EM Block I Flashcards
1
Q
Define coma
A
is characterized by failure of both arousal and content functions of consciousness.
2
Q
Define delirium
A
Delirium refers to an acute state of fluctuating attention and change in cognition
Can happen over minutes
3
Q
Define Dementia
A
Dementia is a chronic disorder of deteriorating cognition.
4
Q
What are 5 DDx for “acute brain failure”
A
Primary Intracranial Dz Systemic Dz Exogenous toxins Drug Withdrawal Major Trauma or Surgery
5
Q
What are the hallmarks of delirium
A
Disordered attention and acute fluctuations
6
Q
What is the W/u for Delirium
A
Serum Electrolytes Hepatic and Renal Studies UA/ HcG CBC CXR \+/- CT (if stroke or bleed) \+/- LP
7
Q
Define Non convulsive status epilepticus
A
May persist for hours or even months after a seizure. There is no post ictal state and they remain altered.
So if you have a patient with a history of seizures or epilepsy that does not wake back up from a seizure, this should raise your suspicion and you must act.
An electroencephalography (EEG) are required for recognition!!! (More on this in the seizure lecture…)
8
Q
What is the standard of care approach to delirium
A
Nonpharmacologic approaches to delirium are the standard of care.
9
Q
Do we use physical restraints on the elderly
A
NO, we give them drugs!
10
Q
What is the initial Rx of choice for acute delirium
A
Haloperidol is a frequent initial choice at a dose of 5 to 10 milligrams PO, IM, or IV, with reduced dosing of 1 to 2 milligrams in older adults.
Avoid giving Benzos to the elderly
In younger Pts, B52!
Benadryl 50mg,
Haldol 5mg
Ativan 2mg
11
Q
If giving B52, what must you monitor for
A
ETCO2
12
Q
When do you admit a pt with delirium
A
Admit the patient with delirium to the hospital for further treatment and additional diagnostic testing, unless a readily reversible cause for the acute mental status change is discovered and treatment initiated.
Consider resources in the home or healthcare facility, and the patient’s safety.
If you feel that the patient may not have great resource listed above, then admit.
13
Q
If a pt presents with abrupt onset of a sentinel event with underlying dementia
What should you think
A
The abrupt onset of symptoms or rapidly progressive symptoms should prompt a search for other diagnoses, including delirium.
14
Q
What is the general W/u for dementia
A
CBC CMP UA Thyroid Function Tests CXR \+/- CT
Serum B12
Serum Syphillis
HIV test
15
Q
what are three conditions that can cause rapid cognitive decline
A
urinary tract infection, congestive heart failure, and hypothyroidism
… are just a few of the conditions that may cause a patient with mild dementia to show rapid decline!
16
Q
When should you ever use antipsychotics in dementia pts
A
Antipsychotics, black box warning against use for behavioral and psychiatric symptoms of dementia
Reserve consideration of antipsychotic use for patients with significant risk of harm to self and others.
17
Q
How is vascular dementia treated
A
Treatment of vascular dementia is limited to treatment of risk factors, including hypertension, tobacco use, glucose control and cholesterol.
18
Q
If you see excessively large ventricles on Head CT mean
A
Normal pressure hydrocephalus
19
Q
What is Uncal Herniation
A
medial temporal lobe shifts to compress the upper brainstem, which results in progressive drowsiness followed by unresponsiveness.
20
Q
A pt presents iwth ipsilateral pupil sluggish that eventually becomes dilated and non reactive
With ipsilateral hemiparesis
Think
A
Uncal Herniation
21
Q
How does a central herniation present
A
A mid line shift without herniation
With a Progressive loss of consciousness, loss of brainstem reflexes, decorticate posturing, and irregular respiration.
22
Q
How do you determine CPP
A
Cerebral perfusion pressure is equal to the mean arterial pressure minus the ICP
(cerebral perfusion pressure = mean arterial pressure – ICP)
23
Q
In a hemispheric hemorrhage where do the eyes deviate
A
Hemispheric hemorrhage and midline shift may have decreased muscle tone on the side of the hemiparesis.
(Like a stroke)
The eyes may conjugately deviate toward the side of the hemorrhage.
24
Q
What is the major DDx finding in toxic metabolic coma
A
Should be no focal or unilateral neurological deficits on exam.
-No hemiparesis
= Pupils may be small but reactive because it mainly preserved in toxic-metabolic comas.
25
A pt presents with small but reactive pupils and in a coma with resp depression.. think
Narc OD
26
Define Cushings triad
Brady HR
Irregular RR
Widened Pulse pressure ( HOTN)
27
If a mass presses on the supratentorial space of the brain what happens
Coma caused by lesions of the hemispheres, or supratentorial (above the tentorium) masses, may present with progressive hemiparesis or asymmetric muscle tone and reflexes.
Ie: Uncal herniation
S/S Cushings reflex
28
If a pt presents with dual pinpoint size pupils
Think herniation where
pontine hemorrhage, which may present with the unique signs of pinpoint-sized pupils.
A Infratentorial hemorrhages
Swelling in the posterior fossa
29
How can you rule out pseudo coma
Avoidance of gaze by the pt
30
What is the imaging of choice for brain hem
Non-Contrasted Head CT is the neuroimaging procedure of choice.
31
If subarachnoid hemorrhage or CNS infection is suspected but the CT in NML what is the next step
LP
Or if suspected basalir artery thrombosis get a MRI and look for a hyper dense basilar artery
32
What is the time frame for NSE
If the motor activity of the seizure stops and the patient does not awaken within 30 minutes, then consider nonconvulsive status epilepticus.
Obtain neurologic consultation and electroencephalography.
33
What are the first steps in treating ICP
HOB 30*
HYPERTONIC OR MANNITOL
IF there is a tumor? THen Dexamethasone
(only from consult instructions)
34
What are the downstream effects of DKA
HYPERGL
Prerenal azotemia
Ketone Formations
Wide Anion Gap Met acidosis
35
What are the 8 “I”s of DKA
```
infection
Infarction (MI)
Infraction (noncompliance)
Infant
Ischemic (CVA)
Illegal drugs
Iatrogenic
Idiopathic
```
36
What causes N/V in DKA
High acidity causes the release of prostaglandins which lead to N/V and Abdominal PAIN
37
What is the better menearles of AMS in DKA, osmolality or ph or glucose?
OSM
38
What is the W/u for DKA
Bed side gl
```
VBG (measure pH)
CMP
CBC
Anion Gap
ABG
```
39
Which is the better marker for determining severity of DKA
Biacrab ?
Or glucose levels?
Bi-carb
40
What is the order of tx in DKA
1. Volume first and foremost
2. Correction of K+ deficits
3. Insulin administration
41
What is the bolus rate for NS in DKA
20ml/kg/hr
42
in DKA, once the glucose reaches 250 what must be changed in the Tx
Switch to 5% dextrose
43
How is fluid managed in the DKA pt
20ml/kg/hr
First 2L / 0-2hours
The next 2L/ 2-6 hrs
Additional 2L/ 6-12 hours
44
What is the most severe electrolyte abNML in DKA
Rapid development of severe hypokalemia is potentially the most life-threatening electrolyte derangement during the treatment of DKA (not glucose management)
45
When should K be withheld in DKA
| When should Insulin be withheld in DKA
IF the K is below 3.3 hold insulin and give K
If the K is above 5.2 then hold K and give insulin
46
What is the definition of DKA resolution
Glucose <200 mg/dL & 2 of the following:
- Bicarbonate level >15 mEq/L
- Venous pH >7.3
- Normal calculated anion gap (Closed Gap)
47
WHere do all DKA pts go
ICU
48
A headache that occurs while execution, heavy lifting, vomitting, sneezing, and straining
Think?
SAH or arterial dissection of the carotid or vertebrobasilar circulation- ALWAYS!!!
49
A headache that is associated with valsalva should make you think /?
possible intracranial abnormality such as mass/tumor.
50
Do migraines increase or decrease with age
Decreases with age
51
Does absence of fever rule out infection with a headache
NO!
52
What is meningismus
Pain with flexion of the neck
53
What family history finding is important in headache W/u
Known aneurysm or sudden death in first-degree relatives with intracranial aneurysm (3-5 times higher than in those without a family history)- so ask about FMH!!
PMH/FMH of autosomal dominant polycystic kidney disease also increases the risk for intracranial aneurysm
54
What is the abnormal number for glaucoma
>21
55
When doing a W/u for a HA
What is the imaging to look at arterial dz
MRA
| CTA right away
56
What are the Dx and Tx uses of LP
Dx: Meningitis, SAH, intracranial hypotension, carcinomatous meningitis
Tx: Pseudotumor cerebri
(However, we do not routinely just draw CSF off of people if we can weight manage or medically manage them.)
Ideally, perform the LP in the lateral decubitus position to allow for the accurate measurement of opening pressure
57
When is it safe to do a LP without imaging
Safe to proceed with LP without prior imaging if…
- No history of immunosuppression
(HIV, AIDS, CX, DMARDS)
-Normal sensorium
(AWOX4)
-No focal neurologic deficits
58
Should ABX be delayed for the results of an LP
NO!
```
If: Deteriorating or altered level of consciousness
(particularly a GCS ≤ 11)
Brainstem signs
(including pupillary changes, posturing, or irregular respirations)
Focal neurologic deficit
Recent seizure
Preexisting neurologic disorder
Immunocompromised state
```
Then do not delay ABX initiation
59
What is the classic triad of Meningitis
Definition:
Headache + classic triad
(fever, altered mentation & neck stiffness)
60
What is the common cause of Bac Meningitis in the military
N. meningitis
61
Should you ever withhold empiric ABX in meningitis
NO
Never withhold empiric antibiotic therapy in order to collect fluid sample
62
What are the C/I for LP
Do not perform if there is coagulopathy or use extreme caution
-Platelet <20,000/µL or INR ≥ 1.5
63
When should you perform a Head Ct before LP in Bac Meningitidis
Complete a Head Ct before LP if you have concerns for possible herniation.
Perform LP as soon as possible to secure the diagnosis (if safe… if not, give empiric AB’s and move on)
64
What are the empiric ABX for 18-49yo in Bac Meningitis
18 – 49 yo
-Ceftriaxone 2gm IV PLUS -Vancomycin 15mg/kg IV
Covers S. pneumoniae and N. meningiditis
65
What is the empiric ABX for BAc Meningitis in pts older than 50
Same ABX but add Ampicillin
66
When shoudl dexamethasone be used in Bac meniginits
Dexamethasone before or with 1st dose of antibiotics to reduce inflammation
Before or with reduces hearing loss and neurological sequelae (neurological deficits).
67
What is the most common cause of SAH
Ruptured Aneurysm
68
What is the 1st step in evaluation of SAH
Non Con CT
69
What is xanthocromia
yellow appearance of the CSF due to the enzymatic breakdown of blood by bilirubin
Which means a SAH
70
When shoudl patients always receive a CT with a SAH or ICH
Elderly, chronic alcohol and substance abuse, and those on antiplatelets & anticoagulants (No trauma)
Patients receiving antiplatelets and anticoagulants should be screened using head CT, regardless of symptoms!!
If they say they have a headache and they are on the above medications, you will scan!!
71
Acute headache + vestibular symptoms (vertigo or ataxia)—> consider…
Cerebellar hem
72
What is the study of choice for detecting Brian tumors
MRI with and without gadolinium (contrast) is the study of choice for detecting brain tumors
73
A periparturm woman presents with recent surgical history and new headache onset
Think
Central Venous Thrombosis
74
What is the Def Dx for Central Venous thrombosis made with
In the presence of abnormal imaging (NCHCT), focal neurologic deficit (Numbness, tingling, weakness), or AMS, the definitive diagnosis of cerebral venous thrombosis made with magnetic resonance venography.
75
A pt with an elevated LP with out suspicion of meningitis think ?
Central Venous Thrombosis
Prompt MR venography and consult neuro
76
50 yo female presents with fatigue, fever, Jaw claudiacaition and Transient vision loss
Elevated ESR.
Think ?
Giant Cell Temp Arteritis
Also check IOP to exclude glaucoma
77
How do you confirm temp arteritis
Bx
78
What is the most common non life threatening headache in the ED
Migraine
79
What is the treatment for migraines in the ED
In the ED, most have failed abortive therapy (triptans)
& require rescue therapy and they need your help.
Initial treatment:
- IV hydration
- IV treatment with NSAIDs and dopamine receptor antagonist (droperidol or metoclopramide)
Combine with antihistamine (diphenhydramine 25 - 50 mg IV)
— Treats akathisias from antiemetics
Dexamethasone for D/c home
80
What drugs are contraindicated for pregnancy migraines
Triptans, Ergotamines, and Combo agents with caffeine’s and isomtheptene
81
Idiopathic intracranial hypertension is most common to what demographic
Most common to obese women between 20-44 years old
82
34 year old obese female presents with HA, visual obsucruations, back pain, and pulsátiles tinnitus
Think what major HA cause that you CAN NOT MISS
Idiopathic intracranial hypertension
83
If the pt has no papilledema or Abducens nerve palsy, what three findings do you need to Dx Idiopathinc Intracranial hypertension
dx without papilledema can be made if at least 3 of the following neuroimaging findings are present:
- Empty sella
- Flattening of the posterior aspect of the globe
- Distention of the perioptic subarachnoid space
- Transverse venous sinus stenosis
84
What is necessary to make the Dx for Idiopathic intracranial HTN
LP!
Target pressure of 15 - 20cm H2O
In general, removal of 1mL of CSF will ↓ CSF pressure by ~1cm H2O
1 for 1
85
What is the treatment for idiopathic intracranial HTN
Acetazolamide can lower ICP and decrease the symptoms
— Treatment is started at 250 to 500mg BID
Treatment is focused on preservation of vision
86
What is the treatment for a cluster headache
Treatment: First Line: 100% oxygen at 12 L/min for 15 minutes through a NRB facemask
- Sumatriptan (6 mg SC) can also be used
87
How does Epi reduce further mediator releases in anaphylaxis
B2 stimulation
88
How does B blockers effect anaphylaxis
Concurrent use of β-blockers is a risk factor for severe prolonged anaphylaxis-
Glucagon* is the reversal agent for Beta Blockers.
89
How does glucagon effect B receptors
*Glucagon activates adenyl cyclase and exerts an inotropic and chronotropic effect by a pathway that bypasses the b receptors.
90
What are the components of Hymenoptera venom
Histamine
Melittin- cause degranulation of basophils and mast cells
Phospholipase and hyaluronidase
91
What is the most common response to a Hymenoptera sting?
is a transient local reaction.
Localized itching, pain, erythema, and swelling are common.
92
What is the diff between brown recluse and black widows
Black widows are painful!
93
What is the cause of death within the first hour from Hymenoptera stings
Fatalities that occur within the first hour after the sting usually result from airway obstruction or hypotension.
In general, the shorter the interval between the sting and the onset of symptoms, the more severe is the reaction!!
94
What is the treatment for Hymenoptera stings
Immediate removal
Pain and nsaids
Elevation of the limb
+/- corticosteroids
95
What is the Tx for a Scorpion sting
Anti venom and send them up stairs
96
What is the mainstay of therapy for snake bites
Anti venom
97
What is the anti venom used in the US
Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) is used in the United States.
98
Define SZR
Temp abnormality in muscle tone and movements, behaviors, sensations or states of awareness
99
Define status epilepticus
Status epilepticus-
| seizure activity for ≥5 min or ≥2 seizures without regaining consciousness between seizures
100
Define refractory status epileptic-us
Refractory status epilepticus- persistent seizure activity despite the IV administration of adequate amounts of 2 antiepileptic agents!
101
Define Generalized SZR
Nearly simultaneous activation of the entire cerebral cortex
Begins with abrupt loss of consciousness!
LOC may be the only clinical manifestation of the seizure
Variety of motor manifestations including Tonic Clonic or jerking rythmatic movements
102
Define Generalized Absence SZR
Very brief, generally lasting only a few seconds
Sudden altered consciousness but no change in postural tone
Appear confused, detached, or withdrawn, and current activity ceases
May stare or have twitching of the eyelids
May not respond to voice or to other stimulation
May exhibit involuntary movements or lose continence
103
Define partial focal SZR
Electrical discharges beginning in a localized region of the cerebral cortex
May remain localized or may spread to involve nearby cortical regions or the entire cortex
More likely to be secondary to a localized structural lesion of the brain
104
Define Partial Focal Simple SZR
Seizure remains localized
Consciousness and mentation are not affected
Possible to deduce the likely location of the initial cortical discharge from the clinical features at the onset of the attack
Tonic/clonic movements limited to one extremity —>motor cortex focus
Visual symptoms—> occipital focus
Olfactory or gustatory hallucinations—> medial temporal lobe focus
Secondary generalization: sensory phenomena (aka auras) are often the initial symptoms of attacks that then become more widespread
105
Define Partial Focal Complex SZR
Seizures in which consciousness or mentation is affected
Often caused by a focal discharge originating in the temporal lobe
(aka temporal lobe seizures)
Commonly misdiagnosed as psychiatric problems because symptoms can be so bizarre
Previously referred to as psychomotor seizures
106
What is the number one most likely cause of SZR
#1 missed doses of antiepileptic medications
#2 Recent alterations in medication
```
Sleep deprivation
Increased strenuous activity
Infection
Electrolyte disturbances
Alcohol or substance use or withdrawal
```
107
Persistent, severe, or sudden HA with seizure, suggest intracranial pathology.
What should you do
Scan ‘em with Non Contrast head Ct (Screening)
108
What is the 1st step in AMS
POC gl
109
Define Todd’s paralysis
Todd's paralysis: transient focal deficit (usually unilateral) following a simple or complex focal seizure.
- Stroke mimic!!!
- Should resolve within 48 hours
110
What is the lab w.u for SZR
Glucose 1st!
Med Hx/ Rx Hx
BMP, Lactate, Calcium, mag, hCG, Tox/drug Screen.
111
when should you get a LP for a SZR
Febrile
Immunocompromised
SAH is suspected & the noncontrast head CT is normal
112
When should you get a CT for a SZR
First-ever seizure or a change in established seizure- r/o structural lesion with a non contrasted head CT!
Non Contrasted CT of the C spine if suspicion of head or neck trauma (always treat head and C spine as a unit. Scan one, scan both!)
113
When should you get an EEG in the ED for a SZR
Emergent EEG can be considered in the evaluation of:
Persistent, unexplained AMS to evaluate for nonconvulsive status epilepticus, subtle status epilepticus, paroxysmal attack when a seizure is suspected, or ongoing status epilepticus after chemical paralysis for intubation
114
What is the MC Cause of SZR
Many occur because of failure to take anticonvulsant med as prescribed!! MC!
115
Is phenytoin compatible with glucose containing solutions?
NO! Use NS
116
Steps to treat Status epilepticus
Call Neuro And arrange for EEG
Order gl and BMP/CMP
Lactate
+/- hCG, TOX screen and Rx levels
Treat hyperthermia with passive cooling
Place Urinary Cath and insert NG tube
If suspected toxin then GI decon with NG tube, activated charcoal or irrigation
If suspected meningitis the enteric ABX
117
What is the initial Rx for Status epilepticus
IV lorazepam
1-2 doses
```
And if needed:
phenytoin
Fosphenytoin
Levietiracetam
Valproate
```
118
What is the treatment approach to Status Epilepticus that is refractory
Refractory: Persistent seizure activity despite two antiepileptic agents and >2 rounds of Benzos!
Usually exceeds 60 min
Iv Midazolam or Proprofol or Phenobarbital
DEF NEED TO INTUBTAE, ICU ADMIN, and CONTINOUS EEG
119
How does mag reduce eclampsia SZR
The mechanism of action of magnesium sulfate is thought to trigger cerebral vasodilation,!!
thus reducing ischemia generated by cerebral vasospasm during an eclamptic event.
The substance also acts competitively in blocking the entry of calcium into synaptic endings, thereby altering neuromuscular transmission
120
Define SIRS criterion
Fever greater than 38.3 or hypothermia below 36*
Pulse greater than 90
Tachypnea greater than 20
Leukocytes greater than 12,000 or less than 4,000
121
What are the criterion for sepsis
Documented or suspected infection
```
With fever Or hypothermia
Pulse greater than 90
Tachypnea
AMS
Signif edema
And hyperglycemia without DM
+ HOTN
Oliguria
Elevated Cr
INR>1.5
Ileus
Hyperlactermia >4
```
122
What is qSOFA
```
Criteria include:
Altered mental status
Respiratory rate ≥22
Systolic BP ≤100
A score ≥2 indicates a high risk for poor outcomes
```
For sepsis
123
What is the most extreme outcome of sepsis
DIC and death
124
How does acute kidney injury present
Acute kidney injury can present with azotemia, oliguria, or anuria
125
If you see marked elevations of transaminases or bilirubin, consider …
Septic shock due to biliary source of infection. (G-bag)
126
What is the most common manifestation in the GI in sepsis
Ileus!
127
What is the common blood loss in GI in sepsis
Major blood loss secondary to UGI bleeding is rare in septic pts
Minor GI blood loss within 24 hours of developing severe sepsis can result from painless erosions in the mucosal layer of the stomach or duodenum (stress gastritis)
128
What are the metabolic presentations of Sepsis
Elevated Lactate
Hyperglycemia
And/or Hypoglycemia
129
A pt with a SBP less than 90 after an initial fluid bolus, with an evidence of EOD
Think
Septic Shock
130
What is the common W/u for Sepsis
```
CBC with platelet count
Electrolytes
(including calcium and glucose)
Renal function panel
Lactic acid level
Liver function panel
Urinalysis
```
131
Any on that comes in with sepsis, what W/u do you need to do for blood
Type and screen and type and cross for blood
Order a coug panel as well
132
What is the tx approach to sepsis
Early recognition (vital signs, ABC’s)
Early infection control (AB’s)
Early reversal of hemodynamic compromise (fluids, pressors)
133
Sepsis resus is based on what 5 criteria
1. ABC’s
2. Administering fluids! Get the body ready!!
3. Adding adjunct therapies including vasopressors based on the conditions, +/-
4. Infection Control (AB’s, surgery or identification of infectious etiology if any)
5. Frequently assessing response! Is what you are doing, working, if not, now what?
134
What is the 1st best choice for pressors in sepsis
NE
2nd line Vasopressin
135
What is the most important reason to get a CT in Stroke Pts
Differentiate between ischemic and hemorrhagic stroke syndromes
136
What is the most common cause of TIA
Thrombotic stroke
137
What is the important baseline question in strokes
Last time seen normal
138
what are the three criteria to Cincinnati stroke scale
facial droop
Arm drift
Speech
139
A woman presents with generalize weakness and dizzyness
| Think a-classical presentation for…
STROKE!
140
The basal artery mostly feeds the..
Cerebellum
Problems here effect balance, coordination, taxia, and gait
141
Todds paralysis is a DDX for
Stroke! Mimicer!
142
What is the vessel most commonly involved in strokes
Middle cerebral artery
143
How does a MCA stroke typically Present
Typically presents with hemiparesis, facial plegia, and sensory loss contralateral to the affected cortex
144
If you see ataxia, nystagmus, AMS and vertigo
Think stroke where ?
Posterior cerebral artery infarction
145
A patient presents with unilateral limb weakness, dizziness, dysarthria, diploplia, and HA
Think Stoke where?
Basically Artery Infarct
146
What is the W/.u for a cerebellar infarct
if the initial noncontrasted head CT is unremarkable and the suspicion is very high, obtain an emergent diffusion-weighted MRI when this diagnosis is suspected.
147
What demographic does Carotid & Vertebral Artery Dissection effect most
young and Middle Aged pt
148
What are the presenting s/y for carotid/ .vertebral artery dissection
Unilateral fronto HA
Pulsatile, eye miosis, and ptosis
Partial horners syndrome with
149
What is the W/u of new onset HA or neck pain what do we do next
Image neck vessels then CT angiogram
150
How does a vertebral artery dissection typicall present
Dizzyness, vertigo, neck pain, HA In the occipital region
151
What is the Image of Choice for Carotid and Vertebral artery dissection
CTA or MRA
152
What are two methods of screening for delerium
Delirium triage screen and the confusion assessment method
153
How do pts with vascular dementia present
Patients with vascular dementia often show similar neurocognitive symptoms but may have chronic neurologic physical deficits from prior cerebrovascular accidents.
154
If a pt presents “wet and wobbly” with urinary incontinente and gait disturbance
Think
Normal pressure hydrocephalus
| Dementia
155
What kind of progression suggest vascular dementia
A fluctuating, stepped course suggests vascular dementia.
156
What is the motor portion of the GCS
```
6- follow commands
5- localizes pain
4- withdrawals from pain
3- flexion
2- extension
1 -none
```
157
What is the verbal portion of the GCS
```
5- A/O
4- Confused
3- Innapropartie words
2- incomprehension
1- none
```
158
What is the eye portion of the GCS
4- spont
3- to command
2- to pain
1- none
159
If the only finding on CT is a hyperdence basilar artery
Think
Suspect basilar artery thrombosis in a comatose patient with “normal” head CT, in which the only finding may be a hyperdense basilar artery.
MRI or cerebral angiography is needed to make the diagnosis of basilar artery thrombosis.
160
What is the time frame to Tx stroke
Evaluate & decide treatment within 60 min (door to needle time) of the patient's arrival in an ED
161
When should a CT be done for Stroke
Obtain emergency non-contrast enhanced CT
| Imaging done in ≤ 20 min of ED arrival
162
What is the only imaging necessary prior to giving rTPa
Non con Ct
163
If a pt is not a candidate for thrombolytics
Which is the treatment for Ischemic Stroke
```
If patient NOT a candidate for thrombolytics or reperfusion
- Permissive hypertension
-No attempts to lower BP unless
SBP is >220 mmHg or
Diastolic is >120 mmHg
```
Or condition requiring acute BP lowering
Reduce BP by 10-15% over the first 24hrs
164
What is the HTN goal for pts with ischemic stroke that meet the criteria for reprofusion
If a patient is a candidate for reperfusion
—Maintain BP <185/110
If the target BP cannot be met—>no longer a candidate for rtPA therapy
>>permissive hypertension is allowed for perfusion of surrounding tissue.
165
What are the HTN drugs used to lower BP before admin of rTPA
Labetalol or nicardipine
166
When should asprin be used in the Tx of ischemic stroke
Current AHA/ASA guidelines recommend aspirin within 24 to 48 hours after stroke onset unless thrombolytics have been given within the last 24 hrs.
167
What stroke scale score is commonly used as one of the criteria for rTPA admin
Between 4-22
168
What is the inclusion exclusion criteria for rTPA in ischemic stroke
inclusion: Dx of Ischemic stroke
Onset less than 3hrs
Age older than 18
Exclusion:
Sig Head Trauma, Bleeding, Heparin within 48hours, high INR, low platelets, High Blood pressure, Using anticlotting agents, Low gl, Multilobular infarctions
169
WHat is the W/u after admin of thrombolytics in strokes
Perform BP & neuro checks q 15 min for 2 hrs after starting the infusion
Do not give anticoagulants or antiplatelet agents in the initial 24 hrs following treatment
Admit patients to a specialized stroke unit or an ICU familiar with the use of thrombolytic drugs and neurologic monitoring
170
Are pts with MCA strokes good candidates for rTPA
Patients with a massive middle cerebral artery-not candidates for thrombolytic therapy
80% mortality rate
May be candidates for decompressive surgery
171
What is the ABCD2 score
Age greater than 60
Blood pressure 140/90
Clinical Features
Duration
Diabetes
172
What is the tx approach to TIA
Aspirin plus Dipyridamole
+/- Clopidogrel
Decoagulate
173
What is the most common cause of ischemic stroke in children
Sickle cell Dz
174
Can you used rTPA in pregnancy
rtPA does not cross the placenta so you can use IV rTPA
ED treatment of stroke in pregnant women should ideally involve early consultation with obstetricians, stroke neurologists, and neonatologists
