CNS Emergencies II Flashcards
What is increased intracranial pressure?
Abnormal increase in vol of any component (brain mostly, CSF or blood in constant space)
How might brain injury happen with increased intracranial pressure?
Brainstem compression (herniation) Reduction in cerebral perfusion pressure (CPP) which is needed to get O2 and nutrients to the brain
Management for increased intracranial pressure
Prompt recognition
Judicious use of invasive monitoring
Therapy aimed at reducing ICP and addressing cause
Presentation of ICP
HA, n/v Papilledema Unilateral or bilateral fixed pupil Loss of consciousness Decorticate or decerebrate posturing Cushings triad
What is Cushings triad?
Ominous finding
Bradycardia, HTN or respiratory depression
Max GCS for intubated pt
10
What does decorticate posturing suggest?
Destructive lesion in corticospinal tract from cortex to upper midbrain
What does decerebrate posturing suggest?
Damage to corticospinal tract at level of brainstem (pons or upper medulla)
Causes of intracranial HTN
TBI/intracranial hemorrhage CNS infection Ischemic stroke Neoplasm Vasculitis Hydrocephalus Hypertensive encephalopathy
Diagnostics that might be ordered with ICP
Type and cross CBC, BMP Osmolality Toxicology Blood alcohol level Glucose INR/PT/PTT CT/MRI (brain, C/T/L, spine)
What can referral to neurosurgery do for ICP?
Decompressive craniectomy
Ventriculostomy
Resuscitation for increased ICP
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
Other management for increased ICP
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
Things you might see with a skull fracture
AMS Cranial nerve or other neuro deficits Scalp lacerations of contusions Bony step off Periorbital or retroauricular ecchymosis
Types of skull fractures
Linear
Depressed
Basilar
What is a linear skull fracture?
Single fracture but majority have minimal or no clinical significance
Sxs of linear skull fracture
No neuro sxs usually
Only small amt get significant intracranial hemorrhage
If on temporal bone- can disturb vasculature and get bleeding
What to do if CT shows no underlying brain injury and no neuro deficit with linear skull fracture?
Observe in ED for 4-6 hrs and then discharge home with supervision (admit if suspicious for brain injury)
What is a depressed skull fracture?
Segment of skull is driven below level of adjacent skull
What to worry about with depressed skull fracture
Often involves injury to brain parenchyma
High risk of CNS infection, seizures and death
Can be closed or open
What to do with open depressed fractures
Examine but not probe them
Management for depressed skull fracture
Get CT, admit to neurosurgery (Td tetanus if needed, prophylactic abs and anticonvulsants)
What might occur with a basilar skull fracture?
Dural tear resulting in communication b/w subarachnoid space, paraspinal sinus and middle ear
Presentation of basilar skull fracture
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
Canadain head CT rule for basilar skull fractures
+Battle sign/racoon eyes, hemotympanum and otorrhea/rhinorrhea are predictive of significant injury
What to remember with basilar skull fracture
Can have CSF leak, infection or cranial nerve injury
Risk for intracranial hemorrhage
Can occur through temporal bone (epidural hematoma)
Management for basilar skull fracture
Admit for observation regardless and get neuro consult
Close monitoring
Penetrating injuries with skull fractures
Typically with significant brain injury and ICH
Consult neuro immediately and then give IV abx
Tangential skull fractures
Usually due to gun shot wound
Risk for ICH so get emergent CT
Imaging for skull fractures
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!!)
What is a concussion?
Trauma induced alteration in mental status that may or may not have loss of consciousness (direct blow with impulsive force to head)
Brain contusion
Areas of bruising with localized ischemia, edema and mass effect
Direct external contact force, acceleration, deceleration trauma
Possible MOI for closed head injury
Coup or contrecoup (hit forward and back
Do a neuro exam with mental status testing if think so
Who needs urgent neuroimaging and neuro consulting?
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
When to admit with closed head injury?
GCS<15 Abnormalities on head CT Seizures Underlying bleeding diathesis or oral anticoag Other neuro deficit Recurrent vomiting No person at home to monitor
When to send home with closed head injury
GCS of 15
Normal exam and CT of head
No predisposition to bleeding
Someone to monitor them
What is a diffuse axonal injury?
Shearing of white matter tracts from traumatic, sudden deceleration injury (blunt trauma) leadin to severe intracranial hemorrhage
Axon disruptions, swelling and cell death
Presentation of diffuse axonal injury
Variable
Can be associated with posttraumatic coma (frequent cause of persistent vegetative state)
Management of diffuse axonal injury
No surgery
CT scan to demonstrate blurring of gray to white matter margin, cerebral hemorrhage or cerebral edema
Types of cerebral hemorrhage
Intracranial hematoma which is external to brain parenchyma (epidural hematoma, subdural hematoma, subarachnoid hemorrhage/ bleeding into CSF) Intracerebral hemorrhage (lesions within brain substance)
What is an epidural hemotoma?
Acute collection of blood b/w skull and dura mater
Presentation of epidural hemotoma
Usually adolescents/young adults
Associated with skull fracture and trauma!! (middle meningeal artery)
Brief LOC, then lucid interval and then rapid clinical deterioration
CT for epidural hemotoma
Lens-shaped or lenticular (bioconvex shaped)
What is a subdural hemotoma?
Collection of VENOUS blood between dura mater and arachnoid (tears bridging veins)
Usually with brain atrophy (elderly or alcoholics)
Presentation of subdural hemotoma
Usually due to fall
Acute: sxs in 24-48 hrs after onset
Subacute: sxs 3-14 days after onset
Chronic>2 wks after onset
CT for subdural hemotoma
Crescent shape
Sxs of intracranial hematoma
Momentary LOC to coma HA Vomiting Drowsiness Confusion Aphasia Seizures Hemiparesis
Management for intracranial hematomas
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)
What is a subarachnoid hemorrhage?
Bleeding within the subarachnoid space
Can be traumatic or non-traumatic
Non traumatic causes of subarachnoid hemorrhage
Aneurysm, vascular malformations, cerebral venous thrombosis
**these are most cases (mortality pretty high)
Presentation of subarachnoid hemorrhage
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
Management for subarachnoid hemorrhage
CT before LP (if needed)
Neuro consult
Support
Interventional neuroradiologist (surgical clipping or endovascular coiling)
Complications of subarachnoid hemorrhage
Rebleeding Vasospasm and delayed cerebral ischemia Hydrocephalus Increased ICP!! Seizures Hyponatremia (if hypothalamic injury)
2nd most common cause of stroke
Intracerebral (intraparenchymal hemorrhage) after ischemic stroke being number 1
Initial goals of tx for intracerebral hemorrhage
Prevent hemorrhage extension
Prevent and manage ICP
Imaging for intracerebral hemorrhage
EMERGENT noncontrast CT!!
Can do MRI of brain for smaller lesions
Angiography (CTA or MRA) for vascular malformations and aneurysm
Causes of nontraumatic intracerebral hemorrhage
HTN (most common) Amyloid angiopathy Ruptured saccular aneurysm Vascular malformation Hemorrhagic infarction Bleeding disorders Brain tumor CNS infection Vasculitis Drugs (cocaine, amphetamines)
Presentation of intracerebral hemorrhage
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
What to remember with intracerebral hemorrhage
Neuro and medical emergency that can lead to permanent disability and death
Imaging for intracerebral hemorrhage
CT without contrast or MRI
Management of intracerebral hemorrhage
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
What is ischemic CVA?
Hypoperfusion
Thrombus formation in an artery leading to reduce blood flow resulting in localized hypoxic brain injury (Can be embolus)
Causes of ischemic CVA
Cardiac (a fib, valvular disease) Large artery (atherosclerosis, thrombus formation, embolism, arterial dissection) Small artery (HTN, DM, vasculitis)
Management for code stroke
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
When to use ASA wtih stroke
If CT shows non hemorrhagic CVA
3 most predictive findings to diagnose ischemic stroke
Facial paresis
Arm drift/weakness
Abnormal speech
What is seen on CT scan for ischemic stroke
May be normal (may have early evidence of ischemia)
What is seen on CT scan for hemorrhagic stroke
Blood seen where stroke is occuring
BP control for hemorrhagicstroke
Risk of decreased cerebral perfusion if too low BP and increased bleeding if too high (keep it 140-160/190)
BP control for ischemic stroke
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)
Who are candidates for IV thrombolysis?
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
Benefits of IV thrombolysis
Restore blood floow and stop progression of brain tissue ischemia but risks of hemorrhage
Classification of seizures
Primary (may present with clear cause)
Secondary (results from identifiable neuro condition or infection)
Post traumatic (may occur within first week after injury)
What is status epilepticus?
Seizure for 5 min continuously OR
Multiple seizures without regaining baseline mental status in 30 min
Management during course of seizure
ABCs and maybe intubate Prevent aspiration Protect from bodily injury 2 IVs, CBX, CMP, tox screen, glucose Maybe administer thiamine or glucose
Management during seizure: known seizure disorder
Check anticonvulsant levels
Management during seizure: eclamptic pts
Emergent obstetrician consult
Management during seizure: first seizure
MRI preferred!!
EEG and LP in select pts
Management during seizure: status epilepticus
Correct metabolic abnormalities and continuous EEG monitoring
Meds for status epilepticus when 5-10 mins
IV lorazepam or diazepam
PLUS
IV fosphenytoin, phenytoin or levetiracetem
Meds for refractory status epilepticus when <30 min
IV midazolam (load with .2 mg and then infusion OR IV propofol or Ketamine OR IV phenobarbitol Intubate, neuro ICU and EEG monitoring
What to do for all pts with new seizure
CT or MRI indicated
When can pts with new onset seizure be discharged with outpt follow-up?
Returned to baseline AND
Normal CT AND
Normal lab eval AND
No prolonged postictal period or seizure relate injury
When can pts with established seizure disorders can be sent home?
Returned to baseline AND
Seizures have not recurred AND
Not acute abnormalities found
Follow up with neuro
Precautions that should be given to pts with seizures
Swimming
Working with heights, hazardous tools
No driving until cleared
Jefferson fracture
C1 (Atlas)
Caused by axial compression
Usually no spinal cord damage
C2 (axis) fracture
Odontoid (dens)
Caused by forceful flexion or extension
Hangman’s fracture
C2 fracture involving bilateral pedicles
Caused by hyperextension with compression
Can transect spinal cord
Usually instantaneous if going to die
Burst fracture
Lower cervical vertebra
Caused by direct axial load
Fragments displaced in all directions, can enter spinal canal
Complete spinal cord injury
Acute <1 day: absent reflexes, flaccid muscles, loss of sensation, priapism in men, urinary retention
1-3 days later: hyperreflexia, +babinksi, spasticity
Incomplete spinal cord injury
Presentation depend on location of lesion (anterior cord syndrome, central cord syndrome, posterior cord syndrome, Brown Dequard)
What is anterior (ventral) cord syndrome?
Anterior 2/3 of spinal cord due to cord infarct or disc herniation
Loss seen in anterior (ventral) cord syndrome
Motor impairment, reflex changes, bilateral loss of pain and temp and bladder dysfunction
What is preserved in anterior (ventral) cord syndrome?
Tactile, proprioception and vibratory sensations
What is central cord syndrome?
Medial aspect of central cord (typically extension injury, spinal cord compression-spondylosis or slow growing lesion)
Loss seen in central cord syndrome
Motor impairment in upper extremities more than lower
Variable sensory loss (light tough/pin prick/ temp)
Bladder dysfunction
What is preserved in central cord syndrome?
Sacral sparing
What is posterior (dorsal) cord syndrome?
Bilateral involvement of dorsal columns and corticospinal tracts (MS, tumors, subluxation)
Loss seen in posterior (dorsal) cord syndrome
Motor Weakness
Hyperreflexia
Gait ataxia
Paresthesia
What is preserved in posterior (dorsal) cord syndrome?
Bladder initially
What is Brown Sequard?
Lateral hemisection, dorsal column unilaterally (penetrating injury and rarely tumors or disc herniation)
Loss in Brown Sequard
ipsilateral motor paralysis and loss of proprioception and vibration
What is preserved in Brown Sequard
Bladder function (good prognosis)
What can result from a spinal cord injury?
Neurogenic shock (systolic hypotension, bradycardia within hours) More with cervical spins injuries
Management for spinal trauma
Airway (palpate entire spine and paraspinals, priapism, abnormal breathing)
Nexus and Canadian C-spine rule (x-rays, CT, MRI)
Surgery vs halo vs collar
Nexus criteria for spinal injureis
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!!!
Canadian C-Spine rule
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)
Imaging for disk herniation
MRI preferred over CT
Urgent is suspect spinal cord compression
What might be seen with disk herniation?
Radiculopathy (dermatomal pain or numbess)
Myelopathy (weakness, loss of bladder or balance-consult neuro)
What is cauda equina syndrome?
Neurosurgical emergency!!
Nerve compression below 1-2 interspace after termination of spinal cord
Causes of cauda equina
Disc herniation, abscess, tumor, spinal stenosis, metastatic disease, infection, autoimmune
Presentation of cauda equina
(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)
Examples of perineal sensory loss
Saddle anesthesia (butt, perineal region, post/superior thighs)
Urinary incontinence with or without overflow incontinence
Decreased anal sphincter tone
Sexual dysfunction
Management for cauda equina
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
What is Guillen Barre syndrome?
Acute onset of peripheral neuropathy (immune mediated)
Most common demyelination neuropathy
Presentation of Guillen Barre syndrome
Progressive, starts distally ascending symmetric muscle weakness
Mild URI or gastroenteritis precedes onset of sxs by 1-3 wks
PE for Guillen Barre syndrome
Absent or depressed DTRs Cranial nerve involvement Difficulty walking/ paralysis Severe respiratory weakness needing ventilation Dysautonomia No fever!!
What is dysautonomia?
Tachycardia/brady Urinary retention Alternating hypo/HTN Loss of sweating Arrhythmias
How to diagnose Guillen Barre syndrome
Presentation
Elevated protein on CSF
EMG-NCS (electromypgram-nerve conduction study- usually on admit tho)
Tx for Guillen Barre syndrome
Consult and admit to ICU
DVT prophylaxis
Monitor and maybe urinary cath
IVIG and plasmapheresis (usually done on admit and not in ED)
