Neuro Emergencies Flashcards
Altered Mental Status
- PE
- -look for immediate life treats such as…
- DDx
PE
- ABCs
- Vital signs
- look for immediate life threats such as:
- -hypoglycemia
- -hypotension/hypertension
- -hypoxia
- -abnormal respirations
- -hypo/hypertermia
- dont be afraid to give glucose or thiamine based on H and P
DDx AEIOU TIPS -Alcohol -Epilepsy, Electrolytes, encephalopathy -Insulin, intussiception -Overdose, opiates -Uremia -Trauma, temperature -Infection, Intracerebral hemorrhage -Psych, Poison -Shock
Status Epilepticus
- definition
- causes
- assessment
- Tx
Definition
-5 or more minutes of convusions or two or more convulsions in a 5 min interval without return to baseline
Causes
- vascular: stoke, SAH, hypocic encephalopathy
- toxic: drugs, achohol, meds
- Metabolic: hypo/hypernatremia, hypoglycemia, hypocalcemia, liver/renal failure
- Infectious: meningioencephalitis, brain abscess
- Trauma
- Neoplastic
Assessment
- ABCs- O2, airway, BP
- labs: CBC, BMP, Ca, Mg, AED levels
Tx
- Thiamine BEFORE D50W
- Benzodiazepines are first line (ativan or valium)
- second line: fosphenytoin, valproic acid
Acute Ischemic Stroke
- PE
- labs
- imaging
- Tx
PE
- level of consciousness
- Eye exam
- CN exam
- motor exam
- sensory exam
- reflexes
- cerebellar exam
Labs
-POCT BG, CBC, CMP, PT/INR, cardiac enzymes, EKG
Imaging
-emergent NON-CONTRAST head CT
Tx INITIAL Tx -ABCDs --Airway (intubate if GCS is less than 8 or inability to protect airway) --Breathing --Circulation (allow permissive HTN: 220/110) --Dextrose -Fever: hyperthermia worsens outcome -Cerebral edema -Seizure control
Thrombolytics (if within 3-4.5 hours of symptom onset)
What is mechanical thrombectomy?
direct tPa and stent removal of clot for pts with stroke in large territory vessel of the proximal circulation
What are the types of intra-cranial hemorrhages?
Intra-parenchymal hemorrhage (IPH)
-within the brain tissue
Intra-ventricular hemorrhage (IVH)
Subarachnoid hemorrhage (SAH)
Intra-parenchymal hemorrhage (IPH)
- sx
- MC cause
Intra-ventricular hemorrhage (IVH)
- cause
- sx
Tx of both
Intra-parenchymal hemorrhage (IPH)
Sx
-hemiparesis, aphasia, hemianopsia and hemisensory loss (can mimic actue ischemic stroke)
MC cause is HTN
Intra-ventricular hemorrhage (IVH)
Cause
-often results from IPH extending into ventricular system
Sx
-HA, N/V, progressive deterioration of consciousness, increased ICP, nuchael ridigity
Tx
- ABCD
- fluid and electrolyte management
- prevent hyperthermia
- seizure ppx
- correct underlying coagulopathy (FFP, platelet infusion, vit K)
- Management of ICP
- Recombinant factor VII (if within 4 hours)
- surgical evacuation of hemorrhage
Subarachnoid Hemorrhage
- risk factors
- signs and sx
- what is the classification system we could use when talking to the neurologist about SAHs to sound really smart?
- tx
Risk Factors
-HTN, smoking, advanced age, cocaine use, alcohol use, CT disorders
Signs and sx
- “worst HA of life”
- CN III palsy (down and out gaze, ptosis)
- CN VI palsy (inability to look out)
- retinal hemorrhages
- altered mental status
- nuchal rigidity
Hunt-Hess Classification (its on slide 43)
Tx
- ABCD
- Tx of vasospasm (Nimodipine, Mg gtt and statin)
- seizure pps
- aminocaproic acid blous/gtt
- -clotting promoter
- EVD for obstructive HCP
- CTA and angiography to ID location of aneurysm
- angiography w/endovascular coiling
- surgical intervention
- -hemicraniectomy w/ surgical vascular clipping
What is the Monroe-Kellie Concept?
ICP is a function of the volume* and compliance* of each component
volume of brain and constituents inside the cranium is fixed and cannot be compressed
What are the initial compensatory mechanisms of increased ICP?
Causes of increased ICP
Initial
- displacement of CSF into thecal sac
- decrease in cerebral venous blood
Causes
- intracranial mass
- cerebral edema
- increased CSF production
- decreased CSF absorption
- obstructive hydrocephalus
- obstruction in venous outflow
- idiopathic
Increased ICP
- signs and sx
- ICP monitoring indications
- noninvasive monitoring techniques
Signs and sx
- HA
- vomiting
- Altered consciousness
- seizures
- papilledema
- unequal and/or unreactive pupils
- cushings triad: bradycardia, HTN, abnormal respirations…impending herniation
Monitoring indications
- abnormal CT showing mass effect and//or midline shift
- GCS less than 8
- high risk for increased ICP (closed head injury)
Noninvasive
- ocular sonography
- transcranial doppler
- intra occular pressure measurement
- tympanic membrane displacement
Increased ICP
-management
- optimize cerebral venous outflow (elevate head)
- prevent fever: APAP and cooling blankets
- hyperventilation-ish: to lower PaCO2 levels (PaCO2 of 35-38)
- intubation: hypoxia and hypercapnea can increase ICP, so dont let that happen
- mannitol: its an osmotic diuretic that draws free water out of the brain and into circulation, monitor sodium…
- hypertonic saline (3%)
- sedation: decreased metabolic demand (propofol)
- -heavy sedation and paralysis used in refractory ICP
-craniectomy
what defines cushing triad?
bradycardia, HTN, abnormal respirations
A patient presents with right sided hemianopsia and memory loss. this is indicative of an ischemic stoke of what vessel?
PCA
Which of the following is not an effective measure of decreasing elevated intracranial pressure?
a) heavy sedation/paralysis
b) hypertonic saline infusion
c) surgical craniectomy
d) induced hypoventilation
d) induced hypoventilation
A pt arrives with AMS along with the following head CT (slide 82). which of the following is this indicative of?
slide 82… maybe it will be a test question
