Neruo Flashcards
What Dx, What Tx
- Post Head injury
- Symptoms occur within 1-2 days of injury, and subside within 7-10 days
- Often accompanied by impaired memory, poor concentration, emotional instability, and increased irritability
Post-Traumatic Headache
Tx
- No special treatment required
- Simple analgesics are appropriate first line therapy
What Dx, What Tx, Labs, Disposition, DDx?
- Disorientation
- Slurred or incoherent speech (making disjointed statements)
- Vacant stare (befuddled facial expression)
- Delayed verbal expression (slower to answer questions)
- Inability to focus attention (easily distracted)
- Hallmarks are confusion and amnesia
- Amnesia almost always includes the traumatic event itself, but may also extend to events before and after trauma
- May occur with or without loss of consciousness
- May be immediately apparent or delayed by several minutes
- Clues such as lack of recall or repetitious questioning should be red flags
- Early symptoms (minutes to hours)
1) Headache, dizziness, vertigo, imbalance, nausea, vomiting - Delayed symptoms (hours to days)
1) Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance
Concussion
- Complete history and physical (MACE within 48hrs)
- Direct observation for 24 hours
- Awaken the patient every two hours to ensure normal alertness
- Low level of activity for 24 hours after injury
- No alcohol, sedatives, or pain relievers other than NSAIDs should be given for 48 hours
Immediate Referral/MEDEVAC for concussion:
(a) Inability to awaken the patient
(b) Severe or worsening headaches
(c) Somnolence or confusion
(d) Restlessness, unsteadiness, or seizures
(e) Difficulties with vision
(f) Vomiting, fever, or stiff neck
(g) Urinary or bowel incontinence
(h) Weakness or numbness involving body part
What Dx, What Tx, Labs, Disposition, DDx?
- Pain, burning, and tingling in the distribution of the median nerve.
- Median nerve innervates thumb, pointer, middle and half of the ring finger
- Initially, most bothersome during sleep.
- Late in the syndrome weakness or atrophy of the thenar eminence may occur
Carpal Tunnel
(1) Tinel or phalen’s sign exacerbates neuropathic symptoms
(2) Diagnosed with ultrasound and nerve conduction studies.
- Patient should modify their hand activities and the affected wrist should be splinted in neutral position for up to 3 months
- Oral or injected steroids or NSAIDS can help decrease inflammation and lesson pain
-REFER if symptoms persist more than 3 months despite conservative treatment, including the use of a wrist splint OR if thenar muscle (e.g., abductor pollicis brevis) weakness or atrophy develops.
Treatment is directed toward relief of pressure on the median nerve
Management for C-spine injury
Treatment and management of spinal cord injury
(1) Should always focus on ABCs first
(2) Take care to immobilize the C-spine with cervical collar ASAP
(3) Patient with high cervical injury may have poor respiratory function and may require
intubation if necessary
(4) Maintain oxygenation and blood pressure
(5) Insert a Foley catheter if bladder paralysis is suspected
(6) Sedate patient if necessary
Steroid use is controversial, consult with Medical Officer prior to administration.
MEDEVAC ASAP!
What Dx? What Tx?
- Bilateral headaches
- Often occurs daily
- Characterized as “vice-like” in nature
- Often exacerbated by emotional stress, fatigue, noise, glare
- May be associated with hypertonicity of neck muscles.
Tension Headache
Tx:
Nsaids
Tylenol
What Dx, What Tx
- Intense unilateral pain that starts around the temple or eye
- Patients is often restless and agitated due to the pain
- Episodes often occur 15 minutes to 3 hours
- Usually occur seasonally and attacks are grouped together
- Other associated symptoms
- Ipsilateral congestion or rhinorrhea
- Lacrimation and redness of the eye
- Horner syndrome (Ptosis, miosis, anhidrosis)
- After resolution of attacks there is a hiatus of several months
Cluster Headache
Tx:
-Inhaled 100% oxygen for 15 minutes is initial treatment of choice
-Subcutaneous Sumatriptan (Imitrex) - Anti-migraine medication
or
-Oral Zolmitirptan (Zomig)
What Dx, What Tx, Labs, Disposition, DDx?
-Pain with back flexion or prolonged sitting
-Radicular pain into the leg due to compression of neural structures
-Lower extremity numbness and weakness
-Discogenic pain typically is localized in the low back at the level of the affected
disk and is worse with activity.
-Sciatica” causes electric shock- like pain radiating down the posterior aspect of
the leg often to below the knee.
- A significant disk herniation can cause numbness and weakness, including weakness with plantar flexion of the foot (L5/S1) or dorsiflexion of the toes
(L4/L5).
The cauda equina syndrome should be ruled out if the patient complains of
perianal numbness or bowel or bladder incontinence
Radiculopathy
Studies
- Straight leg testing
- Lay patient supine and raise patients extended leg on the symptomatic side with foot dorsiflexed
- Lasegue’s sign – presence or worsening of radicular pain with straight leg maneuver
- Plain radiographs are helpful to assess spinal alignment
- MRI is the best method to assess the level and morphology of the herniation and is recommended if surgery is planned.
The cauda equina syndrome should be ruled out if the patient complains of perianal numbness or bowel or bladder incontinence
Tx
First line
- modified activitiesNSAIDs and other analgesics
-Muscle relaxants can help with acute symptomatic relief
Disp
- modified activities
- Reevaluate 4-6 weeks
- If pain is persistent at reevaluation then physical therapy should be considered.
What Dx, What Tx
-Gradual build-up of a throbbing headache, that may be unilateral or bilateral
-Duration of several hours
-Aura may or may not be present
-Visual disturbances such as visual field deficits or visual hallucinations
(stars, light slashes, zigzags, etc)
-Other focal disturbances such as aphasia or numbness, tingling, clumsiness, or weakness in a circumscribed distribution
-Family history often positive for headaches
-May have associated nausea and vomiting
Migrane
Tx:
- Avoidance of precipitating factors, together with prophylactic or symptomatic pharmacologic treatment if necessary.
- During acute attacks - rest in a quiet, darkened room until symptoms subside.
Abortive
- Simple analgesics/NSAIDS
- Zolmitriptan (Zomig)
What Dx, What Tx
- Present in about 50% of patients with chronic daily headaches
- Patients typically present with chronic pain or with complaints of headache unresponsive to medication
- History will often reveal heavy use of analgesics
Medication overuse headache
Treatment is to withdraw medications
-Expect improvement in months, not days
- Fever
- Nuchal rigidity
- Change in mental status
- Headache
- Photophobia
- Rash
Meningitis
Test meningeal irritation
(a) Brudzinski sign – spontaneous flexion of hips during passive flexion of the neck
(b) Kernig sign – inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees
* Lumbar puncture to evaluate CSF
Empiric treatment Ceftriaxone (rocephin) 2G IV Q12H (Crosses BBB) Dexamethasone .15mg/kg IV Q6H (Decreases acute inflammation in CNS)
-Exposed crew
Ciprofloxacin Dose: 500 mg PO x1
- Mask patient and medical personnel in close proximity
- Ensure vaccinations are current
a) Meningiococcal, S. penumoniae, and H. influenza vaccinations
What Dx, What Tx, Labs, Disposition, DDx?
-uncomfortable “creeping, crawling” sensation or “pins and needles feeling” in the limbs, especially in the legs.
-tends to occur during periods of inactivity, particularly the evenings
-may have periodic limb movements of sleep (PLMS)
which may or may not awake a patient from sleep
-May be taking antihistamines
-Unpleasant sensations are partially or totally relieved by movement
-Symptoms are worse during the evening or night
RLS
Tx
- Ferrous sulfate for low iron pt
- Avoidance of aggravating drugs and substances like caffeine
- Increase exercise
- Leg massage
Labs
Iron studies should be considered in evaluation
Disposition
Retain
DDx
- Volitional movements: Foot tapping, bouncing, leg rocking
- Nocturnal leg cramps
- Akathisia: Intense desire to move
What Dx, What Tx, Labs, Disposition, DDx?
-Pain, numbness, or tingling in the lower back and spreading down 1 or both legs
-Leg weakness or a problem called “foot drop,” which is when you cannot seem to hold
your foot up (for example, while walking)
-Problems with bowel or bladder control
-Problems with sex
CAUDA EQUINA= EMERGENCY!!!
- Needs MRI for assessment
- Treatment for cauda equina syndrome involves treating whatever is affecting the nerves and causing the symptoms, SURGERY to remove bits of bone or discs, or tumors.
- If the cause is an infection or inflammation, medications to treat those problems might be needed.
What Dx, What Tx, Labs, Disposition, DDx?
-Abrupt onset of unilateral facial paralysis -Pain about the ear precedes or accompanies the weakness in many cases but usually lasts only for a few days.
-Face feels stiff and pulled on one side
-May be ipsilateral restriction of eye closure and difficulty with eating and fine facial
movements.
-May have changes in taste
-Tearing (68%) or dryness of the eye (16%) and less frequent blinking on the affected side
-Bell’s phenomenon (upward rolling of the eye on attempted lid closure)
-paralysis of the forehead
Bell’s Palsy
- If there is inadequate closure eye protective measures should be implemented
- Can shorten duration of symptoms with oral steroids
- Prednisone is used for mild to moderate Bell’s Palsy
- Antiviral medication is added to steroid treatment regimen for severe Bell’s palsy
- Valacyclovir 1000mg 3 times daily for 7 days
Disposition:
- Immediate referral/MEDEVAC, if eye complications or suspicious of alternative diagnosis (i.e. CVA)
- Referral to neurology/MEDADVICE if mild paresis and no other symptoms to suggest alternative diagnosis
- While onboard follow symptoms and extent of paralysis
What Dx, What Tx, Labs, Disposition?
-sudden onset focal neurological deficit
-drooping or numbness on one side of the face
-one limb being weaker or more numb than the other
-garbled, nonsensical words, inability to respond
normally
hx of one or more of these
(a) History of vascular disease
(b) Atrial fibrillation (not on meds)
(c) Atrial septal defect (ASD)
(d) Ventricular septal defect (VSD) with deep vein thrombosis (DVT)
(e) Recent myocardial infarction
(f) Atherosclerosis
(g) Clotting disorders
Stroke or TIA
Medication
a) Aspirin 325mg
Do not lower BP unless Sbp >220 / Dbp >120
Labs:
a) EKG
b) CBC
c) FBG
d) O2 sat
Imaging
a) Helps to differentiate between ischemic and hemorrhagic stroke
b) Non-contrast CT
c) MRI
Disposition
MEDIVAC
