EMED Block 2 Flashcards
GCS for comatose, need for intubation and normal?
Define AMS
3- comatose
8 or less- intubate
15- normal
Umbrella term for delirium, dementia and coma or any change in mental status
Elderly PT w/ AMS is usually due to one of what 4 things?
What are the 5 contents of consciousness
Pneumonia/sepsis
UTI
Skin infection
Stroke
Reasoning Language Emotions Self-awareness Spatial relationship integration
Define Delirium
Define Dementia
Define Coma
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
AMS Slide 8
Table
Define Mental Status
How is this usually tested?
Clinical state of emotional/intellectual function
Informal- person place time/season, current event
? is a transient d/o w/ impaired attention/cognition*
How will PTs present
Delirium
Difficulty focusing, shifting or sustaining attention
Confusion may fluctuate
How long does it take for delirium to develop?
What are the clinical features of this?
Hrs to days
Inc daytime somnolence
Agitation/sun-downing
HTN Asterixis Tremor Sweating
If delirium PT has hallucinations they are usually ? type
How is delirium D
Visual
Hx and PE
Primarily- Hx from caregiver, family, spouse
How can you tell the difference between depression and delirium?
What two Dxs have to be r/o when working up suspected delirium case
Delirium= rapid fluctuation Depression= absent fluctuation, oriented, able to perform commands
Non-convulsive status epilepticus
Complex partial status epilepticus
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?
Metabolic/thyroid Drugs Infection Neurologic Cariopulmonary
Haloperidol 5-10mg PO/IV/IM
Benzos 0.5-2mg PO/IV/IM
Co2 Capnography
When would delirium PTs NOT be admitted
What are the two largest categories of dementia
Hypoglycemic
Uroseptic
Readily reversible agents
Idiopathic- Alzheimers
Vascular- multiple infarcts
How does dementia onset?
How do PTs w/ dementia present
Slowly w/ insidious Sxs
Hallucinations
Repetitive behaviors
Delusion/Depression
What is the characteristic onset of dementia associated w/ Alzheimers?
What are the 3 stages of dementia?
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
What are the PE findings of vascular dementia?
How would a PT w/ dementia and Parkinson’s present?
Exaggerated/asymmetric DTRs
Gait abnormalities
Extremity weakness
Inc motor tone
Rigidity/movement d/o
What labs are ordered to assess dementia?
Vascular dementia requires ? for Dx
CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate
Signs of cerebrovascular Dz on CT
What is the relation between a stroke and cognitive decline of dementia
Trifecta of ? issues can present as a mild dementia but functioning PT
Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities
CHF UTI Hypothyroid
Define Pseudo-Dementia
How is dementia Tx
Depression imitating dementia
Anti-psychotics for persistent psychotic features due to s/e
How is vascular dementia Tx
When is a Dx of Normal Pressure Hydrocephalus considered in dementia PTs
Dec HTN/cholesterol
Large ventricles on head
Early development of urinary incontinence/gait disturbances (wet and wobbly)
Glasgow Coma Scale, Motor
6 Follow 5 Localize 4 Withdraws 3 Flex 2 Extend 1 None
Glasgow Coma Scale, Verbal
5 Orientated 4 Confused 3 Inappropriate 2 Incomprehensible 1 None If PT is intubated, 'T' added in place
Glasgow Coma Scale, Eye Open
4 Spontaneous
3 To command
2 To pain
1 None
What labs are ordered to assess dementia?
Vascular dementia requires ? for Dx
CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate
Signs of cerebrovascular Dz on CT
What is the relation between a stroke and cognitive decline of dementia
Trifecta of ? issues can present as a mild dementia but functioning PT
Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities
CHF UTI Hypothyroid
Define Pseudo-Dementia
How is dementia Tx
Depression imitating dementia
Anti-psychotics for persistent psychotic features due to s/e
Define Uncal herniation
How does this present on PE
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
Glasgow Coma Scale, Verbal
5 Orientated 4 Confused 3 Inappropriate 2 Incomprehensible 1 None
How does Central Herniation syndrome present
Brain midline shifts w/out herniation correlates w/ ?
What may be the underlying cause?
Decorticate posturing
Irregular respiration
Dec LoC
Cerebral edema causing vascular compression
Inc ICP
What is the max GCS score for an intubated PT
What is the lowest score?
10T
3T
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?
13-15
9-12
8 or less, reqs RSI
Define Monro-Kellie doctrine
What PE findings are used to assign causes of comas into categories?
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
Clinical features of Toxic-Mtabolic coma
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
Clinical features of Supratentorial Lesion coma
Progressive hemiparesis/asymmetric muscle tone or reflexes
Hemipareisis is supsected if asymmetric responses to stimuli or asymmetric extensor/flexor posture ie- Uncal herniation
How are central herniations looked for on imaging?
Cerebral blood flow is at ? MAPs
CT w/out contrast
50-100
What is the equation to find CPP
What happens in the brain during uncontrolled ICP increase?
CPP= MAP - ICP
Cerebral perfusion pressure dec as ICP nears MAP, leads to brain ischemia
What is a unique form of infratentorial induced coma?
What are two methods to differentiate if a PT is faking a pseudocoma?
Pontine hemorrhage- pin point pupils
Locked in Syndrome
PT avoids gaze
Nystagmus w/ caloric vestibular testing
Clinical features of Toxic-Mtabolic coma
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
How does a toxidrome present in comatose PTs
How does opiate syndrome present?
How does cholinergic syndrome present
Red skin EKG pupils sweating
Hypovent, Small pupils
Miosis Lacrimation Seizure
What marks the point in brain to differentiate above/below
Tentorium
What is the neuro imaging modality of choice for coma PTs
When is a PT considered for non-convulsive status epilepticus
Non-contrast head CT
Motor activity of seizure stops but PT doesn’t wake <30min
What is a unique form of infratentorial induced coma?
What are two methods to differentiate if a PT is faking a pseudocoma?
Pontine hemorrhage- pin point pupils
Locked in Syndrome
PT avoids gaze
Nystagmus w/ caloric vestibular testing
What are the DDxs of Coma
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
When conducting PE on coma PTs, what do asymmetric findings mean?
What do extensor/flexor postures mean?
Focal CNS lesion
Profound CNS dysfunction
What is the neuroimaging modality of choice for coma PTs
Non-contrast head CT
What is used for hypoglycemia induced coma Tx
How is inc ICP induced comas Tx
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
What is the 5th MC Sx presenting to ED in US?
Primary HAs have no ? while Secondary HAs have ?
HA
1- no underlying cause (migraine, cluster)
2- associated w/ underlying pathology (tumor meningitis hemorrhage)
HA Red Flags
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
PTs presenting w/ HA after exertion needs to have ? DDx ruled out
HAs associated w/ valsalva are associated w/ ?
Subarachnoid hemorrhage
Arterial dissection of carotid/vertebrobasilar circulation
Intracranial abnormality
? PT population are the high risk groups for HAs
Why is this?
> 50y/o w/ new/worsening HA
Dec incidence of migraines, cluster or tension HAs w/ age increase
HA w/ fever suspects ? Dx
When is this Dx not ruled out
CNS infection
Afebrile
Age extremes
Tylenol/Motrin consumption
PTs using ? illicit drugs are at risk for bad HAs
These PTs can induce ? syndrome on them self?
Coke Meth Amphtemines
Reversible cerebral constriction syndrome
What type of FamHx is of concern for HAs
Sudden deaths
Aneurysm
Migraine w/ FamHx
Autosomal Dom PolyKDz- inc intracranial aneurysm
Define Meningisums
What PE exam needs to be done?
Neck stiffness d/t infection/hemorrhage
ENT for OMedia/sinusitis
What eye conditions can cause HAs
What measurement is taken to aid/rule out one of these reasons
Scleritis
Endophthalmitis
Acute angle closure glaucoma
Intraocular pressure >21- abnormal
Parts of Neuro PE
Mental status CN exam Pupils Motor exam Reflexes Gait/Coordination
Pts presenting w/ HA and are considered high risk get what labs drawn?
Most ED PTs w/ HA get ? imaging and why?
CBC BMP Coags CSF
Blood culture
ESR
Non-contrast CT, most sensitive for hemorrhage and signs of inc ICP
Why would PT w/ HA receive an MRA?
What are the benefits of doing an LP?
Stenosis
Congenital abnormalities
Dissection
CNS vasculitis
Dx- meningitis, SAH, intracranial HOTN
Thx- pseudotumor cerebri
PTs need to be in ? position when performing LP?
When can you perform LP prior to imaging?
Lateral decubitus
No ImmSupp Hx
Normal sensorium and,
No focal neuro deficits
What indications mean get an LP prior to imaging but don’t delay ABX Tx
AMS Brain stem signs Focal neuro deficits Recent seizure Pre-existing neuro d/o ImmComp
What types of HA PTs need to have f/u plans
High risk- GCA, Idiopathic intracranial HTN
Chronic HAs- potential abuse, over utilization of resources, repeat unnecessary images
What is the classic triad of meningitis
When can a head CT be delayed to after LP for meningitis PTs?
HA (MC) + Fever (2nd MC), AMS, Neck stiffness
ANO
No Focal neuro, ImmComp, Papilledema, new onset Seizure
Prior to performing LP, info on what two things is important?
In sequence, what are the 5 most likely microbes causing bacterial meningitis?
Bleeding status
Platelets- <20K/INR 1.5 or higher= c/i
Strep pneumo GBS N meningitidis H influenza L monocytogenes
Where are the 5 MC microbes causing meningitis found?
SP- penetrating head trauma NM- dorms/barracks HI- unvaccinated LM- alcoholics, older PTs SA/Strep- post-craniotomy
How is bacterial meningitis Dx
This test allows what follow on tests to be conducted?
LP
Gram stain Culture Cell count Glucose Protein
Lect 2 Slide
33 table
How is bacterial meningitis Tx
ABCs, rainbow labs, culture Empiric ABXs Non contrast head CT LP Admit w/ droplet isolation
Why are SAHs so dangerous?
75% of these are caused by ?
50% survive 30 days
Ruptures aneurysms
What are the RFs for SAH in AD Pts
What is the first step in evaluating suspected case?
FamHx Alcohol Smoking HTN
Non contrast head CT,
Sens best soon after Sxs
Spec best 6-12hr after Sxss
If suspected SAH has negative CT, what is the next step?
Why is this step helpful?
LP for blood/xanthochromia- yellow appearance of CSF from enzyme breakdown of blood by bilirubin
Normal CT, no xantho/RBCs= excluded SAH
SAHs have the greatest risk for rebleeding when?
How is this reduced/mitigated?
What two are NOT used for control?
First 24hrs
Labetolol
Nicardipine
Nitroprusside
Nitroglycerine
What is the MC occurrence 2d-3wks after SAH?
All SAH PTs are admitted to ? w/ ? consult
Vasospasm
ICU w/ neurosurgeon consult
Subdural hematomas are supplied by blood from ?
Epidural hematomas are supplied from ?
Venous sources
Fast arterial bleeds
LoC, lucid
All PTs that are on anticoag/platelets and are presenting w/ HA receive ? test
Intracranial hemorrhages can occur w/out TraumaHx in ? PTs
Head CT
Elderly
Alcohol/Substance abuse
Anti-platelet/coags
PTs w/ ? duo of Sxs are pre-Dx w/ cerebellar hemorrhage until proven otherwise
What causes brain tumor HAs?
Acute HA and vestibular Sxs (vertigo/ataxia)
CSF flow obstructions
Intracranial HTN
What are the clinical S/Sxs of brain tumors
What is the imaging study of choice?
HA worse w/ valsalva Mental status change Wakes from sleep Abnormal neuro exam Recent Ca Dx Seizures
MRI w/ and w/out gadolinium
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?
CT fails to pick up small masses
New HA and: Female Peripartum Recent SurgHx Hypercoag states
Slowly develop to thunderclap
How are cerebral venous thrombosis definitively Dx if CT, neural exam and mental status are all normal?
What PE finding should increase suspicion?
MR Venography
Inc opening LP pressure
How do Posterior Reversible Encephalopthy Syndromes present?
What usually causes this?
What PTs is it MC to occur in?
Severe HA
Vision changes
Ecephalopathy
HTN
ImmSupp
ImmModulators
Chemo
End stage renal Dz
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
MRA- image of choice
SAH
Coke/Amphetamines
BP control
How does Posterior Reversible Encephalopthy Syndrome present?
What are the key features leading to Dx
Thunderclap w/out SAH
Severe HA
Seizure/focal neuro deficit
Multiple constrictions on angiography 2-3wks after Sxs begin
How does GCA present
What two things need to be checked in these PTs
Fatigue Fever
Proximal muscle weakness
Jaw claudication
Transient visual loss
ESR
IOP to r/o glaucoma
How is GCA Tx
For Dx, 3 of what 5 criteria need to be met
Prednisone 60mg
50y/o or older New HA Abnormal temporal artery ESR 50mm or higher Abnormal biopsy
What is the MC non-life threatening HA seen in the ER?
How do these PTs present and w/ ? characteristics?
Migraines
Mod/sev intensity x 4-72hrs
Unilateral, pulsatile
Photo/phonophobia
Worse w/ activity
What are the MC migraine aura Sxs
When does migraine occurrence peak and in ? gender
Light headed and visual changes (scotoma, scintillations)
Peak 40y/o F>M
How are migraines Tx
Benzo/opiates are only considered for HA Tx when?
Triptans- abortive agents
IV hydration, NSAIDs, anti-emetics, antihistamine
Steroids reduce rebounds
Standard Tx failure
How are migraines during pregnancy Tx?
What 3 classes can’t be used?
NO Triptan
CCS Opioid Metoclopramide Acetaminophen can be used
No triptans
No NSAIDs after 3rd-T
No ergotamines (caffeine/isometheptene combo)
What is prescribed for migraine PTs upon discharge?
Idiopathic Intracranial HTN is AKA and is MC in ? PTs
Abortive meds
Pseudotomor cerebri
Obese women 20-44y/o
How does Idiopathic Intracranial HTN present
What can happen if this is left un-Tx?
Transient visual disturbance
Back pain
Pulsatile tinnitus
HA
Permanent visual impairment
How is Idiopathic Intracranial HTN Dx
What is necessary for Dx
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
If Pt presents w/ absent papilledema or abducens nerve palsy, how can a Dx of Idiopathic Intracranial HTN be made?
3 of:
Empty sella
Flat posterior aspect of globe
Distented perioptic subarachnoid space
Transverse venous sinus stenosis
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
Acetazolamide w/ Opto/Neuro guidance and consult
Later in day in males w/ ipsilateral Sxs- lacrimation
Worse w/ alcohol
PT needs to pace
Cluster HAs can mimic ? issue
What criteria is needed to dx
Dental pain
Circadian Unilateral Time 15-180min Severe w/ one: Ptosis Edema on face Nasal congestion Conjunctival injection Lacrimation Sweating
How are cluster HAs Tx
Stokes occurring at ? location shuts off blood supply to whole brain?
100% O2 12L/min x 15min via NRB mask
Sumatriptan 6mg SC
Temporopolar artery
The actual injury from a stroke is due to ?
What subsequent results can exacerbate an initial stroke?
Loss of O2 and glucose needed for phosphate production
Edema
Mass effects
What are the two categories and subsequent types of strokes
What type of strokes are common causes of TIAs?
Ischemic- MC
Thrombotic Hypoperfusion Embolic
Hemorrhagic-
Intracerebral Subarachnoid
Ischemic- thrombotic
Thrombotic Stroke mechanism and notes
Emoblic stroke mechanism and notes
Hypoperfusion stroke mechanism and notes
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
Intracerebral strokes mechanism and notes
Non-traumatic subarachnoid stroke mechanisms and notes
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
Intracerebral strokes are more common in ? PT populations
What is the critical component to stroke prehospital care?
Asian/Africans
Time
Clinical features of strokes
What score system is used
Facial droop
Arm drift
Abnormal speech
Cincinnati prehospital scale
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?
Sudden AMS
Generalized weakness
Sudden hiccups
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?
Sudden onset
Wax/wane
Valsalva w/ immediate HA/sudden onset when lifting
Recent neck trauma/manipulation
RFs for thrombus strokes
RFs for embolus strokes
HTN DM Atherosclerotic dz
Transient neuro deficit
Afib
Valve replacement
Recent MI
Transient neuro deficit
Time of stroke Sxs is paramount and starts when?
Define stroke imitator Todd’s Paralysis
Time of last known baseline/normal
Transient paralysis after seizure that dissipates
