Neuro Emergencies Flashcards
What is the GSC score of
- mild
- moderate
- severe
TBI?
mild: 13-15
moderate: 9-12
severe: less than 8
Guidlines for CT scan in the ER
GCS less than 15
suspected open/depressed skull fx
any sign of basil fracture
two or more episodes of vomiting
65yrs or older
amnesia before impact of 3 or more minutes
dangerous mechanism (MVA)
bleeding diathesis or oral anticoagulant use
seizure
focal neuro sign
intoxication
TBI: who do we hospitalize?
Outpatient signs to return to ER.
- GCS less than 15
- abnormal CT
- Seizures
- Abnormal bleeding parameters
Signs:
- worsening HA, vomiting, confusion
- inability to awaken patient
- urinary/bowel incontinence
- seizures
- stiff neck
- etc….
How do you repair a scalp laceration?
- Anesthatize wound edges w/ lidocaine 1-2% with epinephrine
- debride and irrigate
- sutures/staples
…palpate the skull for depression or “step off”….fracture
What are the clinically significant skull fractures?
How long will it take for skull fx to heal in adults and children?
- pass through an air filled space (sinuses)
- associated with an overlying scalp laceration
- depressed below the level of the skulls inner table
- overlie a major dural venous sinus or the middle meningeal artery (especially a linear skull fx)
Heal:
adults: 3 years
children: 3-6months
Explain what happens with a basilar skull fx
linear fx at the base of the skull, this often causes a dural tear producing a communication between the subarachnoid space, the paranasal sinuses, and the middle ear.
- may produce CSF leak through the nose
What is considered open skull fx? Tx?
-defined as open if there is an overlying scalp laceration and the dura is disrupted, and/or a fx that disrupts the paranasal sinuses or middle ear structures.
Tx:
debridement and irrigation
What are the primary HA syndromes? Signs/sx and Tx of each
Migraine: unilateral, throbbing, aura, nausea, vomiting, photosensitivity
Tx: 1st line = tryptans
2nd line = Ketorolac (torodol) + antiemetic (Reglan, compazene) + Ibuprofen
Cluster HA: seen in middle aged med, ice pick pain behind the eye
Tx: 1st line = 100% O2
2nd line = sumatriptan
Thunderclap HA:
-worse HA of your life!!! if you have migraines this is different.
What are some potentially life threatening causes of HA?
- subarachnoid hematoma
- bacterial meningitis
- cerebral ischemia
- subdural hematoma
- brain tumor
Status/Seizure management
- airway management
- thiamine (alcoholics)
- Benzodiazepine (Lorazapam/ativan, Valium/diazapam)
- narcan, dextrose bolus (for opiod overdose)
2nd line:
-phenytoin (does not suppress the electrical activity andd takes 20mins to onset, benzodiazepine support should be continued)
AND
phenobarbital (causes sedation)
What are the Central, somatic, and peripheral causes of vertigo?
Central:
- migrainous
- brainstem ischemia
- cerebellar infarction & hemorrhage
- MS
Somatic:
-panic attack
Peripheral:
- benign paroxysmal positional vertigo
- vestibular neuritis
- herpes zoster oticus
- Labyrinthitis
- aminoglycoside toxicity
- otitis media
How do you differentiate between central and peripheral vertigo?
N/V, last few minutes to 2-3hrs, are recurrent = peripheral
Gait disturbances, lasts hours to days = central
TIA work up for
- low flow
- embolic
- lacunar
Low flow:
- internal carotid: Duplex US or transcranial doppler
- MCA: MRA or CT angiography
- Vertebrobasilar:CT angiography
Embolic:
- echocardiography
- EKG
Lacunar: r/o others; dx of exclusion
What is the difference between Positive and Negative Sx?
Positive: indicate active discharge from CNS neurons (e.g. visual, auditory, somato-sensory, motor)
Negative: indicate absence or loss of function (e.g loss of vision, feeling or ability to move a part of the body)
CVA management; immediate studies
- noncontrast CT or MRI
- EKG
- CBC w/ platelets
- CMP
- glucose
- PTT, PT, INR
- O2 saturation
- pregnancy test
- blood cultures in 2 different sites
ischemic: dont treat BP unless SBP greater than 220 or DBP greater than 120
- TPA within 3-4.5hrs
hemorrhagic: SBP 140-160
* if on warfarin need to give Vit K/FFP
