Encephalopathy Flashcards
Acute encephalopathy =
Delirium
Delirium vs Dementia
Dementia = baseline has deficits
Delirium = baseline is normal, something causing deficits
Encephalopathy S/s history
Aphasia Mania Psychosis Depression Transient Global Amnesia (TGA)
Hallucinations
Psyc vs. organic brain dz
Psyc = auditory
Organic brain dz = visual
Present w/ delirium?
Promp evaluation
Delirium = Neurons? Neurotransmitters?
Neurons = cortical + subcortical
NT =
Ach,
Dopa
Encephalopathy risks
Old
Dementia
Critically ill
Immunocompromised
Confusion differential?
Infxn
Which electrolytes can cause confusion?
Mg
Ca
Glucose
Na
Replace Na too quickly =
Central pontine myelinosis (CPM) = brain demyelination (pons)
Confusion: metabolic differential
- Electolyte (Mg, Ca, Glucose, Na)
- Hyperosmolality
- Central pontine myelinosis
- acidosis/alkalosis
Confusion : Organ failure differential
- Respiratory
- CV
- Iiver
- renal
HX
HA =
- acute: SAH, ICH
- progressive: CNS tumor, infxn, hydrocephalus
Previous Brain damage
*try to doc baseline
Preexisitng conditions
*cardio/lung
Drugs/Meds
Exposure (Mening, HIV, CO, work)
PE
- HypoTN
- Tachycardia
- Hypoventilation
- UP temp
- Hypothermia
- Nuchal rigidity
- Head trauma evidence
- Nares purulent drainage
- TM
- Scleral Icterus
- Nasal septum erosion
- Skin
Neuro Exam:
- level of consciousness
- Attention
- orientation
- memory
- perception
- thinking organization
- emotional
- level of consciousness= fluctuate
- Attention = poor/hallmark of delirium
- orientation = person, but not time and place
- memory = maybe
- perception = visual/auditory
- thinking organization = disordered
- emotional = lability
Nocturnal confusion
Sundowning
Neuro Exam red flags
- papilldema
- pupil changes
- ocular motility changes
- abnorm movement
- weakness
Can ICP raise w/o Papilledema
Yes
Weakness
Delirium + quadriparesis
- Central Pontine Myelinolysis
- Progressive multifocal leukoencephalopathy
- Acute disseminated encephalopalomyelitis
Weakness
D
Delirium + Paraperesis
Cryptococcus
Vit b12 deficiency
ADEM
Weakness
Proximal muscle weakness
Diff
Cushing’s
Don’t do LP if suspect
Herniation
DX approach:
- ABCs, Vitals
- Stable? = full neuro exam (ICP, focal s/s)
- Unstable? - urgent head CT
- Labs/EKG = metabolic/cardio/toxic cause
- CN infxn/SAH suspected? = LP
- Seizures? EEG
- Structural lesions w/ stable patient? MRI
- Last resort –> brain biopsy
Suspect CNS vasculitis?
Brain biopsy
Abnormal movements
Seizures Myclonus Asterixis (neg myoclonus) Tremor Gait Ataxia
Ocular changes
= UP ICP/Brainstem dysfunction
- upgaze palsy
- unilateral impaired eye adduction + pupillary dilation + lowered consciousness = ER NEURO
- unilateral 6th nerve palsy
Inital labs
CBC w/ diff CMP Serum Ammonia Thryoid Blood gas Cardio enzyme UA drug screen Blood alcohol level
IF LABS negative, consider these labs:
- HIV
- Syphilis (rapid plasma reagin)
- Thyroid (TSH/free T4)
- Cortisol
- Autoimmume (Anti-nuclear antibody)
unilateral impaired eye adduction \+ pupillary dilation \+ lowered consciousness
ER Neuro EMERGENCY
