Neuro 2 Flashcards
Hallmark sx of concussion/mild TBI
- confusion
- amnesia
- +/- LOC*
- HA
- dizzy
- NV
- light sensitivity
- perseverating
- irritability
- GCS 13-15
Describe the GCS score of mild, moderate, and severe TBI
Mild: 13-15
mod: 9-12
severe: <9
what is a primary concussion injury
- Primary neuronal damage occurs immediately at impact and is dependent on the cause and severity of the event
- Contusion, damage to blood vessels, shearing, etc
Secondary injury to concussion typically occurs when
minutes to days after the event
-intracranial or systemic cause
Prevent secondary injury of concussios by correcting:
- hypotension
- hypoxemia
- anemia
- hyperthermia
- hypoglycemia
Describe the New Orleans Head CT rules for who to image
- GCS 15 plus 1 of the following:
- HA
- Vomiting
- Age >60
- Alcohol/drug intox
- Short term memory deficits
- Visible trauma above the clavicles
- Seizure
Describe the PECARN pediatric head injury algorithm for kids <2y/o
- GCS 14 or other signs of AMS
- Palpable skull fx
- any scalp hematoma (except frontal)
- LOC >5 sec
- Severe MOI
S/S of increased ICP in Infants
- full fontanel
- split sutures
- AMS
- persistent emesis
**low threshold to scan kids <2y/o, older kids have a more classic presentation
Etiologies of infant/toddlers and school aged head traumas
infant/toddler: falls
school age: MVA and sports
Important historical factors for minor head trauma in children
- age
- height of fall
- impact surface
- LOC at scene
- changes in MS
Indications for hospitalization for head trauma
- Lengthy LOC > 5 minutes
- Severe HA , amnesia or vomiting
- Somnolence, irritability or confusion
- Changes in LOC
- Abnormal CT or displaced fractures
- Focal deficits on exam
- Seizures
- Unreliable caretakers
- Symptomatic infants
10 . Suspected child abuse
Describe concussion dispo
- Observe in ED until patient clears, or at least improving
- Home with reliable observer:
- Any change in mental status should return
- Tylenol preferred over motrin initially
- Don’t need to wake, but observe every few hours
- Avoid Etoh, Caffeine
- REST
*most complications are seen in the first 4hrs
Describe the return to activity guidelines and return to ED guidelines for concussion dispo
Return to activity:
- no return to place the day of injury
- stepwise return to activity
Return to ED:
- vomiting more than twice
- any change in mental status
- worsening HA
Describe the colorado medical system guidelines for return to play
- Grade I w/o amnesia– 15 min. rest
- Grade 2 confusion and amnesia– 1 week rest
- Grade 3 LOC– 1-6 month rest
- Player must be symptom free after a minimum time period both at rest and with activity, in order to return to play
- With subsequent concussion, period of rest is longer
s/s of increased ICP in children
- HA
- Stiff neck
- Photophobia
- AMS
- Persistent emesis
- Papilledema
- Posturing
- CN abnormalities
*Bottom Line: low threshold to scan kids <2yo; older kids have a more classic presentation
What is second impact syndrome
- Second concussive injury while the athlete is still recovering from the first concussion or still experiencing symptoms
- May occur days to weeks after first concussion
* Leads to acute brain swelling resulting in a 50% mortality and 100% morbidity rate
New research supports that anyone who sustains a concussion may subsequently have a lower threshold for further concussions
Neurologic and cognitive recovery may be __ after subsequent concussions
slower
Sx of post concussive syndrome
- vague complaints such as HA
- dizzy
- nausea
- inability to concentrate
- memory changes
- usually lasts several weeks to several months after the injury
- After 1 year 85-90% have recovered
- Consider referral to neurology
__ is the third leading cause of death and #1 cause of disability in the US
Stroke
8% die within 30 days
20% die within 1 year
16% require inpatient rehab
Blood reaches the brain through 4 major vessels:
- 2 carotid arteries (80% of cerebral blood flow)
- 2 vertebral arteries (combine to form a single basilar artery– 20%)
*These two systems are interconnected at various levels, the principal one being the Circle of Willis
Describe the anterior circulation
- originates from internal carotid arteries
- carotid arteries branch into:
- anterior and middle cerebral arteries at the circle of willis - Anterior circulation supplies the optic nerve, retina, frontoparietal nerve and anterotemporal lobes of the brain
Describe the posterior circulation
- Derived from two vertebral arteries
- Vertebral arteries branch into the basilar artery which forms the posterior cerebral arteries - Posterior circulation supplies the brainstem, cerebellum, thalamus, auditory and vestibular functions
- Brainstem function affects normal consciousness, movement and circulation
Signs of anterior cerebral artery infarct
- contralateral leg weakness
- sensory changes
- leg»arm
Signs of middle cerebral artery infarct
- Most common (90% of Anterior Strokes)
- Contralateral hemiparesis and hemisensory changes
- (arm, face > leg)
- Leg may be spared; arm and face most often involved
- Aphasia (dominant hemisphere) or
- hemineglect (non dominant hemisphere)
Describe sx of posterior circulation syndrome
- Posterior cerebral artery and Vertibrobasilar artery
2. HA,
3. visual changes,
4. nausea,
5. dizzy,
6. vertigo,
7. diplopia,
8. ataxia,
9. ‘clumsiness’,
10. dyslexia
11. Homomynous hemianopsia (contralateral)
Describe sx of Lacunar infarct syndrome
- pure motor or sensory deficits due to infarction of small penetrating arteries
- associated w/ chronic HTN
Causes of ischemic strokes (80%)
- thrombotic: secondary to atherosclerotic lesion
- Emoblic: caused by obstructive emboli from cardiac or prox. vessles sourecs, afib, recurrent MI
- Small artery or lacunar: from uncontrolled HTN
- hypo-perfusion: due to cardiac pump failure
- Thrombus: local obstructive process
- Embolus: obstruction from a distant source
- *Most strokes are ischemic— won’t find abnormalities on head CT–> need MR
Risk factors for ischemic stroke
- age
- Heredity/race
- Gender
- Prior CVA, TIA
- Atrial fibrillation/heart disease
- Carotid stenosis
- DM
- Hyperlipidemia
- HTN
- Smoking
hemorrhagic strokes (ICH) is associated w/ what
- associated w/ increased ICP and
- secondary vasconstriction
- baseline weakened arterioles
hemorrhagic strokes (nontraumatic SAH) is associated w/ what
- berry aneurysm rupture
- AVMs
- may be preceded by a sentinel HA/bleed
Risk factors for hemorrhagic stroke
- HTN
- tobacco
- alcohol
- hx of previous CVA
- race (AA, asian)
- increasing age
- cocaine
Headache and Vomiting are more consistent with a ___ stroke
hemorrhagic (NOT ISHCEMIC STROKE)
Irreversible neuronal injury w/ ischemic strokes occur within __
___appears to be the cutoff time before the pneumbra is lost
minutes
6 hrs
Describe the EMS management of stroke
- O2
- Iv access
- labs
- notify to receiving hospital to ensure imaging is available and stroke team can be called
FAST: facial droop, arm drift, speech, time:
Patients with 1 of these 3 findings as a new event have a 72% probability of anischemic stroke. If all 3 findings are present the probability of an acute stroke is more than 85%
Key hx question for stroke management
History should guide you to also consider and/or r/o other causes – hypoglycemia, seizure, migraine, drug toxicity, conversion disorder
Describe the general managment for a stroke
- ABCs, IV access, cardiac monitor
- Oxygen >92%
- NPO
- Glucose evaluation
- “Permissive Hypertension”
- ? TPA <3 – 4.5 hrs
- Elevate HOB to 30 degrees if increased ICP
Describe the NIHSS scoring to help determine the prognosis of a stroke
NIHSS: the higher the number, the worse the stroke
0 : no stroke
21-42: severe stroke
<6 suggests good prognosis
>16 strong probability of death
Door to CT completion time for a stroke is __
25 minutes
Why do you get a CT for a stroke
- r/o bleed or any other obvious brain abnormalities
- 98% sensitive to blood within 12 hours of onset
- Treatment depends on presence or absence of blood - Most early ischemic changes are not usually seen on initial CT (need MR)
if a Pt woke up with a neuro deficit (stroke like), ask ___
when was she last normal?
**assume it was when they were last normal even if that was more than 1 hr ago
Other studies to get w/ a stroke
- EKG
- CXR
- CBC
- Chem7
- Coagulation studies
- Cardiac enzyme
- CTA or MRI - w/ neuro consult
What is BP goal w/ stroke care when someone is a TPA candidate and when they are NOT a TPA candidiate
If NOT a TPA candidate
-permissive hypertension: treat only if SBP >220 or DBP >120
If YES a TPA candidate
-keep BP <185/110; usually labetolol (titratable)
*Aspirin, Anticoagulation in select patients may go out 4.5 hours instead of 3 hours at stroke centers
tPA may be given if what criteria are met?
- Measureable diagnosis of Acute Ischemic Stroke
- Patient is > 18 years old
- Less than 4.5 hrs since symptom onset
BUT, observe 3 hour cut off if
- > 80yo
- previous stroke/DM
- active anticoagulant
- NIHSS>25
- multilobar infarct on CT
What families need to know about thrombolytics
- 30% greater chance of improved clinical outcome at 3 months and 1 year with rt-PA
- 6% have a bleed associated with early worsening
- No significant difference in mortality at 3 months or 1 year despite the increased hemorrhage rate
Increased risk of hemorrhage with w/ thrombolytics if:
- NIHSS > 22,
- treatment > 3 hours,
- significant CT findings,
- elevated B/P
**The earlier, the better
ACEM recognizes intravenous thrombolysis as a potentially beneficial intervention for acute ischemic stroke. There is however, conflicting evidence such that the administration of stroke thrombolysis by ED staff is a controversial area and cannot currently be considered a __
standard of care
Management of heomorrhagic CVA
- Regulate blood pressure
- Control of brain edema
- Anti epileptics?
- Neurosurgical consultation
What is TIA
Defined as a “ transient episode of neurological dysfunction caused by brain ischemia without acute infarction on imaging”
Ie - Negative CT scan
TIA is associated w/ high risk for stroke in the first __- highest risk within ___
90 days;
48 hours
Tx of TIA
- antiplatelet medications (ASA, Plavix etc);
- Coumadin if high risk for cardiac emboli
- New onset TIA should be evaluated for cardiac sources of TIA: echocardiogram, carotid US
Describe the dispo of TIA patients
- recommend hospitalizing TIA patients who present within 72 hours of symptom onset and are high risk
- If not hospitalized, need additional imaging within 24-48 hours
- CTA, MRA and/or carotid US
Describe TIA risk stratification
- Age (>60=1)
- BP (>140/90=1)
- Clinical features of TIA (unilateral weakness=2, speech disturbance w/o weakness =1)
- Duration of sx (>60min=2, 10-59 min=1, <10min=0)
- Diabetes (=1)
*corresonding 2 day risk for a subsequent stroke are ABCD2 score:
0-3=1% (low risk, start ASA 300mg OD and refer to TIA clinic)
4-5= high risk, consider admission, asa 300mg, urgent tia clinic
6-7= as above
Dizzy can be:
- Otologic/vestibular 33%
- cardiovascular
- resp.
- neurolgocial
- metabolic
- psych 7%
Illusion of motion; acute asymmetry of vestibular system
vertigo/vertinginous
Prodromal symptom of fainting or a near faint; palpitation
presyncope/LH
Sense of imbalance that occurs primarily when walking
Dysequilibrium/ ataxic
Mismatch of the perception of movement by the visual, vestibular and proprioceptive systems
A sensation of movement when none exists
vertigo
Peripheral vertigo is caused by:
Central vertgio is from:
is caused by dysfunction of the inner ear or vestibular nerve (BPPV, vestibular neuritis, menieres)
is from etiologies of the brain and brain system
Sx of peripheral vertigo
- DR FLIP
1. Deafness
2. Ringing in the ears
3. Fatigable on repeat tests
4. Latency s/p Dix Hallpike
5. Intense Symptoms
6. Position in nature
*Classically, central lesions tend to have ‘softer’ clinical findings, peripheral often presents with violent vomiting, reproducie symptoms. (peripheral is more benign)
sx of central vertigo
(CVA)
- CN deficits
- vertical nystagmus
- ataxia
*Classically, central lesions tend to have ‘softer’ clinical findings, peripheral often presents with violent vomiting, reproduciel symptoms.
Key PEX parts of dizzy
- Eyes: nystagmus- suggests vertigo; vertical/rotary vs lateral
- ears: infection, perforation, hearing fxn
- comprehensive neuro exam
*Note that “few beat nystagmus with lateral gaze is normal”; it becomes abnormal if it is prolonged, pronounced, or asymmetric it is abnormal
Describe BPPV
MC*
- otoliths in semicircular canal
- Recurrent episodes with head turning.
- no hearing loss or tinnitus
- Rx w/ Dix Hallpike Epley
Describe Neuritis
- commonly postviral, affecting vestibular portion of 8th CN.
- Sudden onset,
- occ hearing loss/
- tinnitush.
Describe Menieres
- Attributed to excess endolymphatic fluid
- recurrent bouts of vertigo, tinnitus and hearing loss. Dx requires multiple episodes.
- Less acute onset.
*Less common (10%)
Other common causes of peripheral vertigo
- Closed Head Injury: vertigo may persist for weeks after trauma
- Ototoxicity: common offenders include salicylates, aminoglycosides (Tobramycin, gentamycin)
Causes of central vertigo
- Cerebellar hemorrhage/infarct
- Vertebral basilar ischemia
- Multiple sclerosis
- Vertebral artery dissection
tx of peripheral vertigo
- IVF
- Antiemetics/antidopinergic (Phenergan, Reglan)
- Antihistamines (Meclizine, diphenhydramine)
- Benzodiazepines prn (Valium, Ativan)
- Epley maneuver
- Antivirals for Ramsey Hunt (Herpes Zoster Oticus)
- R/o central vertigo
- clinical exam or imaging prn (often MRI)
- HINTS exam
What is Bells Palsy
- Paralysis of the facial muscle due to inflammation of the facial nerve CN 7
- Onset tends to be sudden
often over a day or two
Bells Palsy is most often linked to
- reactivation of HSV
- Also, VZV, CMV, EBV, flu, Cocksackie
- Frequently c/o recent URI
Bells vs stroke
Bells: loss of forehead and brow movement
Stroke: preservation of forehead and brow movement
tx of unilateral facial palsy
- Steroids- Prednisone 60mg qd x 1 week
- Antivirals if severe-
Valacylovir 1000mg TID x 1 week - Eye care- Artificial tears q hour; lacrilube at night; may use eye patch at night
- Follow up w/ PCP, optho
-May take weeks to months, recovery can be variable
What imaging should you get for a suspected cord injuries
CT is better for fractures and can miss ligamentous injuries
MRI has the most sensitive view of the ligaments and neural structures
Describe Anterior cord SC injury
- ie – diving board injury
- Complete loss of pain, temp and motor function below the lesion
- Poor prognosis
Describe central cord injury
- Hyperextension ie – MVC**
- Loss of motor function>sensory loss; some decreased pain and temp
- Greater in upper > lower extremities.
- good prognosis
Describe cauda equina
- : ie Disc prolapse, tumor
- decreased bowel/bladders sensation
- saddle anesthesia.
- Good prognosis
Describe Brown Sequard Syndrome
- : transverse hemisection of cord
- loss of proprioception and vibratory sensation;
- contralateral loss of pain and temp.
- good prognosis
