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IPAP > EMED Block 2 > Flashcards

EMED Block 2 Flashcards

1
Q

GCS for comatose, need for intubation and normal?

Define AMS

A

3- comatose
8 or less- intubate
15- normal

Umbrella term for delirium, dementia and coma or any change in mental status

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2
Q

Elderly PT w/ AMS is usually due to one of what 4 things?

What are the 5 contents of consciousness

A

Pneumonia/sepsis
UTI
Skin infection
Stroke

Reasoning
Language
Emotions
Self-awareness
Spatial relationship integration
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3
Q

Define Delirium

Define Dementia

Define Coma

A

D/o of consciousness affecting arousal, wakefulness or basic alerting- flickering light, who’s home?

Failure of content portion of consciousness w/ preserved alertness- lights on, nobody home

Failure of both arousal and content functions- lights off, nobody home

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4
Q

AMS Slide 8

A

Table

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5
Q

Define Mental Status

How is this usually tested?

A

Clinical state of emotional/intellectual function

Informal- person place time/season, current event

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6
Q

? is a transient d/o w/ impaired attention/cognition*

How will PTs present

A

Delirium

Difficulty focusing, shifting or sustaining attention
Confusion may fluctuate

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7
Q

How long does it take for delirium to develop?

What are the clinical features of this?

A

Hrs to days

Inc daytime somnolence
Agitation/sun-downing
HTN Asterixis Tremor Sweating

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8
Q

If delirium PT has hallucinations they are usually ? type

How is delirium D

A

Visual

Hx and PE
Primarily- Hx from caregiver, family, spouse

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9
Q

How can you tell the difference between depression and delirium?

What two Dxs have to be r/o when working up suspected delirium case

A 
Delirium= rapid fluctuation
Depression= absent fluctuation, oriented, able to perform commands

Non-convulsive status epilepticus
Complex partial status epilepticus

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10
Q

What are 5 classes of issues that can induce acquired delirium

How are PTs w/ delirium Tx

What step is taken if a certain Tx step is done?

A 
Metabolic/thyroid
Drugs
Infection
Neurologic
Cariopulmonary

Haloperidol 5-10mg PO/IV/IM
Benzos 0.5-2mg PO/IV/IM

Co2 Capnography

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11
Q

When would delirium PTs NOT be admitted

What are the two largest categories of dementia

A

Hypoglycemic
Uroseptic
Readily reversible agents

Idiopathic- Alzheimers
Vascular- multiple infarcts

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12
Q

How does dementia onset?

How do PTs w/ dementia present

A

Slowly w/ insidious Sxs

Hallucinations
Repetitive behaviors
Delusion/Depression

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13
Q

What is the characteristic onset of dementia associated w/ Alzheimers?

What are the 3 stages of dementia?

A

Impaired memory/orientation w/ preservation of motor/speech disability

Early: memory loss of names/items
Mid: early + reading, dec social function, loss of direction
Late: extreme disorientation, no self care, personality changes

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14
Q

What are the PE findings of vascular dementia?

How would a PT w/ dementia and Parkinson’s present?

A

Exaggerated/asymmetric DTRs
Gait abnormalities
Extremity weakness

Inc motor tone
Rigidity/movement d/o

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15
Q

What labs are ordered to assess dementia?

Vascular dementia requires ? for Dx

A

CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate

Signs of cerebrovascular Dz on CT

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16
Q

What is the relation between a stroke and cognitive decline of dementia

Trifecta of ? issues can present as a mild dementia but functioning PT

A

Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities

CHF UTI Hypothyroid

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17
Q

Define Pseudo-Dementia

How is dementia Tx

A

Depression imitating dementia

Anti-psychotics for persistent psychotic features due to s/e

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18
Q

How is vascular dementia Tx

When is a Dx of Normal Pressure Hydrocephalus considered in dementia PTs

A

Dec HTN/cholesterol

Large ventricles on head
Early development of urinary incontinence/gait disturbances (wet and wobbly)

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19
Q

Glasgow Coma Scale, Motor

A 
6 Follow
5 Localize
4 Withdraws
3 Flex
2 Extend
1 None
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20
Q

Glasgow Coma Scale, Verbal

A 
5 Orientated
4 Confused
3 Inappropriate
2 Incomprehensible
1 None
If PT is intubated, 'T' added in place
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21
Q

Glasgow Coma Scale, Eye Open

A

4 Spontaneous
3 To command
2 To pain
1 None

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22
Q

What labs are ordered to assess dementia?

Vascular dementia requires ? for Dx

A

CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate

Signs of cerebrovascular Dz on CT

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23
Q

What is the relation between a stroke and cognitive decline of dementia

Trifecta of ? issues can present as a mild dementia but functioning PT

A

Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities

CHF UTI Hypothyroid

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24
Q

Define Pseudo-Dementia

How is dementia Tx

A

Depression imitating dementia

Anti-psychotics for persistent psychotic features due to s/e

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25
Q

Define Uncal herniation

How does this present on PE

A

Medial temporal lobe shifts, compresses brain stem= progressive drowsiness to unresponsive

Sluggish ipsilateral pupil that dilates and is non-reactive as CN3 is compressed
Ipsilateral hemiparesis

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26
Q

Glasgow Coma Scale, Verbal

A 
5 Orientated
4 Confused
3 Inappropriate
2 Incomprehensible
1 None
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27
Q

How does Central Herniation syndrome present

Brain midline shifts w/out herniation correlates w/ ?

What may be the underlying cause?

A

Decorticate posturing
Irregular respiration

Dec LoC

Cerebral edema causing vascular compression
Inc ICP

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28
Q

What is the max GCS score for an intubated PT

What is the lowest score?

A

10T

3T

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29
Q

What GCS score correlates w/ a mild head injury?

What GCS score correlates w/ a moderate head injury?

What GCS score correlates w/ a severe head injury?

A

13-15

9-12

8 or less, reqs RSI

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30
Q

Define Monro-Kellie doctrine

What PE findings are used to assign causes of comas into categories?

A

Sum of brain, CSF and intracerebral blood volumes, inc of one causes dec of other one/two forces

Breathing/eye movement/pupil findings
Diffuse CNS dysfunction- toxic/metabolic coma
Focal CNS- structural coma

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31
Q

Clinical features of Toxic-Mtabolic coma

A

No focal PE findings
Small reactive pupils
No EOMs= no value to differentiate toxic-metabolic from structural coma

Except- barbituate poisoning= large pupils, no EOMs, flaccid muscles and apneic PT

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32
Q

Clinical features of Supratentorial Lesion coma

A

Progressive hemiparesis/asymmetric muscle tone or reflexes

Hemipareisis is supsected if asymmetric responses to stimuli or asymmetric extensor/flexor posture ie- Uncal herniation

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33
Q

How are central herniations looked for on imaging?

Cerebral blood flow is at ? MAPs

A

CT w/out contrast

50-100

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34
Q

What is the equation to find CPP

What happens in the brain during uncontrolled ICP increase?

A

CPP= MAP - ICP

Cerebral perfusion pressure dec as ICP nears MAP, leads to brain ischemia

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35
Q

What is a unique form of infratentorial induced coma?

What are two methods to differentiate if a PT is faking a pseudocoma?

A

Pontine hemorrhage- pin point pupils
Locked in Syndrome

PT avoids gaze
Nystagmus w/ caloric vestibular testing

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36
Q

Clinical features of Toxic-Mtabolic coma

A

No focal PE findings
Small reactive pupils
No EOMs= no value to differentiate toxic-metabolic from structural coma

Except- barbituate poisoning= large pupils, no EOMs, flaccid muscles and apneic PT

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37
Q

How does a toxidrome present in comatose PTs

How does opiate syndrome present?

How does cholinergic syndrome present

A

Red skin EKG pupils sweating

Hypovent, Small pupils

Miosis Lacrimation Seizure

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38
Q

What marks the point in brain to differentiate above/below

A

Tentorium

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39
Q

What is the neuro imaging modality of choice for coma PTs

When is a PT considered for non-convulsive status epilepticus

A

Non-contrast head CT

Motor activity of seizure stops but PT doesn’t wake <30min

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40
Q

What is a unique form of infratentorial induced coma?

What are two methods to differentiate if a PT is faking a pseudocoma?

A

Pontine hemorrhage- pin point pupils
Locked in Syndrome

PT avoids gaze
Nystagmus w/ caloric vestibular testing

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41
Q

What are the DDxs of Coma

A 
AEIOUTIPS
Alcohol Acidosis Ammonia Arrhythmia
Endocrine E+ Encephalopathy
Infection 
O2 Overdose Opiates
Uremia  
Trauma Temp Thiamine
Insulin 
Poison Psych 
Stroke Seizure Syncope Space lesion Shunt
42
Q

When conducting PE on coma PTs, what do asymmetric findings mean?

What do extensor/flexor postures mean?

A

Focal CNS lesion

Profound CNS dysfunction

43
Q

What is the neuroimaging modality of choice for coma PTs

A

Non-contrast head CT

44
Q

What is used for hypoglycemia induced coma Tx

How is inc ICP induced comas Tx

A

Dextrose
Alcohol induced= thiamine
Do not use flumazenil, risk of withdrawal Sxs

HOB at 30*
Mannitol 0.5-1mg/kg IV
Dexameth 10mg IV if tumor w/ brain edema
Hyperventilate
3% hypertonic saline
45
Q

What is the 5th MC Sx presenting to ED in US?

Primary HAs have no ? while Secondary HAs have ?

A

HA

1- no underlying cause (migraine, cluster)
2- associated w/ underlying pathology (tumor meningitis hemorrhage)

46
Q

HA Red Flags

A

Papilledema Exertion Trauma Sudden

Seizure Vision Fever AMS Neuro/Neck sxs

Anticoagsplatelets ImmSuppressants Recent abx

No Hx
Sudden change Progressive deterioration

Pregnant/post-partum
Lupus Behcet’s Sarcoidosis

47
Q

PTs presenting w/ HA after exertion needs to have ? DDx ruled out

HAs associated w/ valsalva are associated w/ ?

A

Subarachnoid hemorrhage
Arterial dissection of carotid/vertebrobasilar circulation

Intracranial abnormality

48
Q

? PT population are the high risk groups for HAs

Why is this?

A

> 50y/o w/ new/worsening HA

Dec incidence of migraines, cluster or tension HAs w/ age increase

49
Q

HA w/ fever suspects ? Dx

When is this Dx not ruled out

A

CNS infection

Afebrile
Age extremes
Tylenol/Motrin consumption

50
Q

PTs using ? illicit drugs are at risk for bad HAs

These PTs can induce ? syndrome on them self?

A

Coke Meth Amphtemines

Reversible cerebral constriction syndrome

51
Q

What type of FamHx is of concern for HAs

A

Sudden deaths
Aneurysm
Migraine w/ FamHx

Autosomal Dom PolyKDz- inc intracranial aneurysm

52
Q

Define Meningisums

What PE exam needs to be done?

A

Neck stiffness d/t infection/hemorrhage

ENT for OMedia/sinusitis

53
Q

What eye conditions can cause HAs

What measurement is taken to aid/rule out one of these reasons

A

Scleritis
Endophthalmitis
Acute angle closure glaucoma

Intraocular pressure >21- abnormal

54
Q

Parts of Neuro PE

A 
Mental status
CN exam
Pupils
Motor exam
Reflexes
Gait/Coordination
55
Q

Pts presenting w/ HA and are considered high risk get what labs drawn?

Most ED PTs w/ HA get ? imaging and why?

A

CBC BMP Coags CSF
Blood culture
ESR

Non-contrast CT, most sensitive for hemorrhage and signs of inc ICP

56
Q

Why would PT w/ HA receive an MRA?

What are the benefits of doing an LP?

A

Stenosis
Congenital abnormalities
Dissection
CNS vasculitis

Dx- meningitis, SAH, intracranial HOTN
Thx- pseudotumor cerebri

57
Q

PTs need to be in ? position when performing LP?

When can you perform LP prior to imaging?

A

Lateral decubitus

No ImmSupp Hx
Normal sensorium and,
No focal neuro deficits

58
Q

What indications mean get an LP prior to imaging but don’t delay ABX Tx

A 
AMS
Brain stem signs
Focal neuro deficits
Recent seizure
Pre-existing neuro d/o
ImmComp
59
Q

What types of HA PTs need to have f/u plans

A

High risk- GCA, Idiopathic intracranial HTN

Chronic HAs- potential abuse, over utilization of resources, repeat unnecessary images

60
Q

What is the classic triad of meningitis

When can a head CT be delayed to after LP for meningitis PTs?

A

HA (MC) + Fever (2nd MC), AMS, Neck stiffness

ANO
No Focal neuro, ImmComp, Papilledema, new onset Seizure

61
Q

Prior to performing LP, info on what two things is important?

In sequence, what are the 5 most likely microbes causing bacterial meningitis?

A

Bleeding status
Platelets- <20K/INR 1.5 or higher= c/i

Strep pneumo
GBS
N meningitidis
H influenza
L monocytogenes
62
Q

Where are the 5 MC microbes causing meningitis found?

A 
SP- penetrating head trauma
NM- dorms/barracks
HI- unvaccinated
LM- alcoholics, older PTs
SA/Strep- post-craniotomy
63
Q

How is bacterial meningitis Dx

This test allows what follow on tests to be conducted?

A

LP

Gram stain
Culture
Cell count
Glucose
Protein
64
Q

Lect 2 Slide

A

33 table

65
Q

How is bacterial meningitis Tx

A 
ABCs, rainbow labs, culture
Empiric ABXs
Non contrast head CT
LP
Admit w/ droplet isolation
66
Q

Why are SAHs so dangerous?

75% of these are caused by ?

A

50% survive 30 days

Ruptures aneurysms

67
Q

What are the RFs for SAH in AD Pts

What is the first step in evaluating suspected case?

A

FamHx Alcohol Smoking HTN

Non contrast head CT,
Sens best soon after Sxs
Spec best 6-12hr after Sxss

68
Q

If suspected SAH has negative CT, what is the next step?

Why is this step helpful?

A

LP for blood/xanthochromia- yellow appearance of CSF from enzyme breakdown of blood by bilirubin

Normal CT, no xantho/RBCs= excluded SAH

69
Q

SAHs have the greatest risk for rebleeding when?

How is this reduced/mitigated?

What two are NOT used for control?

A

First 24hrs

Labetolol
Nicardipine

Nitroprusside
Nitroglycerine

70
Q

What is the MC occurrence 2d-3wks after SAH?

All SAH PTs are admitted to ? w/ ? consult

A

Vasospasm

ICU w/ neurosurgeon consult

71
Q

Subdural hematomas are supplied by blood from ?

Epidural hematomas are supplied from ?

A

Venous sources

Fast arterial bleeds
LoC, lucid

72
Q

All PTs that are on anticoag/platelets and are presenting w/ HA receive ? test

Intracranial hemorrhages can occur w/out TraumaHx in ? PTs

A

Head CT

Elderly
Alcohol/Substance abuse
Anti-platelet/coags

73
Q

PTs w/ ? duo of Sxs are pre-Dx w/ cerebellar hemorrhage until proven otherwise

What causes brain tumor HAs?

A

Acute HA and vestibular Sxs (vertigo/ataxia)

CSF flow obstructions
Intracranial HTN

74
Q

What are the clinical S/Sxs of brain tumors

What is the imaging study of choice?

A 
HA worse w/ valsalva
Mental status change
Wakes from sleep
Abnormal neuro exam
Recent Ca Dx
Seizures

MRI w/ and w/out gadolinium

75
Q

What are MRIs w/ contrast preferred for viewing brain tumors over CT?

When are PTs considered to have Cerebral Venous Thrombosis?

How can these present?

A

CT fails to pick up small masses

New HA and:
Female
Peripartum 
Recent SurgHx
Hypercoag states

Slowly develop to thunderclap

76
Q

How are cerebral venous thrombosis definitively Dx if CT, neural exam and mental status are all normal?

What PE finding should increase suspicion?

A

MR Venography

Inc opening LP pressure

77
Q

How do Posterior Reversible Encephalopthy Syndromes present?

What usually causes this?

What PTs is it MC to occur in?

A

Severe HA
Vision changes
Ecephalopathy

HTN

ImmSupp
ImmModulators
Chemo
End stage renal Dz

78
Q

How is Posterior Reversible Encephalopthy Syndrome Dx

This Dx is considered when ? Dx is r/o?

What are two proposed etiologies that lead to how is it Tx

A

MRA- image of choice

SAH

Coke/Amphetamines
BP control

79
Q

How does Posterior Reversible Encephalopthy Syndrome present?

What are the key features leading to Dx

A

Thunderclap w/out SAH
Severe HA
Seizure/focal neuro deficit

Multiple constrictions on angiography 2-3wks after Sxs begin

80
Q

How does GCA present

What two things need to be checked in these PTs

A

Fatigue Fever
Proximal muscle weakness
Jaw claudication
Transient visual loss

ESR
IOP to r/o glaucoma

81
Q

How is GCA Tx

For Dx, 3 of what 5 criteria need to be met

A

Prednisone 60mg

50y/o or older
New HA
Abnormal temporal artery
ESR 50mm or higher
Abnormal biopsy
82
Q

What is the MC non-life threatening HA seen in the ER?

How do these PTs present and w/ ? characteristics?

A

Migraines

Mod/sev intensity x 4-72hrs
Unilateral, pulsatile
Photo/phonophobia
Worse w/ activity

83
Q

What are the MC migraine aura Sxs

When does migraine occurrence peak and in ? gender

A

Light headed and visual changes (scotoma, scintillations)

Peak 40y/o F>M

84
Q

How are migraines Tx

Benzo/opiates are only considered for HA Tx when?

A

Triptans- abortive agents
IV hydration, NSAIDs, anti-emetics, antihistamine
Steroids reduce rebounds

Standard Tx failure

85
Q

How are migraines during pregnancy Tx?

What 3 classes can’t be used?

A

NO Triptan
CCS Opioid Metoclopramide Acetaminophen can be used

No triptans
No NSAIDs after 3rd-T
No ergotamines (caffeine/isometheptene combo)

86
Q

What is prescribed for migraine PTs upon discharge?

Idiopathic Intracranial HTN is AKA and is MC in ? PTs

A

Abortive meds

Pseudotomor cerebri
Obese women 20-44y/o

87
Q

How does Idiopathic Intracranial HTN present

What can happen if this is left un-Tx?

A

Transient visual disturbance
Back pain
Pulsatile tinnitus
HA

Permanent visual impairment

88
Q

How is Idiopathic Intracranial HTN Dx

What is necessary for Dx

A

Pappilledema w/ normal neuro exam
Inc opening pressure on LP
(>25cm w/ normal CSF)

LP- Dx and Thx w/ 1mL CSF dec= 1cm dec of pressure

89
Q

If Pt presents w/ absent papilledema or abducens nerve palsy, how can a Dx of Idiopathic Intracranial HTN be made?

A

3 of:
Empty sella

Flat posterior aspect of globe

Distented perioptic subarachnoid space

Transverse venous sinus stenosis

90
Q

What med can be used to help lower ICP in PTs w/ Idiopathic Intracranial HTN

How do cluster HAs present

What is a distinguishing feature of these types of HA

A

Acetazolamide w/ Opto/Neuro guidance and consult

Later in day in males w/ ipsilateral Sxs- lacrimation
Worse w/ alcohol

PT needs to pace

91
Q

Cluster HAs can mimic ? issue

What criteria is needed to dx

A

Dental pain

Circadian Unilateral Time 15-180min Severe w/ one: 
Ptosis 
Edema on face
Nasal congestion
Conjunctival injection 
Lacrimation
Sweating
92
Q

How are cluster HAs Tx

Stokes occurring at ? location shuts off blood supply to whole brain?

A

100% O2 12L/min x 15min via NRB mask
Sumatriptan 6mg SC

Temporopolar artery

93
Q

The actual injury from a stroke is due to ?

What subsequent results can exacerbate an initial stroke?

A

Loss of O2 and glucose needed for phosphate production

Edema
Mass effects

94
Q

What are the two categories and subsequent types of strokes

What type of strokes are common causes of TIAs?

A

Ischemic- MC
Thrombotic Hypoperfusion Embolic

Hemorrhagic-
Intracerebral Subarachnoid

Ischemic- thrombotic

95
Q

Thrombotic Stroke mechanism and notes

Emoblic stroke mechanism and notes

Hypoperfusion stroke mechanism and notes

A

Narrowing of damages lumen by in situ process- clots
Gradual onset that can wax/wane

Obstruction of normal lumen by material from remote source
Sudden onset, 1/5 of ischemic strokes

Low blood flow leading to hypoperfusion of brain
Diffuse injury in watershed areas
Sxs may wax/wane

96
Q

Intracerebral strokes mechanism and notes

Non-traumatic subarachnoid stroke mechanisms and notes

A

Intraparenchymal hemorrhage from weakened arterioles
Inc ICP causes neuro damage
Secondary constriction causes perfusion changes

Hemorrhage into sub-arachnoid space
Preceded by sentinal HA- warning leak

97
Q

Intracerebral strokes are more common in ? PT populations

What is the critical component to stroke prehospital care?

A

Asian/Africans

Time

98
Q

Clinical features of strokes

What score system is used

A

Facial droop
Arm drift
Abnormal speech

Cincinnati prehospital scale

99
Q

What is the traditional Sx of stroke seen in female PTs

What is the non-traditional Sx of stroke seen in female PTs

What is a non-traditional Sx seen in both genders?

A

Sudden AMS

Generalized weakness

Sudden hiccups

100
Q

What is the timing of Sxs in embolic/hemorrhagic stroke

What is the timing of Sxs seen in thrombotic/hypoperfustion strokes?

What is the timing seen in cerebral aneurysm ruptures/

What is the timing seen in cervical artery dissection?

A

Sudden onset

Wax/wane

Valsalva w/ immediate HA/sudden onset when lifting

Recent neck trauma/manipulation

101
Q

RFs for thrombus strokes

RFs for embolus strokes

A

HTN DM Atherosclerotic dz
Transient neuro deficit

Afib
Valve replacement
Recent MI
Transient neuro deficit

102
Q

Time of stroke Sxs is paramount and starts when?

Define stroke imitator Todd’s Paralysis

A

Time of last known baseline/normal

Transient paralysis after seizure that dissipates

IPAP (212 decks)

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