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Emergency Medicine > Neuro 2 > Flashcards

Neuro 2 Flashcards

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1
Q

Hallmark sx of concussion/mild TBI

A
  1. confusion
  2. amnesia
  3. +/- LOC*
  4. HA
  5. dizzy
  6. NV
  7. light sensitivity
  8. perseverating
  9. irritability
  10. GCS 13-15
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2
Q

Describe the GCS score of mild, moderate, and severe TBI

A

Mild: 13-15

mod: 9-12
severe: <9

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3
Q

what is a primary concussion injury

A
  • 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
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4
Q

Secondary injury to concussion typically occurs when

A

minutes to days after the event

-intracranial or systemic cause

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5
Q

Prevent secondary injury of concussios by correcting:

A
  1. hypotension
  2. hypoxemia
  3. anemia
  4. hyperthermia
  5. hypoglycemia
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6
Q

Describe the New Orleans Head CT rules for who to image

A
  1. GCS 15 plus 1 of the following:
  2. HA
  3. Vomiting
  4. Age >60
  5. Alcohol/drug intox
  6. Short term memory deficits
  7. Visible trauma above the clavicles
  8. Seizure
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7
Q

Describe the PECARN pediatric head injury algorithm for kids <2y/o

A
  1. GCS 14 or other signs of AMS
  2. Palpable skull fx
  3. any scalp hematoma (except frontal)
  4. LOC >5 sec
  5. Severe MOI
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8
Q

S/S of increased ICP in Infants

A
  1. full fontanel
  2. split sutures
  3. AMS
  4. persistent emesis

**low threshold to scan kids <2y/o, older kids have a more classic presentation

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9
Q

Etiologies of infant/toddlers and school aged head traumas

A

infant/toddler: falls

school age: MVA and sports

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10
Q

Important historical factors for minor head trauma in children

A
  1. age
  2. height of fall
  3. impact surface
  4. LOC at scene
  5. changes in MS
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11
Q

Indications for hospitalization for head trauma

A
  1. Lengthy LOC > 5 minutes
  2. Severe HA , amnesia or vomiting
  3. Somnolence, irritability or confusion
  4. Changes in LOC
  5. Abnormal CT or displaced fractures
  6. Focal deficits on exam
  7. Seizures
  8. Unreliable caretakers
  9. Symptomatic infants
    10 . Suspected child abuse
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12
Q

Describe concussion dispo

A
  1. Observe in ED until patient clears, or at least improving
  2. Home with reliable observer:
  3. Any change in mental status should return
  4. Tylenol preferred over motrin initially
  5. Don’t need to wake, but observe every few hours
  6. Avoid Etoh, Caffeine
  7. REST

*most complications are seen in the first 4hrs

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13
Q

Describe the return to activity guidelines and return to ED guidelines for concussion dispo

A

Return to activity:

  1. no return to place the day of injury
  2. stepwise return to activity

Return to ED:

  1. vomiting more than twice
  2. any change in mental status
  3. worsening HA
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14
Q

Describe the colorado medical system guidelines for return to play

A
  1. Grade I w/o amnesia– 15 min. rest
  2. Grade 2 confusion and amnesia– 1 week rest
  3. 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
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15
Q

s/s of increased ICP in children

A
  1. HA
  2. Stiff neck
  3. Photophobia
  4. AMS
  5. Persistent emesis
  6. Papilledema
  7. Posturing
  8. CN abnormalities

*Bottom Line: low threshold to scan kids <2yo; older kids have a more classic presentation

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16
Q

What is second impact syndrome

A
  1. Second concussive injury while the athlete is still recovering from the first concussion or still experiencing symptoms
  2. May occur days to weeks after first concussion
    * Leads to acute brain swelling resulting in a 50% mortality and 100% morbidity rate
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17
Q

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

A

slower

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18
Q

Sx of post concussive syndrome

A
  1. vague complaints such as HA
  2. dizzy
  3. nausea
  4. inability to concentrate
  5. memory changes
  6. usually lasts several weeks to several months after the injury
  • After 1 year 85-90% have recovered
  • Consider referral to neurology
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19
Q

__ is the third leading cause of death and #1 cause of disability in the US

A

Stroke

8% die within 30 days
20% die within 1 year
16% require inpatient rehab

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20
Q

Blood reaches the brain through 4 major vessels:

A
  1. 2 carotid arteries (80% of cerebral blood flow)
  2. 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

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21
Q

Describe the anterior circulation

A
  1. originates from internal carotid arteries
  2. carotid arteries branch into:
    - anterior and middle cerebral arteries at the circle of willis
  3. Anterior circulation supplies the optic nerve, retina, frontoparietal nerve and anterotemporal lobes of the brain
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22
Q

Describe the posterior circulation

A
  1. Derived from two vertebral arteries
    - Vertebral arteries branch into the basilar artery which forms the posterior cerebral arteries
  2. Posterior circulation supplies the brainstem, cerebellum, thalamus, auditory and vestibular functions
  3. Brainstem function affects normal consciousness, movement and circulation
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23
Q

Signs of anterior cerebral artery infarct

A
  1. contralateral leg weakness
  2. sensory changes
  3. leg»arm
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24
Q

Signs of middle cerebral artery infarct

A
  1. Most common (90% of Anterior Strokes)
  2. Contralateral hemiparesis and hemisensory changes
  3. (arm, face > leg)
  4. Leg may be spared; arm and face most often involved
  5. Aphasia (dominant hemisphere) or
  6. hemineglect (non dominant hemisphere)
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25
Q

Describe sx of posterior circulation syndrome

A
  • 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)
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26
Q

Describe sx of Lacunar infarct syndrome

A
  1. pure motor or sensory deficits due to infarction of small penetrating arteries
  2. associated w/ chronic HTN
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27
Q

Causes of ischemic strokes (80%)

A
  1. thrombotic: secondary to atherosclerotic lesion
  2. Emoblic: caused by obstructive emboli from cardiac or prox. vessles sourecs, afib, recurrent MI
  3. Small artery or lacunar: from uncontrolled HTN
  4. 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
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28
Q

Risk factors for ischemic stroke

A
  1. age
  2. Heredity/race
  3. Gender
  4. Prior CVA, TIA
  5. Atrial fibrillation/heart disease
  6. Carotid stenosis
  7. DM
  8. Hyperlipidemia
  9. HTN
  10. Smoking
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29
Q

hemorrhagic strokes (ICH) is associated w/ what

A
  1. associated w/ increased ICP and
  2. secondary vasconstriction
  3. baseline weakened arterioles
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30
Q

hemorrhagic strokes (nontraumatic SAH) is associated w/ what

A
  1. berry aneurysm rupture
  2. AVMs
  3. may be preceded by a sentinel HA/bleed
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31
Q

Risk factors for hemorrhagic stroke

A
  1. HTN
  2. tobacco
  3. alcohol
  4. hx of previous CVA
  5. race (AA, asian)
  6. increasing age
  7. cocaine
32
Q

Headache and Vomiting are more consistent with a ___ stroke

A

hemorrhagic (NOT ISHCEMIC STROKE)

33
Q

Irreversible neuronal injury w/ ischemic strokes occur within __
___appears to be the cutoff time before the pneumbra is lost

A

minutes

6 hrs

34
Q

Describe the EMS management of stroke

A
  1. O2
  2. Iv access
  3. labs
  4. 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%

35
Q

Key hx question for stroke management

A

History should guide you to also consider and/or r/o other causes – hypoglycemia, seizure, migraine, drug toxicity, conversion disorder

36
Q

Describe the general managment for a stroke

A
  1. ABCs, IV access, cardiac monitor
  2. Oxygen >92%
  3. NPO
  4. Glucose evaluation
  5. “Permissive Hypertension”
  6. ? TPA <3 – 4.5 hrs
  7. Elevate HOB to 30 degrees if increased ICP
37
Q

Describe the NIHSS scoring to help determine the prognosis of a stroke

A

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

38
Q

Door to CT completion time for a stroke is __

A

25 minutes

39
Q

Why do you get a CT for a stroke

A
  1. 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
  2. Most early ischemic changes are not usually seen on initial CT (need MR)
40
Q

if a Pt woke up with a neuro deficit (stroke like), ask ___

A

when was she last normal?

**assume it was when they were last normal even if that was more than 1 hr ago

41
Q

Other studies to get w/ a stroke

A
  1. EKG
  2. CXR
  3. CBC
  4. Chem7
  5. Coagulation studies
  6. Cardiac enzyme
  7. CTA or MRI - w/ neuro consult
42
Q

What is BP goal w/ stroke care when someone is a TPA candidate and when they are NOT a TPA candidiate

A

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

43
Q

tPA may be given if what criteria are met?

A
  1. Measureable diagnosis of Acute Ischemic Stroke
  2. Patient is > 18 years old
  3. Less than 4.5 hrs since symptom onset

BUT, observe 3 hour cut off if

  1. > 80yo
  2. previous stroke/DM
  3. active anticoagulant
  4. NIHSS>25
  5. multilobar infarct on CT
44
Q

What families need to know about thrombolytics

A
  1. 30% greater chance of improved clinical outcome at 3 months and 1 year with rt-PA
  2. 6% have a bleed associated with early worsening
    - No significant difference in mortality at 3 months or 1 year despite the increased hemorrhage rate
45
Q

Increased risk of hemorrhage with w/ thrombolytics if:

A
  1. NIHSS > 22,
  2. treatment > 3 hours,
  3. significant CT findings,
  4. elevated B/P

**The earlier, the better

46
Q

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 __

A

standard of care

47
Q

Management of heomorrhagic CVA

A
  1. Regulate blood pressure
  2. Control of brain edema
  3. Anti epileptics?
  4. Neurosurgical consultation
48
Q

What is TIA

A

Defined as a “ transient episode of neurological dysfunction caused by brain ischemia without acute infarction on imaging”
Ie - Negative CT scan

49
Q

TIA is associated w/ high risk for stroke in the first __- highest risk within ___

A

90 days;

48 hours

50
Q

Tx of TIA

A
  1. antiplatelet medications (ASA, Plavix etc);
  2. Coumadin if high risk for cardiac emboli
  3. New onset TIA should be evaluated for cardiac sources of TIA: echocardiogram, carotid US
51
Q

Describe the dispo of TIA patients

A
  1. recommend hospitalizing TIA patients who present within 72 hours of symptom onset and are high risk
  2. If not hospitalized, need additional imaging within 24-48 hours
    - CTA, MRA and/or carotid US
52
Q

Describe TIA risk stratification

A
  1. Age (>60=1)
  2. BP (>140/90=1)
  3. Clinical features of TIA (unilateral weakness=2, speech disturbance w/o weakness =1)
  4. Duration of sx (>60min=2, 10-59 min=1, <10min=0)
  5. 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

53
Q

Dizzy can be:

A
  1. Otologic/vestibular 33%
  2. cardiovascular
  3. resp.
  4. neurolgocial
  5. metabolic
  6. psych 7%
54
Q

Illusion of motion; acute asymmetry of vestibular system

A

vertigo/vertinginous

55
Q

Prodromal symptom of fainting or a near faint; palpitation

A

presyncope/LH

56
Q

Sense of imbalance that occurs primarily when walking

A

Dysequilibrium/ ataxic

57
Q

Mismatch of the perception of movement by the visual, vestibular and proprioceptive systems
A sensation of movement when none exists

A

vertigo

58
Q

Peripheral vertigo is caused by:

Central vertgio is from:

A

is caused by dysfunction of the inner ear or vestibular nerve (BPPV, vestibular neuritis, menieres)

is from etiologies of the brain and brain system

59
Q

Sx of peripheral vertigo

A
  • 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)

60
Q

sx of central vertigo

A

(CVA)

  1. CN deficits
  2. vertical nystagmus
  3. ataxia

*Classically, central lesions tend to have ‘softer’ clinical findings, peripheral often presents with violent vomiting, reproduciel symptoms.

61
Q

Key PEX parts of dizzy

A
  1. Eyes: nystagmus- suggests vertigo; vertical/rotary vs lateral
  2. ears: infection, perforation, hearing fxn
  3. 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

62
Q

Describe BPPV

A

MC*

  1. otoliths in semicircular canal
  2. Recurrent episodes with head turning.
  3. no hearing loss or tinnitus
  4. Rx w/ Dix Hallpike Epley
63
Q

Describe Neuritis

A
  1. commonly postviral, affecting vestibular portion of 8th CN.
  2. Sudden onset,
  3. occ hearing loss/
  4. tinnitush.
64
Q

Describe Menieres

A
  1. Attributed to excess endolymphatic fluid
  2. recurrent bouts of vertigo, tinnitus and hearing loss. Dx requires multiple episodes.
  3. Less acute onset.

*Less common (10%)

65
Q

Other common causes of peripheral vertigo

A
  1. Closed Head Injury: vertigo may persist for weeks after trauma
  2. Ototoxicity: common offenders include salicylates, aminoglycosides (Tobramycin, gentamycin)
66
Q

Causes of central vertigo

A
  1. Cerebellar hemorrhage/infarct
  2. Vertebral basilar ischemia
  3. Multiple sclerosis
  4. Vertebral artery dissection
67
Q

tx of peripheral vertigo

A
  1. IVF
  2. Antiemetics/antidopinergic (Phenergan, Reglan)
  3. Antihistamines (Meclizine, diphenhydramine)
  4. Benzodiazepines prn (Valium, Ativan)
  5. Epley maneuver
  6. Antivirals for Ramsey Hunt (Herpes Zoster Oticus)
  7. R/o central vertigo
    - clinical exam or imaging prn (often MRI)
    - HINTS exam
68
Q

What is Bells Palsy

A
  1. Paralysis of the facial muscle due to inflammation of the facial nerve CN 7
  2. Onset tends to be sudden
    often over a day or two
69
Q

Bells Palsy is most often linked to

A
  1. reactivation of HSV
  2. Also, VZV, CMV, EBV, flu, Cocksackie
  3. Frequently c/o recent URI
70
Q

Bells vs stroke

A

Bells: loss of forehead and brow movement

Stroke: preservation of forehead and brow movement

71
Q

tx of unilateral facial palsy

A
  1. Steroids- Prednisone 60mg qd x 1 week
  2. Antivirals if severe-
    Valacylovir 1000mg TID x 1 week
  3. Eye care- Artificial tears q hour; lacrilube at night; may use eye patch at night
  4. Follow up w/ PCP, optho
    -May take weeks to months, recovery can be variable
72
Q

What imaging should you get for a suspected cord injuries

A

CT is better for fractures and can miss ligamentous injuries

MRI has the most sensitive view of the ligaments and neural structures

73
Q

Describe Anterior cord SC injury

A
  1. ie – diving board injury
  2. Complete loss of pain, temp and motor function below the lesion
  3. Poor prognosis
74
Q

Describe central cord injury

A
  1. Hyperextension ie – MVC**
  2. Loss of motor function>sensory loss; some decreased pain and temp
  3. Greater in upper > lower extremities.
  4. good prognosis
75
Q

Describe cauda equina

A
  1. : ie Disc prolapse, tumor
  2. decreased bowel/bladders sensation
  3. saddle anesthesia.
  4. Good prognosis
76
Q

Describe Brown Sequard Syndrome

A
  1. : transverse hemisection of cord
  2. loss of proprioception and vibratory sensation;
  3. contralateral loss of pain and temp.
  4. good prognosis

Emergency Medicine (22 decks)

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