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Emergency Medicine > Neuro > Flashcards

Neuro Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

how much CSF is present in spinal canal

A

30 ML

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2
Q

where is CSF produced

A

ventricular choroid plexus

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3
Q

where is CSF absorbed

A

arachnoid villi

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4
Q

LP indications

A

suspected meningitis. SAH, CNS syphilis, IIH

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5
Q

absolute contraindications for LP

A

presence of infection near puncture site, increased ICP

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6
Q

relative contraindications for LP

A

unstable patient, coagulopathy, brain abscess, epidural/subdural fluid collection, spinal cord tumor, severe thrombocytopenia

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7
Q

usual volume of CSF removed at LP

A

15-20 mL

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8
Q

rate of CSF production

A

0.35 mL/min

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9
Q

how long does it take the CSF to regenerate that is extracted via LP

A

about an hour

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10
Q

net flow of CSF out of ventricles per day

A

50-100 mL

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11
Q

what meningitis patients may not show meningeal signs

A

elderly, debilitated, immunocompromised, receiving anti-inflammatories, partial abx tx

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12
Q

signs of meningitis in an infant

A

bulging fontanelle, toxic appearance, +/-nuchal rigidity, +/-positive blood cultures

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13
Q

most common signs of meningitis in peds 1-3 y/o

A

fever, irritability, vomiting

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14
Q

what is jolt accentuation test

A

patient’s pain is exacerbated by lateral rotation of the head to either side

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15
Q

petechial rash in febrile patient raises suspicion for ____

A

neisseria meningitis

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16
Q

ssx of SAH

A

thunderclap HA, N/V, AMS, meningeal signs (may occur later), fever

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17
Q

IIH ssx

A

chronic headaches that worsen with maneuvers that increase ICP, papilledema, 6th CN palsies, visual loss

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18
Q

IIH diagnosis

A

LP after neuroimaging while measuring opening pressure

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19
Q

IIH management via LP

A

remove 5-10 mL at a time of CSF and recheck opening pressure until ICP is normal

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20
Q

IH drug therapy

A

acetazolamide, other diuretics

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21
Q

what ssx warrant caution before LP

A

lateralizing signs (hemiparesis), uncal herniation (unilateral 3rd nerve palsy with AMS)

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22
Q

ssx of brain abscess (high risk of herniation with LP)

A

HA, AMS, focal signs. (-)meningeal signs

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23
Q

who is at risk for spinal epidural hematoma after LP

A

bleeding diathesis, anticoagulant Pts, thrombocytopenia

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24
Q

how to correct warfarin-induced coagulopathy prior to LP

A

FFP or prothrombin complex concentrate together with vitamin K (only if time permits)

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25
Q

where to do LP and how to find this spot

A

line connecting posterior superior iliac crests intersecting the midline at the L4 spinous process (use adjacent interspace above or below). Can be performed from L2-L3 interspace to L5-S1 interspace

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26
Q

where to perform LP in infants

A

L4-L5 or L5-S1 interspace

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27
Q

needle sizes used for adults and peds in LP

A

adults: 3.5 inch 20 gauge. Peds: 2.5 inch 22 gauge

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28
Q

how to insert LP needle

A

bevel toward ceiling in a patient on their side. (bevel pointed towards patient’s right regardless of position) Start with needle parallel to bed, then angle toward umbilicus once subq tissue has been penetrated

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29
Q

when will dura be penetrated in normal patients

A

when the needle is advanced approx 1/2-3/4 of its length

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30
Q

how to withdraw LP needle

A

replace stylet into needle before withdrawing it

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31
Q

which CSF tubes have cell counts performed

A

1st and 3rd

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32
Q

post-LP HA onset

A

usually within first 48 hours after LP

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33
Q

post LP HA ssx

A

worse on standing and better lying down, cervical/suboccipital location, +/-N/V

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34
Q

suspected mechanism of post-LP HA

A

leading of CSF through dural hole

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35
Q

post LP HA tx

A

caffeine (300 mg PO or 500 mg IV), . Epidural blood patch for refractory cases. aminophylline (5-6 mg/kg IV), +/-lying flat/sumatriptan: Article yes, Terry says no

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36
Q

when to perform CT before LP

A

trauma, age>60, severely altered mental status, focal neuro deficits, HIV positive/immunocompromised, papilledema, suspected intracranial mass lesion, progressively worsening HA, seizure

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37
Q

position of Pt in order to measure opening pressure

A

lateral decubitus

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38
Q

normal CSF pressure

A

6-25 cm H2O

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39
Q

elevated opening pressure for most children

A

> 28 cm H20

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40
Q

how much blood must be in CSF for it to appear grossly bloody

A

> 6000 RBCs/microliter

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41
Q

what is xanthochromia

A

yellow-orange discoloration of the supernate of centrifuged CSF produced by red cell lysis indicative of SAH of at least a few hours’ duration

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42
Q

WBC greater than ___ indicates pathological CSF

A

5 cells/microliter

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43
Q

neutrophilic pleocytosis in CSF is associated with _____

A

bacterial meningitis, or early stages of viral/TB meningitis

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44
Q

eosinophils in CSF are associated with

A

parasitic CNS infection

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45
Q

normal RBC count for CSF

A

less than 10 cells/microliter

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46
Q

normal range of CSF glucose

A

50-80 mg/dl

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47
Q

normal range of CSF protein

A

15-45 mg/dl

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48
Q

bacterial meningitis CSF findings

A

elevated WBC, polymorphonuclear predominance on differential, glucose <40, protein >50

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49
Q

viral meningitis CSF findings

A

elevated WBC (but not as elevated as bacterial), lymphocytic/mononuclear predominance on differential, normal glucose, normal to slightly elevated protein

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50
Q

most commonly identified organism in viral meningitis

A

enteroviruses (coxsackievirus, echoviruses, etc)

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51
Q

cryptococcus CSF findings

A

slightly elevated WBC, lymphocytic pleocytosis, low glucose, high protein

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52
Q

CSF findings in Guillain-Barre

A

elevated protein

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53
Q

CSF findings in MS

A

oligoclonal bands, elevated protein

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54
Q

CSF findings in SLE

A

elevated WBC, protein, IgG

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55
Q

common pathogens of bacterial meningitis

A

strep pneumo, group b strep, neisseria meningitidis

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56
Q

common cause of amebic meningitis

A

naegleri fowleri

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57
Q

causes of non-infectious meningitis

A

cancer, SLE, head injury, etc

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58
Q

what is kernig sign

A

painful knee extension when hip is flexed

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59
Q

what is brudzinski sign

A

passive flexion of neck elicits flexion of knee and hip

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60
Q

who is most likely to get group B strep meningitis

A

infants< 2 months old

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61
Q

most common cause of bacterial meningitis overall

A

strep pneumo

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62
Q

who gets neisseria meningitidis

A

11-17 y/o

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63
Q

who gets h. flu meningitis

A

unvaccinated

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64
Q

who gets listeria meningitis

A

immunocompromised (including liver disease), newborns, elderly

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65
Q

what is true of the diagnosis of traumatic SAH

A

usually found on CT, not LP

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66
Q

what is most sensitive (or specific?) ssx for SAH

A

“worst headache” followed by thunderclap onset

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67
Q

ottowa SAH rule population

A

for alert patients older than 15 y/o with new, severe, nontraumatic HA reaching maximum intensity within 1 hour

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68
Q

ottowa SAH rule excluded populations

A

new neuro deficits, previous aneurysms or SAH, brain tumors. hx of recurrent HA

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69
Q

ottowa SAH rules when to investigate

A

if at least 1 of these variables present: Age at least 40, neck pain/stiffness, witnessed LOC, onset during exertion, thunderclap, limited neck flexion on exam

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70
Q

cerebral edema CT findings

A

effaced basilar cistern and loss of “smile sign,” slit-like lateral ventricles, effaced sulci

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71
Q

what to do before LP if thrombocytopenia and at what severity of thrombocytopenia

A

FFP if platelets<20,000

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72
Q

what to do after LP if thrombocytopenia

A

monitor for neuro signs (spinal epidural hematoma)

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73
Q

common complications of LP

A

spinal headache, low back pain, dry tap

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74
Q

uncommon complications of LP

A

localized cellulitis, dural abscess, discitis, localized bleeding, cerebral herniation

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75
Q

how much autologous blood goes in blood patch

A

10-20mL

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76
Q

quincke vs whitacre needle

A

Quincke is more blunt, Whitacre is super pointy. Quincke is used most commonly

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77
Q

pre-treatment for LP

A

IV fluids, pain meds (50 mcg fentanyl), anti-emetics (4 mg zofran), anxiolytics (midazolam 1 mg)

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78
Q

needle size for adults

A

22g or larger

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79
Q

causes of high opening pressure

A

IIH, SAH, meningitis, encephalitis, Guillain-Barre, brain abscess, venous sinus thrombosis, intracranial mass/vasculitis

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80
Q

CSF orders

A

cell count with diff, gram stain/culture, protein, glucose, xanthochromia

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81
Q

methods of assessing xanthochromia

A

spectrophotometry, visual comparison

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82
Q

how to assess for SAH vs traumatic tap

A

in a traumatic tap there should be a 30% decrease in RBCs between tubes 1 and 4, less than 500 RBCs in tube 4

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83
Q

tx for bacterial meningitis

A

steroids, abx (ceftriaxone, vanc, ampicillin)

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84
Q

tx for viral meningitis

A

antivirals (acyclovir, valcyclovir)

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85
Q

emergent causes of HA

A

SAH, epidural, subdural, intracerebral hemorrhage, stroke, CNS infection, CNS mass, CO poisoning, acute angle closure glaucoma

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86
Q

dizziness plus headache is concerning for

A

cerebellar bleed

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87
Q

HA red flags

A

new onset, neuro findings, thunderclap, fever, immunocompromise, elderly, jaw claudication, multiple Pts, pregnancy, clotting disorder, eye pain, cervical manipulation, age >50, exertional

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88
Q

what is true of headaches in the ED

A

most are benign and do not require immediate intervention

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89
Q

physical exam components for HA

A

full neuro exam plus palpate temporal artery if suspicion of temporal arteritis

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90
Q

red flags on physical exam for HA

A

AMS, meningeal signs, focal deficits, rash

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91
Q

what could rash with HA signify

A

rocky mountain spotted fever or meningococcemia

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92
Q

most common HA in ED/primary care

A

tension

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93
Q

common migraine aka

A

migraine without aura

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94
Q

classic migraine aka

A

migraine with aura

95
Q

what is a scotoma

A

“hole in vision”

96
Q

what are soft neuro findings

A

confusion, lightheadedness, trouble focusing

97
Q

what are hard neuro findings

A

things that can be explained by a specific lesion, focal deficits, ataxia

98
Q

tension HA characteristics

A

constricting, bilateral, no associated ssx except pre-cranial muscle tenderness

99
Q

migraine characteristics

A

4-72 hours, unilateral, +/-aura, severe, pulsatile, aggravated by exertion, with N/V, photophobia, phonophobia

100
Q

cluster HA characteristics

A

nocturnal onset (awaken Pt), severe, unilateral, located around eye, clustered episodes, +/-autonomic ssx (lacrimation, congestion, miosis, ptosis)

101
Q

cluster HA tx

A

high-low O2, +/-triptans

102
Q

SAH tx in ED

A

confine to bed, advise against exertion or straining, ssx control, nimodipine, keep BP<140, Keppra x 7 days for seizure prophylaxis

103
Q

if acute HA patient has any of the following, investigate further (Ottowa)

A

age >39, meningeal signs, witnessed LOC, exertional onset, thunderclap

104
Q

how to differential traumatic tap vs SAH in LP (for testing purposes)

A

a positive LP for SAH is when RBCs do not completely clear to 0 in the final tube

105
Q

what is true of kernigs and brudzinski sign

A

low sensitivity, high specificity

106
Q

ssx of meningitis in peds

A

irritable, lethargic, poor feeding

107
Q

ssx of neisseria meningitis

A

DIC, purpuric rash

108
Q

what to do if high suspicion of bacterial meningitis

A

initiate tx before confirmation of diagnosis

109
Q

tx for bacterial meningitis in 6-50 y/o

A

ceftriaxone + vanc

110
Q

tx for bacterial meningitis in newborns, elderly

A

ceftriaxone, vanc, ampicillin

111
Q

temporal arteritis ssx

A

fatigue, fever, proximal muscle weakness, jaw claudication, transient vision loss, tender/nonpulsatile temporal artery, HA

112
Q

lab findings in temporal arteritis

A

elevated ESR/CRP, normochromic, normocytic anemia, thrombocytosis

113
Q

temporal arteritis diagnostics

A

temporal artery biopsy, CT/MRI

114
Q

temporal arteritis tx

A

prednisone

115
Q

what opening pressure suggests IIH

A

> 25

116
Q

IIH diagnostics

A

CT to r/o intracranial mass, LP, ocular US

117
Q

ssx of IIH

A

disabling HA, papilledema, vision loss, pulsatile tinnitus, N/V, diplopia

118
Q

red flags for tumor as cause of HA

A

getting worse over time, history of malignancy, HA worse in the morning/with head down/with valsalva, HA awakening from sleep, seizures or acute mental status change

119
Q

characteristics of CO poisoning

A

others in home are sick, worse in the morning, normal SpO2, myalgias, N/V, dizziness, AMS, focal deficit

120
Q

how to assess for CO poisoning

A

carboxyhemoglobin level

121
Q

indications for hyberbaric O2

A

neuro/cardiovascular signs, pregnancy

122
Q

ssx of acute angle-closure glaucoma

A

red eye, mid-range/fixed pupil. cloudy cornea, decreased visual acuity

123
Q

acute glaucoma etiology

A

obstruction of aqueous humor flow 2/2 narrow anterior chamber angle

124
Q

peak age of onset of acute glaucoma

A

> 70 y/o

125
Q

acute glaucoma diagnostics

A

tonometry

126
Q

what tonometry reading is indicative of acute glaucoma

A

> 21 mmHg, but usually >30 mmHg

127
Q

acute glaucoma tx

A

timolol, diamoz, pilocarpine, optho consult

128
Q

cervical/vertebral artery dissection characteristics

A

young pt with HA +/-face/neck pain, sharp pain up the back/front of neck after low mechanism trauma

129
Q

cervical/vertebral artery dissection diagnostics and treatment

A

CT or MR angiogram, tx with heparin

130
Q

terry cocktail for HA

A

reglan 10 mg, benadryl 25-50 mg, decadron 10 mg

131
Q

don’t give triptans and ergotamines to:

A

Pts with CAD, severe HTN, or history of AMI

132
Q

don’t give ketorolac to _____

A

Pt’s with PUD or renal insufficiency

133
Q

nerve blocks for HA

A

occipital, spleno-palatine

134
Q

ED tx for HA options

A

IV fluids, NSAIDs, APAP, dopamine antagonists, triptans, DHE, IV corticosteroids, caffeine, valproate, ketamine

135
Q

route for HA meds in ED

A

NOT PO

136
Q

most common location for epidural hematoma

A

temporoparietal

137
Q

what limits expansion of subdural

A

falx cerebri, tentorium, falx cerebelli

138
Q

subdural locations in adults vs infants

A

usually unilateral in adults, bilateral in infants

139
Q

temporal arteritis is associated with ____

A

polymyalgia rheumatica

140
Q

facial pain indicates dissection of _____ artery

A

carotid

141
Q

neck pain indicates dissection of _____ artery

A

vertebral

142
Q

what is a seizure

A

sudden, uncontrolled electrical discharge in brain, usually bursts of action potentials

143
Q

do patients remain conscious during atonic seizure

A

yes

144
Q

what type of seizure often occurs during sleep

A

tonic

145
Q

what is a focal seizure

A

generally confined to one hemisphere and may look very different depending on what part of the brain is affected

146
Q

types of generalized seizures

A

tonic-clonic, absence, myoclonic, atonic

147
Q

simple partial seizure aka

A

focal-aware

148
Q

focal aware seizures affecting temporal/parietal region ssx

A

affect movement and speech

149
Q

focal aware seizures affecting frontal lobe ssx

A

confusion, behavior disturbance

150
Q

focal aware seizures affecting occipital lobe ssx

A

changes in coordination/vision

151
Q

what is more indicative of psychogenic non-epileptic seizures

A

forced eye closure, responsiveness to toxic stimuli, pelvic thrusting, side-to-side motion and out-of-phase movement of limbs, recall of events with generalized-appearing seizures, no intra-oral bruising or lacs, no elevation of lactate or procalcitonin, optokinetic nystagmus

152
Q

tx for psychogenic non-epileptic seizures

A

CBT

153
Q

6 broad categories of seizure causes

A

vital sign abnormalities, tox, trauma/mass, infection, epilepsy, pregnancy

154
Q

vital signs causes of seizures

A

hypoglycemia, hypoxia, AMI, hypertensive emergency, febrile, electrolytes

155
Q

simple febrile seizure age

A

6 months-5 y/o

156
Q

simple febrile seizure characteristics

A

generalized, lasts <15 minutes, returns to baseline after brief postictal period

157
Q

workup for febrile seizure

A

only for ssx of meningitis or 6-12 month olds that aren’t fully immunized. No further workup needed for simple febrile seizures

158
Q

electrolytes as cause of seizure

A

sodium, calcium, potassium, magnesium

159
Q

mortality rate of delirium tremens

A

30%

160
Q

what meds can cause seizures

A

antihistamines, local anesthestics, wellbutrin, clozapine, abx, tramadol, TCA OD, antiseizure drug OD

161
Q

TCA OD mortality rate and tx

A

50%, sodium bicarb

162
Q

what is the final common pathway

A

seizure coma death

163
Q

what % of pts with penetrating brain injury end up with epilepsy

A

30-40%

164
Q

why dies intracranial bleeding cause seizures

A

blood is irritating, and compression from blood buildup can cause ischemia

165
Q

what is purpura fulminans

A

bad purpural rash associated with meningococcal meningitis

166
Q

every hour of delay in starting abx in bacterial meningitis leads to ____

A

30% increase in mortality

167
Q

causes of breakthrough seizures

A

stress, infection, insomnia, menstrual cycle, med noncompliance

168
Q

what is status epilepticus

A

any seizure >5 minutes or 2+seizures without a return to baseline in between

169
Q

what to do about someone who has a first time seizure and no other abnormal findings

A

refer to outpatient neuro follow up

170
Q

indications for admission for seizures

A

multiple seizures, recurrent seizure without inciting factor/different from past seizures, other abnormalities on labs/VS

171
Q

initial treatment for status epilepticus

A

Lorazepam: 0.1 mg/kg up to 4 mg IV
Midazolam: 0.2-0.3 mg/kg up to 10 mg IM (do this if no IV access already)

172
Q

2nd line treatments for status epilepticus

A

another benzo dose, followed by (if needed) antiepileptic

173
Q

antiepileptic choices for status epilepticus

A

levetiracetam (60 mg/kg), fosphenytoin (20 mg/kg), valproate (40 mg/kg)

174
Q

3rd line meds for status epilepticus

A

massive dose of: propofol, ketamine, midazolam, phenobarbital followed by intubation

175
Q

caution with intubating status epilepticus

A

paralytic won’t stop them from seizing, but they won’t appear to be seizing outwardly/ So continuous EEG is necessary

176
Q

tx for eclampsia

A

magnesium: 4-6 gram bolus over 15-20 minutes, then 2 g/hour infusion

177
Q

1st line antihypertensives in pregnancy

A

nefedipine, methyldopa, labetalol, hydralazine

178
Q

BP goal in pregnancy

A

140/90

179
Q

definitive treatment for eclampsia

A

delivery

180
Q

cause and tx for seizures in the setting of TB infection

A

INH toxicity, administer pyroxidine (B6)

181
Q

at what sodium level do seizures become a possibility?

A

<124

182
Q

causes of hyponatremia leading to seizures

A

polydipsia, SIADH, MDMA, tea and toast

183
Q

consideration in correcting hyponatremia

A

correct it slowly

184
Q

definition of thrombotic stroke

A

narrowing of a damaged vascular lumen by an in situ process

185
Q

which type of stroke is also a common cause of TIA

A

thrombotic

186
Q

causes of thrombotic stroke

A

atherosclerosis, vasculitis, dissection, polycythemia, hypercoagulable state, infection

187
Q

what is an embolic stroke

A

obstruction of a normal vascular lumen by intravascular material from a remote source

188
Q

causes of embolic strokes

A

valvular vegetations, thromboembolism, paradoxical emboli, myxomas, fat/particulate/septic emboli

189
Q

level 1 stroke alert

A

LKW < 6 hours

190
Q

level 2 stroke alert

A

LKW 6-24 hours

191
Q

level 3 stroke alert

A

negative BE FAST, but clinical suspicion and LKW<24 hours

192
Q

BE FAST

A

balance, eyes, face, arm drift, speech, time

193
Q

internal carotid occlusion ssx

A

progressive or stuttering onset of MCA syndrome

194
Q

vertebrobasilar stroke ssx

A

crossed sensory deficits, CN palsies, diplopia, dizziness, N/V, ataxia, motor deficits, coma

195
Q

lacunar stroke ssx

A

pure motor or pure sensory deficits, hemiparesis, dysarthria

196
Q

PCA stroke ssx

A

ataxia, nystagmus, AMS, vertigo, homonymous hemianopsia, can’t read but can still write, hallucinations, 3rd nerve palsy

197
Q

BP goal for stroke without tPA

A

<220/120

198
Q

BP goal for stroke with tPA

A

<185/110

199
Q

BP goal for intracerebral hemmorhage

A

<180/90

200
Q

BP goal for subarachnoid hemorrhage

A

<160/90

201
Q

most important initial lab test in CVA

A

BGL

202
Q

otherstudies in CVA

A

CBC, electrolytes, coags, troponin, ECG, CXR

203
Q

only mandatory initial imaging for CVA

A

non contrast head CT

204
Q

additional imaging for CVA

A

consider CT angiogram to look for large vessel occlusion, consider CT perfusion to evaluate penumbra to assist with thrombolytic decision in unknown LKW

205
Q

risk of intracerebral hemorrhage with tPA

A

5-8%

206
Q

CVA tx if not a tPA candidate

A

325 mg ASA, NPO, CTA, +/- mechanical thrombectomy if LVO found, admit to ICU

207
Q

tPA aka

A

alteplase

208
Q

exclusion criteria for tPA

A

non-ischemic stroke, age<18, LKW>4.5 hours, neurosurgery/head trauma/stroke within the last 3 months, BP>185/110, history of intracerebral hemorrhage, AVM/neoplasm/aneurysm, active internal bleeding, endocarditis, thrombocytopenia, INR>1.7, BGL<50

209
Q

hemorrhage stroke seen on CT interventions

A

CTA, elevate head of bed 30%, goal BP <160/90, nimodipine, reverse anticoagulants, antiepileptics, neurosurgical consultation

210
Q

what sound you not give for hemorrhagic stroke

A

platelets

211
Q

risk stratification tool for risk of stroke after TIA

A

abcd2

212
Q

anterior fossa houses

A

frontal lobe

213
Q

middle fossa houses

A

temporal lobes

214
Q

posterior fossa houses

A

lower brainstem and cerebellum

215
Q

ICP greater than ___ associated with poor outcome

A

20 mmHg

216
Q

what is the monro-kellie doctrine

A

total volume of intracranial content must remain constant

217
Q

intra-axial means

A

within the brain parenchyma

218
Q

extra-axial means

A

above the brain parenchyma, including epidural, subdural, and SAH

219
Q

normal intracranial pressure is approximately

A

10 mmHg

220
Q

at what MAPs can brain autoregulate

A

50-150 mmHg

221
Q

MAP =

A

(pulse pressure)/3 *diastolic

222
Q

always consider what other injury when head injury is present

A

c-spine

223
Q

when to get a CT after head trauma

A

suspected skull fracture, age>65, anticoagulants, focal neuro findings, acute MOI, loss of consciousness

224
Q

mild brain injury GCS

A

13-15

225
Q

Moderate brain injury GCS

A

9-12

226
Q

disposition for moderate brain injury

A

CT then admission with serial neruo exams

227
Q

management of mild brain injury

A

serial neuros followed by discharge if appropriate

228
Q

severe brain injury GCS

A

3-8

229
Q

severe brain injury management

A

neurosurgery consult, treat hypotension, hypovolemia, hypoxia, get CT, type/cross, coags, keep PCO2 around 35. Mannitol, anticonvulsants

230
Q

what is chronic traumatic encephalopathy

A

deposition of tau proteins in the brain due to repeated trauma

231
Q

chronic traumatic encephalopathy ssx

A

early onset memory loss, depression, dysarthric speech, shuffling gait, ataxia

232
Q

chronic traumatic encephalopathy imaging

A

ventricular dilation, sulcal widening, widening of septum pellucidum

233
Q

what is second impact syndrome

A

rapid cerebral edema with high mortality rate, usually in young athletes

Emergency Medicine (3 decks)

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