
Acute: sxs in 24-48 hrs after onset
Subacute: sxs 3-14 days after onset
Chronic>2 wks after onset

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46
Q

CT for subdural hemotoma

A

Crescent shape

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47
Q

Sxs of intracranial hematoma

A 
Momentary LOC to coma
HA
Vomiting
Drowsiness
Confusion
Aphasia
Seizures
Hemiparesis
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48
Q

Management for intracranial hematomas

A

Emergent neuro consult
Decide for surgery based on GCS, neuro exam/pupillary signs or brain imaging findings
Craniotomy with hematoma evacuation vs observation (burr hole-trephination)

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49
Q

What is a subarachnoid hemorrhage?

A

Bleeding within the subarachnoid space

Can be traumatic or non-traumatic

50
Q

Non traumatic causes of subarachnoid hemorrhage

A

Aneurysm, vascular malformations, cerebral venous thrombosis
**these are most cases (mortality pretty high)

51
Q

Presentation of subarachnoid hemorrhage

A 
Acute onset of worst HA of life (thunderclap HA)
Impaired consciousness
Neck stiffness
N/v
Exertion or valsalva immediately preceding onset of TCH
Elevated BP
Occipital HA
History of smoking
52
Q

Management for subarachnoid hemorrhage

A

CT before LP (if needed)
Neuro consult
Support
Interventional neuroradiologist (surgical clipping or endovascular coiling)

53
Q

Complications of subarachnoid hemorrhage

A 
Rebleeding
Vasospasm and delayed cerebral ischemia
Hydrocephalus
Increased ICP!!
Seizures
Hyponatremia (if hypothalamic injury)
54
Q

2nd most common cause of stroke

A

Intracerebral (intraparenchymal hemorrhage) after ischemic stroke being number 1

55
Q

Initial goals of tx for intracerebral hemorrhage

A

Prevent hemorrhage extension

Prevent and manage ICP

56
Q

Imaging for intracerebral hemorrhage

A

EMERGENT noncontrast CT!!
Can do MRI of brain for smaller lesions
Angiography (CTA or MRA) for vascular malformations and aneurysm

57
Q

Causes of nontraumatic intracerebral hemorrhage

A 
HTN (most common)
Amyloid angiopathy
Ruptured saccular aneurysm
Vascular malformation
Hemorrhagic infarction
Bleeding disorders
Brain tumor
CNS infection
Vasculitis
Drugs (cocaine, amphetamines)
58
Q

Presentation of intracerebral hemorrhage

A

Acute onset of focal neuro deficit that corresponds to part of brain affected
Increasing neuro sxs/signs over time
HA, vomiting, decreased LOC or sezures

59
Q

What to remember with intracerebral hemorrhage

A

Neuro and medical emergency that can lead to permanent disability and death

60
Q

Imaging for intracerebral hemorrhage

A

CT without contrast or MRI

61
Q

Management of intracerebral hemorrhage

A 
Emergent neuro consult (maybe surgical decompression)
Admit to ICU
BP control
Manage ICP
Avoid hyperglycemia (glucose b/w 140-180)
Seizure prophylaxis
Reversal of anticoag
NPO
62
Q

What is ischemic CVA?

A

Hypoperfusion
Thrombus formation in an artery leading to reduce blood flow resulting in localized hypoxic brain injury (Can be embolus)

63
Q

Causes of ischemic CVA

A 
Cardiac (a fib, valvular disease)
Large artery (atherosclerosis, thrombus formation, embolism, arterial dissection)
Small artery (HTN, DM, vasculitis)
64
Q

Management for code stroke

A 
ABCs rapidly
NIHSS for severity (>20 means severe)
O2 sat (maybe intubate)
ECG and troponins
IVF
Labs (coag, CBC, CMP, tox) and fingerstick glucose
Early noncontrast CT or MRI
Neuro consult
Evaluate for thrombolytic therapy or interventional txs
65
Q

When to use ASA wtih stroke

A

If CT shows non hemorrhagic CVA

66
Q

3 most predictive findings to diagnose ischemic stroke

A

Facial paresis
Arm drift/weakness
Abnormal speech

67
Q

What is seen on CT scan for ischemic stroke

A

May be normal (may have early evidence of ischemia)

68
Q

What is seen on CT scan for hemorrhagic stroke

A

Blood seen where stroke is occuring

69
Q

BP control for hemorrhagicstroke

A

Risk of decreased cerebral perfusion if too low BP and increased bleeding if too high (keep it 140-160/190)

70
Q

BP control for ischemic stroke

A

Candidate for IV thrombolysis??
No (allow for permissive HTN–no intervention unless SBP is >220 mmHg or DBP >120)
Yes (target BP pressures are SBP <185 and DBP <110)

71
Q

Who are candidates for IV thrombolysis?

A

Onset of sxs<4.5 hrs before beginning of tx (or define as last time pt defined as being normal)
CT or MRI within 25 mins
Infusion should begin <60 min from time of arrival

72
Q

Benefits of IV thrombolysis

A

Restore blood floow and stop progression of brain tissue ischemia but risks of hemorrhage

73
Q

Classification of seizures

A

Primary (may present with clear cause)
Secondary (results from identifiable neuro condition or infection)
Post traumatic (may occur within first week after injury)

74
Q

What is status epilepticus?

A

Seizure for 5 min continuously OR

Multiple seizures without regaining baseline mental status in 30 min

75
Q

Management during course of seizure

A 
ABCs and maybe intubate
Prevent aspiration
Protect from bodily injury
2 IVs, CBX, CMP, tox screen, glucose
Maybe administer thiamine or glucose
76
Q

Management during seizure: known seizure disorder

A

Check anticonvulsant levels

77
Q

Management during seizure: eclamptic pts

A

Emergent obstetrician consult

78
Q

Management during seizure: first seizure

A

MRI preferred!!

EEG and LP in select pts

79
Q

Management during seizure: status epilepticus

A

Correct metabolic abnormalities and continuous EEG monitoring

80
Q

Meds for status epilepticus when 5-10 mins

A

IV lorazepam or diazepam
PLUS
IV fosphenytoin, phenytoin or levetiracetem

81
Q

Meds for refractory status epilepticus when <30 min

A 
IV midazolam (load with .2 mg and then infusion
OR IV propofol or Ketamine
OR 
IV phenobarbitol
Intubate, neuro ICU and EEG monitoring
82
Q

What to do for all pts with new seizure

A

CT or MRI indicated

83
Q

When can pts with new onset seizure be discharged with outpt follow-up?

A

Returned to baseline AND
Normal CT AND
Normal lab eval AND
No prolonged postictal period or seizure relate injury

84
Q

When can pts with established seizure disorders can be sent home?

A

Returned to baseline AND
Seizures have not recurred AND
Not acute abnormalities found
Follow up with neuro

85
Q

Precautions that should be given to pts with seizures

A

Swimming
Working with heights, hazardous tools
No driving until cleared

86
Q

Jefferson fracture

A

C1 (Atlas)
Caused by axial compression
Usually no spinal cord damage

87
Q

C2 (axis) fracture

A

Odontoid (dens)

Caused by forceful flexion or extension

88
Q

Hangman’s fracture

A

C2 fracture involving bilateral pedicles
Caused by hyperextension with compression
Can transect spinal cord
Usually instantaneous if going to die

89
Q

Burst fracture

A

Lower cervical vertebra
Caused by direct axial load
Fragments displaced in all directions, can enter spinal canal

90
Q

Complete spinal cord injury

A

Acute <1 day: absent reflexes, flaccid muscles, loss of sensation, priapism in men, urinary retention
1-3 days later: hyperreflexia, +babinksi, spasticity

91
Q

Incomplete spinal cord injury

A

Presentation depend on location of lesion (anterior cord syndrome, central cord syndrome, posterior cord syndrome, Brown Dequard)

92
Q

What is anterior (ventral) cord syndrome?

A

Anterior 2/3 of spinal cord due to cord infarct or disc herniation

93
Q

Loss seen in anterior (ventral) cord syndrome

A

Motor impairment, reflex changes, bilateral loss of pain and temp and bladder dysfunction

94
Q

What is preserved in anterior (ventral) cord syndrome?

A

Tactile, proprioception and vibratory sensations

95
Q

What is central cord syndrome?

A

Medial aspect of central cord (typically extension injury, spinal cord compression-spondylosis or slow growing lesion)

96
Q

Loss seen in central cord syndrome

A

Motor impairment in upper extremities more than lower
Variable sensory loss (light tough/pin prick/ temp)
Bladder dysfunction

97
Q

What is preserved in central cord syndrome?

A

Sacral sparing

98
Q

What is posterior (dorsal) cord syndrome?

A

Bilateral involvement of dorsal columns and corticospinal tracts (MS, tumors, subluxation)

99
Q

Loss seen in posterior (dorsal) cord syndrome

A

Motor Weakness
Hyperreflexia
Gait ataxia
Paresthesia

100
Q

What is preserved in posterior (dorsal) cord syndrome?

A

Bladder initially

101
Q

What is Brown Sequard?

A

Lateral hemisection, dorsal column unilaterally (penetrating injury and rarely tumors or disc herniation)

102
Q

Loss in Brown Sequard

A

ipsilateral motor paralysis and loss of proprioception and vibration

103
Q

What is preserved in Brown Sequard

A

Bladder function (good prognosis)

104
Q

What can result from a spinal cord injury?

A 
Neurogenic shock (systolic hypotension, bradycardia within hours)
More with cervical spins injuries
105
Q

Management for spinal trauma

A

Airway (palpate entire spine and paraspinals, priapism, abnormal breathing)
Nexus and Canadian C-spine rule (x-rays, CT, MRI)
Surgery vs halo vs collar

106
Q

Nexus criteria for spinal injureis

A 
Absence of posterior midline tenderness
Normal level of alertness
No evidence of intoxication
No abnormal neuro findings
No other painful distracting injuries
If all 5 are met then don't need imaging!!!
107
Q

Canadian C-Spine rule

A

Condition 1: perform x-rays when 65+, dangerous MOI and paresthesia in extremities
Condition 2: in pts without high risk factors assess for low risk factors that allow for safe assessment of neck ROM (simple MVA rear end, sitting in ED, ambulatory at any time, delayed onset of neck pain or midline pain, ROM to 45 degrees means no imaging needed)

108
Q

Imaging for disk herniation

A

MRI preferred over CT

Urgent is suspect spinal cord compression

109
Q

What might be seen with disk herniation?

A

Radiculopathy (dermatomal pain or numbess)

Myelopathy (weakness, loss of bladder or balance-consult neuro)

110
Q

What is cauda equina syndrome?

A

Neurosurgical emergency!!

Nerve compression below 1-2 interspace after termination of spinal cord

111
Q

Causes of cauda equina

A

Disc herniation, abscess, tumor, spinal stenosis, metastatic disease, infection, autoimmune

112
Q

Presentation of cauda equina

A

(lower motor neuron)
Leg weakness in multiple distributions (L3-S1)
Weak plantar flexion and loss of ankle reflex (S1-S2)
LBP with radiation to bilateral legs
Perineal sensory loss (S2-S4)

113
Q

Examples of perineal sensory loss

A

Saddle anesthesia (butt, perineal region, post/superior thighs)
Urinary incontinence with or without overflow incontinence
Decreased anal sphincter tone
Sexual dysfunction

114
Q

Management for cauda equina

A

Emergent MRI with contrast of lumbar and sacral spine (CT myelogram if can’t get for whole spine)
Administer dexamethasone 10 mg IV if suspicious
Consult

115
Q

What is Guillen Barre syndrome?

A

Acute onset of peripheral neuropathy (immune mediated)

Most common demyelination neuropathy

116
Q

Presentation of Guillen Barre syndrome

A

Progressive, starts distally ascending symmetric muscle weakness
Mild URI or gastroenteritis precedes onset of sxs by 1-3 wks

117
Q

PE for Guillen Barre syndrome

A 
Absent or depressed DTRs
Cranial nerve involvement
Difficulty walking/ paralysis
Severe respiratory weakness needing ventilation
Dysautonomia
No fever!!
118
Q

What is dysautonomia?

A 
Tachycardia/brady
Urinary retention
Alternating hypo/HTN
Loss of sweating
Arrhythmias
119
Q

How to diagnose Guillen Barre syndrome

A

Presentation
Elevated protein on CSF
EMG-NCS (electromypgram-nerve conduction study- usually on admit tho)

120
Q

Tx for Guillen Barre syndrome

A

Consult and admit to ICU
DVT prophylaxis
Monitor and maybe urinary cath
IVIG and plasmapheresis (usually done on admit and not in ED)

X Emergency Med Exam 2 (6 decks)

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