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Critical Care Boards > Neuro > Flashcards

Neuro Flashcards

1
Q

In myasthenia gravis, what happens when you put ice on the patient’s eyelids?

A

Symptoms transiently resolve

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2
Q

What is consistent with ophthalmoplegia, areflexia and descending paralysis? Also diplopia, dysphagia, and dry mouth

A

Botulism. Can be from wound infection, contaminated food, self-injection

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3
Q

Recall a table of diagnostic tests and treatments for common causes of NM weakness

A
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4
Q

How many patients with TBI also have a concurrent C-spine injury?

A

50%

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5
Q

Which patients with TBI should get AEDs prophylactically?

A

GCS <10 or abnormal CT (mod-severe TBI)

Phenytoin or keppra are equally effective, give for 7 days

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6
Q

Recall TBI grading

A

Mild- I- no visible injury (mortality 10%)

Moderate - II - cisterns open, <5mm MLS, mall high density lesions (mortality 14%)

Severe - III - cisterns compressed (mortality 34%)

Severe - IV- midline shift >5mm (mortality 56%)

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7
Q

What are the indications for surgical interventions in SDH?

A

Craniotomy, not burr holes
>10mm or MLS >5mm. Mortality increases if after 4h. Give 24hr abx prophylaxis

Follow up CT in 36h. Rebleeds in 7%

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8
Q

Which fluids in TBI are recommended?

A

Isotonic, non-glucose containing.

Not albumin (SAFE study)
Not too much blood (Hgb 7 no different than 10 in outcomes)
Not hypertonic

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9
Q

What is the cerebral perfusion calculation and what is the goal?

A

CPP= MAP-ICP, goal 50-70

Max normal ICP 15

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10
Q

What is the mechanism behind hyperventilation and reducing ICP?

A

Causes transient (min-hr) vasoconstriction to reduce blood flow therefore intracranial volume. Meant to be a bridge to definitive therapy
Don’t go under pCO2 30

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11
Q

What are side effects of mannitol?

A

Dose 0.25-1gm/kg bolus q2-4hr

Onset 10-15m, max effect 20-60min

Target osmolarity 320

AKI if using more than 200g/day, volume depletion, hyperchloremic alkalosis

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12
Q

What are hypertonic saline side effects?

A

Dose 2mL/kg bolus

Target osmolarity 320 and Na <155

Pulmonary edema, hyperchloremic acidosis, vein sclerosis

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13
Q

What other agents can reduce ICP other than mannitol and 3% NS?

A

Steroids for tumorgenic edema
Barbituates (but no clinical benefit)
Hypothermia (no clinical benefit)

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14
Q

What is the preferred timing for craniotomy for elevated ICP

A

Early- lowers ICP dramatically, but had more unfavorable outcomes

Late- similar good recovery and better mortality

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15
Q

What thresholds show a positive apnea test?

A

Start with initial pCO2 35-45, abort for hypoxemia, observe for 10min, pCO2 >60 or 20+ above baseline

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16
Q

When is ancillary testing for brain death indicated?

A

Uncertain clinical exam, severe face/head injury, inability to do apnea test (high cord injury/pulmonary disease)

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17
Q

What options are there for ancillary testing for brain death?

A

Cerebral angiography
NM scan
TCD
CTA
MRA
EEG (flat for 30min)

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18
Q

Which causes of seizure are better prognosis versus worse?

A

Better- AED noncompliance, ETOH, CVA

Worse- hypoxemia, CNS infection, tumor, head trauma

Poor patient prognostic factors: elderly, prolonged seizures, focal onset, medical comorbidities

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19
Q

What is first line therapy for in-hospital status epilepticus?

A

Benzos.
Lorazepam- 0.1mg/kg (4mg), 60-90% initial control, slower onset but fewer recurrences, tighter GABA binding

Diazepam- 0.15mg/kg (10mg) faster onset, 42-76% initial control, 50% recurrence within 2hr, rectal form available, can cause vein irritation

Midazolam- 0.25mg/kg (10mg), 42-76% initial control, IM/IV/nasal/buccal, better initial control than lorazepam with no difference in intubation rates or seizure recurrence

20
Q

What is second line therapy for status epilepticus?

A

Phenytoin- 18-20mg/kg, can have hypotension and arrhythmias (limit infusion rate to <50mg/min), not dextrose compatible, has propylene glycol

Fosphenytoin- 15-20mg/kg, pro-drug that needs 15min to convert, hypotension (limit to 100-150mg/min), dextrose compatible, available in IM

21
Q

What is third line therapy in status epilepticus?

A

In no particular order:
Pentobarbital
Propofol
Phenobarbital
Continuous BZ infusion
Levetiracetam
Valproate

22
Q

What are the examples of EEG waveforms given in the lecture that are comparable to EKG waveforms?

A

VT = seizures
Fine VF = normal
Asystole = dead
Asystole with PVCs in between = burst suppression

23
Q

If patients have seizures lasting 30+ minutes and coma, how many develop non-convulsive status afterwards?

A

1/2 within 24hrs of termination

24
Q

Which brain injury benefits from prophylactic seizure medications?

A

mod-severe TBI/acute SDH
7 days

25
Q

What are examples of stroke mimickers?

A

Hypoglycemia
Migraine
Seizure
Tumor
Abscess
West Nile
Wernicke’s
Aortic dissection
Intoxication
Contusion/trauma
Na+/Ca++

26
Q

When can late tpa (up to 9h) be considered?

A

If there is a large penumbra

27
Q
A
28
Q

What are the risk factors for hemorrhagic conversion after ischemic stroke?

A

Hypodensity/edema/mass effect on CT (particularly if more than 1/3 MCA distribution), hyperglycemia/Hx DM, Hx CHF, increased time to tPA, increased age

29
Q

What are the contraindications for tpa?

A

All times: BG<50, head trauma within 3m, Hx ICH/SAH, brain tumor, active hemorrhage, arterial puncture, platelets <100, heparin with elevated PTT, warfarin with INR >1.7, oral DIT/Xai with abnormal coags, SBP >185 or DBP >110

3-4.5h: 80+yo, NIHSS >25, oral AC, Hx DM with prior stroke

Relative: major surgery <14d, GI/GU bleed<21d, seizures, rapidly improving symptoms, MI within 3m, pregnancy

30
Q

Who is a candidate for endovascular therapy for ischemic strokes?

A

Pre-stroke Rankin score 0-1, received tPA within 4.5h, large vessel occlusion on CTA, NIHSS>6, best within 6h of symptom onset, use a stent retriever, and comprehensive stroke center

May benefit if there’s a penumbra up to 24hr (20cc in 80+yo, 30cc in <80, 30-50cc if NIHSS >20 and under 80yo)

31
Q

What are guidelines for post-ischemic stroke care?

A

ASA within 24-48h, add plavix for TIA?NIHSS <3, high intensity statin, ICU glucose ranges, treat fevers, SBP under 85 prior to tpa and under 180 after tpa, SBP under 220 if no tpa

Avoid: albumin, pentoxifylline, ticagrelor, TTM, hyperbaric oxygen, early mobilization, hypervolemia

32
Q

When does edema from hemorrhagic stroke occur?

A

peaks day 5-7

33
Q

When is ICP monitoring appropriate for hemorrhagic stroke?

A

GCS <9, hydrocephalus, IVH, exam that suggests herniation

34
Q

How do you treat warfarin coagulopathy in hemorrhagic stroke?

A

4 factor PCC (vit K and FFP is slower and lower volume) but otherwise no different in outcomes

35
Q

Does blood pressure control improve functional outcomes in hemorrhagic stroke?

A

No, just reduces clot expansion

36
Q

When is surgical management indicated for hemorrhagic stroke?

A

Cerebellar bleeds if clot >3cm or if there’s brainstem compression or hydrocephalus

stereotactic catheter delivered tPA reduced clot size/edema but unclear benefit

37
Q

What are guideline recommendations for post hemorrhagic stroke management?

A

Keep SBP<180, DVT ppx at 48h, 4PCC for warfarin, ICP monitor for coma/IVH/herniation/hydrocephalus, surgery for cerebellar or superficial clot, restart anticoagulation during hospitalization

Avoid: seizure ppx, recombinant favor VII, hypervolemia, steroids, surgery for deep clots, platelet transfusions for aspirin

38
Q

What cranial nerve is most commonly affected by a SAH?

A

3rd nerve palsy

39
Q

What LP features are consistent with SAH?

A

Increased opening pressure
RBCs if early, xanthochromia if late

40
Q

What is the BP goal for epidural hematomas?

A

None- HTN is compensatory. Let it ride.

41
Q

What treatments are available for dysautonomia due to GBS?

A

fludrocortisone for volume expansion and midodrine for vascular tone

42
Q

What neurologic symptoms do you see if fat embolism?

A

Neuro dysfunction, but not typically coma

43
Q

What are the common causes of SAH

A

Cerebral aneurysms, vasculitis, cerebral or spinal AVMs

44
Q

What are the features of neurogenic shock

A

Reduced sympathetic tone, hypotension, bradycardia. See in injuries above T6

45
Q

What are AC reversal agents?

A

Warfarin- FFP and vit K
Apixaban/factor Xa inhibitiors- andexanet alfa or 4FPCC
Dabigatran (direct thrombin inhibitor)- idarucizumab

46
Q

What are the features of acute disseminated encephalomyelitis?

A

Postinfectious autoimmune encephalopathy which attacks white matter and spares cortical gray matter. See elevated CSF WBC and IgG index. A variant called acute hemorrhagic leukoencephalititis can have multifocal hemorrhage and patchy demyelination. Tx with steroids. Plasmaphoresis is second line. IVIG as last ditch

Critical Care Boards (10 decks)

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