Neuro EM Flashcards
status epilepticus - defined
*one seizure episode lasting > 30 min OR multiple seizure episodes without a return to neurologic baseline/consciousness
status epilepticus - clinical presentation
*generalized, bilateral tonic-clonic movements in the setting of impaired mental status for > 5 min
status epilepticus - management
*after ABCs:
1. benzodiazepines: diazepam, lorazepam, or midazolam
2. if unsuccessful at halting seizure activity after TWO doses: give an antiseizure med (valproic acid, levetiracetam, or phenytoin)
3. after seizure cessation: EEG, full neuro exam, additional diagnostic evaluation
intracranial hemorrhage (ICH) - risk factors
- hypertension/hypertensive vasculopathy
- anticoagulant usage (warfarin > direct oral anticoagulants)
intracranial hemorrhage (ICH) - clinical presentation
*rapid development of neurologic symptoms, including: headache, vomiting, decreased levels of consciousness
*neuro sx greatly depend on LOCATION, much like ischemic stroke
intracranial hemorrhage (ICH) - diagnosis
*non-contrast head CT: visualizes size and location
*labs:
-PT INR
-aPTT
-CBC with platelet count
*ask about anticoagulation usage
intracranial hemorrhage (ICH) - Spot sign
*high-yield marker that suggests increased risk for hemorrhage expansion
*characterized by: small focal areas of contrast enhancement within a hemorrhage on CTA; looks like a BRIGHT WHITE DOT inside the hemorrhage; linked to poorer outcomes and higher mortality
intracranial hemorrhage (ICH) - Swirl sign
*high-yield marker that suggests increased risk for hemorrhage expansion
*characterized by: rounded, linear, or irregular regions that are hypodense inside the hemorrhage
intracranial hemorrhage (ICH) - management
2 cornerstones of rapid therapy that must occur ASAP in the ED:
1. anticoagulation reversal: discontinue all anticoagulative agents & reverse their effects:
-warfarin reversal = IV vitamin K AND 4-factor prothrombin complex concentrate (PCC)
-heparin reversal: protamine sulfate
2. BP management: preferred agents = clevidipine drip > nicardipine drip, labetalol, esmolol, or enaliprilat
-for SBP 160 to 220, target ~140 SBP
-for SBP > 220, target ~140-160 SBP
eligibility for IV thrombolysis (tPA/alteplase) and/or endovascular thrombectomy (EVT) in acute strokes
*tPA/alteplase: onset of symptoms < 4.5 hours
*EVT: onset of symptoms <24 hours
top predictive symptoms for stroke
- facial paresis
- arm drift/weakness
- abnormal speech (either dysarthria or language comprehension)
acute stroke - workup
- CT head - looking for hemorrhage vs. ischemia
-
fingerstick glucose - correct immediately if < 60
note - if 1 and 2 are performed and negative, you can likely give tPA safely - CTA
acute stroke - dispo
*ALL patients who receive tPA get admitted to the ICU for 24 hours of monitoring
most common bacterial causes of meningitis by age group
- < 1 month old: GBS, E. coli, Listeria m.
- > 1 month old: S. pneumo, E. coli, N. meningitidis, H. influenzae
- > 60 years old: same bugs plus Listeria m.
meningitis - clinical presentation
*pts typically present within 24h of sx
*classic triad: fever, nuchal rigidity, change in mental status
*other sx: headache, fever, GCS < 14
*children/teens: irritability & fever
meningitis - workup
*aka “full septic workup:”
-CBC
-CMP
-lactate
-blood cultures
-early IV fluids (if hypotensive)
-LUMBAR PUNCTURE
lumbar puncture results for meningitis, broken down by causative agent
- bacterial: neutrophils, decreased glucose, increased protein
- viral: lymphocytes, normal glucose, normal/increased protein
- fungal/TB: lymphocytes, decreased glucose, normal/increased protein
note - opening pressure can be very high in BACTERIAL meningitis and HSV encephalitis (>200)
septic meningitis treatment (neonates)
*ampicillin plus cefotaxime OR ampicillin plus gentamicin
septic meningitis treatment (childhood)
*vancomycin, ceftriaxone or cefotaxime
septic meningitis treatment (adult)
*vancomycin, ceftriaxone or cefotaxime
*dexamethasone prior to antibiotics if unknown organism
*ampicillin if > 65yo (covers Listeria)
