Neuro Emergencies Flashcards
- Consciousness has 2 main components what are they?
2. Describe how they are different in Delirium and Dementia?
- Arousal and Cognition.
- Delirium: alteration of both arousal and cognition. Dementia: alteration in cognition, not arousal
- Arousal is controlled by the what?
2. Cognition is controlled by ?
- ascending reticular activating system (ARAS) in the brainstem.
- cerebral cortex.
AMS - PE
3
- ABCs; Vital signs
- Bedside glucose
- Look quickly for immediate life threats
AMS PE
Look quickly for immediate life threats, such as:
5
- Hypoglycemia
- Hypotension/ Hypertension
- Hypoxia
- Abnormal respirations
- Hypo/ Hyperthermia
AMS PE Head to toe exam 1. Head? 5 2. Neck? 1 3. CV? 3 4. Pulm? 1 5. Abd? 2 6. Skin? 4
- Head –
- trauma;
- Pupil size, symmetry, and reactivity.
- Pinpoint pupils: OD vs pontine hemorrhage;
- Blown pupil: uncal herniation;
- Fundi: papilledema - Neck – stiffness?
- CV –
- dysrhythmia (atrial fib),
- murmurs (endocarditis),
- rubs (pericarditis) - Pulm-
- symmetry of sounds, rate, wheezes - Abd –
- masses?
- Organomegaly? (alcoholic liver, splenic sequestration in sicklers) - Skin –
- color,
- turgor (dehydration);
- rashes (petechiae, purura: TTP vs meningococcemia?);
- Infection (cellulitis, fasciitis)
AMS – DDx: AEIOU TIPS
A – Alcohol E – Epilepsy; Electrolytes; Encephalopathy (HTN, Hepatic) I – Insulin (hyper and hypo); Intuss (peds) O – Overdose; Opiates U – Uremia T – Trauma; Temperature (Hyper and hypo) I – Infection; Intracerebral hemorrhage P – Psych; Poison S - Shock
When would you intubate?
GCS less than 8
Are they brain dead/herniating?
PE?
6
- DTR
- Cranial nerves best they can
- responsive to pain
- suction and see if they have a cough or gag reflex
- dolls eye test- stays in line is bad
- anyone with a blown pupil is uncle herniation until proven otherwise
Status Epilepticus
1. Considered how long without return to preconvulsive neurologic baseline?
- Traditionally considered to be convulsions > ______, however do not halt treatment!
- 5 minutes or more of convulsions or 2 or more convulsions in a 5 min interval
- 30 min
Status Epilepticus
Etiologies
6
- Vascular: stroke, SAH, hypoxic encephalopathy
- Toxic: drugs, alcohol withdrawal, medications (Isoniazid, TCA’s, chemo agents), AED non-compliance
- Metabolic: Hyper/hypo-natremia, hypoglycemia, hypocalcemia, liver/renal failure
- Infectious: meningioencephalitis, brain abscess
- Trauma
- Neoplastic
Initial Assessment/Treatment of status epilepticus
3
1, ABC’s – O2, airway, BP
Monitor for hypotension
2. Labs:
3. Dx hypoglycemia as cause
Initial Assessment/Treatment of status epilepticus
5
- CBC,
- BMP,
- Ca,
- Mg,
- AED levels
How would you treat status epilepticus if hypoglycemia was the cause? 2
- D50W amp and Thiamine 100 mg IV
- Needs to have thiamine given before dextrose as 20-40% of seizure pts are alcoholics
Treatment for status epilepticus:
- Initially? 2
- Then? 2
- Refractory? 4
- Benzodiazepines are first line
Ativan 4mg IV or Valium 5mg IV - Second line
-Fosphenytoin load 20 mg/kg (up to 150 mg/min)
-Valproic acid load 40 mg/kg, 2nd dose of 20 mg/kg - Refractory status
- Phenobarb 20 mg/kg,
- Pentobarb,
- Versed gtt,
- Propofol, etc.)
Post-ictal State
- What do we have to differentiate this from?
- What does the post ictal state consist of? 4
- tx?
- Work up?
- Differentiate post-ictal state and syncope of another cause
- Post-ictal state
- Usually sleepy and may be confused
- During the possible prior seizure the pt has usually been incontinent
- Tongue bitten - Supportive care
- Work up why seizure occurred
Acute Ischemic Stroke
- Caused by? Results in?
- Within seconds to minutes of loss of perfusion, an ischemic cascade occurs resulting what?
- Goal of tx?
- Caused by the sudden loss of blood circulation to an area of the brain resulting in ischemia and corresponding loss of neurologic function
- a central area of irreversible infarction surrounded by an area of potentially reversible ischemic penumbra
- Goal of treatment is to preserve ischemic penumbra
Acute Ischemic Stroke
Hx questions?
4
- Time last known well
- tPA contraindications?
- History of diabetes? Seizures?
- Detailed description of symptoms
Acute Ischemic Stroke
Detailed description of symptoms such as
1. What would indicate ICH? 3
- What about a vertebral or carotid dissection? 2
- Onset with HA,
- seizure,
- syncope .. Possible ICH..
- Neck pain,
- history of neck trauma ..
Possible vertebral or carotid dissection
PE for acute ischemic stroke?
7
- Level of consciousness
- Eye exam
- CN exam
- Motor exam
- Sensory exam
- Reflexes
- Cerebellar exam
Work up: Acute ischemic stroke:
- Labs? 6
- Imaging?
- Labs:
- POCT BG,
- CBC,
- CMP,
- PT/INR,
- cardiac enzymes,
- EKG - Imaging:
- Emergent non-contrast head CT
Why do we do a noncontrast CT for acute ischemic stroke? 3
- Distinguished hemorrhagic from ischemic stroke
- Defines age and anatomic distribution of stroke
- Large hypodense areas seen within 3 area can indicate timing of AIS and can predict poor outcome
ED-Based Care
Action Time:
1. Door to clinician ___ minutes
2. Door to stroke team ____ minutes
3. Door to CT initiation ____ minutes
4. Door to CT interpretation ____ minutes
5. Door to drug (≥80% compliance) ____ minutes
6. Door to stroke unit admission: How long?
- ≤10
- ≤15
- ≤25
- ≤45
- ≤60
- ≤3 hours
ACA stroke symptoms?
4
- Dysarthria, aphsasia
- Unilateral contralateral motor weakness (lower > upper)
- Lower extremity sensory changes
- Urinary incontinence
MCA stroke symptoms? 4
- Contralateral hemiparesis (face/arms > legs) and hemianopsia
- Ipsilateral gaze preference
- Aphasia (if dominant hemisphere)
- Broca’s/Wernike’s/Global
Hemi-neglect (if non-dominant hemisphere)
PCA stroke symptoms? 4
- Contralateral hemianopsia
- Cortical blindness
- Altered mental status
- Impaired memory
Initial Treatment
for ischemic stroke?
7
ABCD’s
1. Airway: intubate for GCS
Thrombolytics for Tx of ischemic stroke:
- What is the drug?
- Considered in eligible patients treated within how long of symptom onset?
- Alteplase (IV tPa)
- 9 mg/kg w/ max dose of 90 mg
- 3-4.5 hours
Thrombolytics for Tx of ischemic stroke:
Indications? 3
- Acute neurological deficit expected to result in significant long-term diasability
- Non-contrast head CT w/ no hemorrhage
- Stroke symptom onset clearly identified between 3-4.5 hours before tPa given
tPa Contraindications
8
- SBP > 185 or DBP > 110 (Labetolol 10mg q10 min)
- CT head w/ ICH or SAH
- Recent intracranial or spinal surgery, head trauma or stroke (> 3 mos)
- Major trauma or surgery within 3 mos
- Hx of ICH or aneurysm/vascular malformation/brain tumor
- Recent active internal bleeding
- Platelets 40; INR > 1.7
- Known bleeding disorder
2013 AHA Guidelines
for tPA
9
- Give IV tPA in patients who meet 3 hour criteria (IA)
- Getting it within window is not enough, shoot for the 2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arterial rtPA (Class III; Level of Evidence C)
Mechanical Thrombectomy
- For pts with what?
- Composed of?
- For patients w/ stroke in large territory vessel of the proximal circulation
- Composed of direct IA tPa and stent removal of clot if necessary
What are the types of intracranial hemorrhages?
3
- Intra-parenchymal hemorrhage (IPH)
- Intra-ventricular hemorrhage (IVH)
- Subarachnoid hemorrhage (SAH)
Intra-Parenchymal Hemorrhage
- Hemorrhage where?
- Often presents how?
- Signs and symptoms depend on what?
- MC signs and symptoms? 4
- Can mimic what?
- Hemorrhage within the brain tissue
- Often clinically silent
- Signs and symptoms depend on location of hemorrhage
- M/C are
- hemiparesis,
- aphasia,
- hemianopsia and
- hemisensory loss - Can mimic acute ischemic stroke symptoms
IPH Etiology
- What is the #1 cause?
- Other causes?6
- Hypertension is #1 cause
- Cerebral amyloid angiopathy
- Anticoagulation/Anti-platelet meds
- Systemic anticoagulated states (eg. DIC)
- Sympathomimetic drugs (eg. Cocaine, MDMA, methamphetamines)
- Aneurysms, AVM’s, Cavernous Angiomas
- Brain tumors
Intra-Ventricular Hemorrhage
- Often results from what?
- S/S can include? 5
- Increased risk of what?
- Often results from IPH extending into ventricular system
- S/S can include
- HA,
- N/V,
- progressive deterioration of consciousness,
- increased ICP,
- nuchal rigidity - Increased risk of obstructive hydrocephalus
IPH/IVH Treatment
6
- ABCD’s
- Intubation if necessary
- SBP goal
Fluid and electrolyte in IPH tx
- Utilize what? Avoid what?
- Watch for?
- Utilize normal saline, avoid dextrose
2. Watch for SIADH/Cerebral Salt Wasting
IPH/IVH Treament Cont
1. Correct underlying coagulopathy such as? 3
- Management of?
- Recombinant Factor VII (NovoSeven)
- Can be beneficial when?
- Risk of? 2 - Surgical evacuation of what?
- Correct Underlying Coagulopathy
- FFP,
- platelet infusion,
- Vitamin K - Management of ICP
- Recombinant Factor VII (NovoSeven)
- Can be beneficial if given within 4 hours
- Risk of MI and AIS - Surgical evacuation of hemorrhage
Subarachnoid Hemorrhage
1. What accounts for 80% of cases?
- Risk factors? 6
- Fatality rate is 50% within?
- Aneurysmal rupture accounts for 80% of cases
- Risk factors:
- HTN,
- smoking,
- advanced age,
- cocaine use,
- alcohol use,
- connective tissue disorders - Fatality rate is 50% within 2 weeks
SAH signs and symptoms
6
- Sudden onset “worst headache of life”
- CN III palsy (PCOMM aneurysm)- ‘Down and out’ gaze, ptosis
- CN VI palsy (increased ICP)
- Inability to look out - Retinal hemorrhages
- Altered mental status
- Nuchal rigidity
SAH Treatment ABCD’s 1. Intubation for GCS less than? 2. Treat HTN: SBP goal less than? 3. Maintain what? 2 4. Temperature?
- Tx of vasospasm? 3
Seizure ppx - What clotting promoter would we use?
- what for obstructive HCP?
- 9
- 150
- normo-glycemia and euvolemia
- Normothermia
- Nimodipine,
- Mg gtt
- Statin
- Aminocaproic acid bolus/gtt
Clotting promoter - EVD
SAH Aneurysm Tx
1. What would we do to identify the location of the aneurysm?
- Then?
- CTA and eventual angiography to identify location of aneurysm
- Angiography w/ endovascular coiling - Surgical intervention
Hemicraniectomy w/ surgical vascular clipping
Leading cause of traumatic death in pts under 25?
Head Injury - TBI
Describe the difference between primary and secondary TBI?
- Primary (at time of impact)
2. Secondary (develop over time due to inflammatory and neurochemical responses)
Head Trauma-history
7
- When, where and how injury happened
- Mechanism of injury (Details matter!!)
- If there was LOC at the scene
- If alcohol or drugs were involved
- Length of time from injury
- Underlying medical problems (i.e. diabetes, previous stroke, CVD, etc.)
- Allergies and medications
TBI
1. Once at ER assess neurological status
Use Glasgow coma scale—If pt has deteriorated during transport needs what?
- If patient is stable and not comatose with stable VS and no focal neurologic findings–management?
- Goal is to do what? 3
- immediate non-contrast CT scan and possible neurosurgery consult
- can proceed more slowly
- prevent brainstem or
- uncal herniation and
- brain edema w/ elevated ICP that causes further brain injury
Head Injury - PE
6
- Rapid primary survey
- Vital signs
- Glasgow coma scale
- Examining head for signs of outward trauma (i.e. penetrating trauma, lacerations, swelling, bruises, abrasions etc.)
- Pt should be in cervical spine collar
- Neurological exam
What should we do on the PE for TBI? 3
- Pupils
- Level of alertness
- Look for focal deficits
Describe the following in the glascow coma scale?
- Eye opening 1-4?
- Best verbal response 1-5?
- Best motor response 1-6?
Eye Opening (E)
4 = spontaneous 3 = to voice 2 = to pain 1 = none Verbal Response (V)
5 = normal conversation 4 = disoriented conversation 3 = words, but not coherent 2 = no words, only sounds 1 = none Motor Response (M)
6 = normal 5 = localized to pain 4 = withdraws to pain 3 = Flexion to pain 2 = Extension to pain 1 = none
TBI:
- Initial GCS correlates to what?
- Avoidance of secondary insults by what is extremely important in reducing injury severity? 2
- GCS less than 8: ?
- severity of injury
- hypotension
- hypoxemia
- Intubate
What labs do you want?
for TBI? 4
- Cbc,
- chem,
- coags,
- toxicology
Guidelines for CT Scan in the ER
11
- GCS less than 15
- Suspected open or depressed skull fracture
- Any sign of basilar skull fracture (hemotympanum, raccoon eyes, Battle’s sign, cerebrospinal fluid leak)
- Two or more episodes of vomiting
- 65 years of age or older
- Amnesia before impact of 3 or more minutes
- Dangerous mechanism (ejected from vehicle)
- Bleeding diathesis or oral anticoagulant use
- Seizure
- Focal neurologic sign
- Intoxication
