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Emed/Surg Exam 2 🚑 (ASL) > Neuro Emergencies 🏌️‍♂️(Lauren🌭) > Flashcards

Neuro Emergencies 🏌️‍♂️(Lauren🌭) Flashcards

1
Q

How might someone with increased ICP present?

A

Headache

NV

Papilledema

Fixed pupil(s)

Decreased consciousness

Decorticate or decerebrate posturing

Cushing’s triad (ominous)

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2
Q

What 3 things are in Cushing’s triad? What does Cushing triad indicate?

A

Bradycardia

Hypertension

Respiratory depression

Indicates increased ICP

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3
Q

What do you need to do to work up someone you suspect has increased ICP?

A

Neuro exam (motor/sensory/reflexes, gait)

Cereballar testing

GCS score

Cranial nerve testing

And here are some labs you would consider ordering, although the specific lab depends on the cause:

Type and cross

CBC

BMP

Osmolality

Toxicology screen

Blood alcohol

Glucose

PT/INR

CT/MRI

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4
Q

What kinds of things can cause increased ICP?

A

TBI/ intracranial hemorrhage

CNS infection

Ischemic stroke (hypoxia—> necrosis —> swelling)

Neoplasm

Vasculitis

Hydrocephalus

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5
Q

When you call neurosurgery for increased ICP, what 2 proceudeures might they do?

A

Decompressive craniectomy (remove piece of skull)

Ventriculosotiomy ( draw fluid from ventricles)

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6
Q

Why is it important to OXYGENATE patients with increased ICP? (even if their pulse ox is normal)

A

Because any amount of hypoxia + hypotension will cause a vasodilation response which will increase ICP even more

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7
Q

What can you do as a lowly PA to help someone with increased ICP?

A

Elevate bed to 30 degrees

Analgesia and sedation

Treat fever AGGRESSIVELY (Tylenol + mechanical cooling)

Monitor ICP and keep it under 20

Mannitol- diuresis decreases brain volume

Anti-seizure meds (prevent seizure cause that will increase ICP too)

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8
Q

What symptoms in someone with a skull fracture should make you start lubing up your ET tube cause you are probably gonna have to intubate them

A

AMS

Cranial nerve/neuro deficits

Scalp laceration/contusion

Bony “Step-off” (depressed fracture)

Periorbital or retroauricular ecchymosis

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9
Q

What are the 3 types of skull fracture

A

Linear

Depressed

Basilar

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10
Q

What is a linear fracture

A

Single fracture, no big deal

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11
Q

What do you do if someone has a linear Skull fracture but, the CT was normal and they have no neurological deficit?

A

Observe in ED for 4-6 hrs

Send them home with a responsible caretaker

IF YOU HAVE ANY CONCERN OF BRAIN INJURY YOU NEED TO ADMIT THEM

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12
Q

What is a depressed skull fracture?

A

Segment of the skill is driven below the level of the adjacent skull.

Usually involves injury to Brain

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13
Q

Do depressed skull fractures have a high risk of CNS infection?

A

Yes (from skin bacteria). Do not probe their fracture lol

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14
Q

What do you need to do to manage a depressed skull fracture?

A

CT scan

Admit to neurosurgery

Tetanus shot

Prophylactic antibiotics

Anticonvulsants

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15
Q

What is a basilar skull fracture?

A

A fracture that can produce a dural tear resulting in communication between subarachnoid space, parang Sal sinus, and the middle ear

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16
Q

What is one of the first clues that your patient might have a basilar skull fracture?

A

Clear/blood tinged fluid coming from their nose or ear

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17
Q

What is this:

Retroauricualur or mastoid ecchymosis

A

Battle sign

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18
Q

What are battle sign and raccoon eyes indicative of

A

Basilar skull fracture

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19
Q

How long after suffering from a basilar skull fracture will Battle sign and Racoon eyes show up?

A

1-3 days later

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20
Q

Which kind of skull fracture may have hemotympanum (blood behind TM)

A

Basilar

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21
Q

If someone has battle sign, racoon eyes, hemotympanum, and otorrhea/rhinorrhea, can we predict that they probably have a significant head injury even without injury

A

Um yes

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22
Q

What are the possible risks of basilar skull fracture?

A

CSF leak

Infection

Cranial nerve injurty

Epidural hematoma if through temporal bone

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23
Q

What do you need to do to treat a basilar skull fracture?

A

Admit NO MATTER WHAT

Neuro consult

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24
Q

What causes penetrating skull fractures?

A

Gunshot

Stab

Blast

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25
Q

What do you need to do if someone has a penetrating injury to their skull?

A

Call neurosurgery

IV antibiotics

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26
Q

What is a tangential skull fracture, and what do you do about it?

A

Its like if the bullet just grazed the side of their head.

You need to do an emergency CT scan cause they have a big risk for intracranial hemorrhage

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27
Q

For all skull fractures, what kind of imaging needs to be done?

A

Non-contrast CT scan

MRI if you suspect vascular injury

if no CT is available, do 2 x ray views

CT of cervical spine if they have AMS *****

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28
Q

Why do you need to do a CT of someone’s C spine if they have a skull fracture?

A

Because a lot of the time they will have c spine fractures too

DONT get too distracted by their horrible skull fracture and forget to look at their FUCKING NECKKKKKK

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29
Q

What is a concussion

A

A mild TBI.

Trauma induced alteration in mental status that may or may not involve loss of consciousness

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30
Q

What is a brain contusion?

A

Areas of brain bruising associated with localized ischemia, edema, and mass effect

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31
Q

What can cause a brain contusion?

A

Direct external contact force

Acceleration/deceleration trauma

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32
Q

What effect would a Brian contusion have on a concussion?

A

Delays recovery from your concussion lol

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33
Q

What is a coup vs contrecoup injury?

A

Step 1: get hit with a baseball bat on front of head/brain (“coup”)

Step 2: your brain smashes into the back of your skull for impact #2 (“contrecoup”

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34
Q

Who requires urgent neuroimaginf and neurosurgical consultation?
(Youre gonna love this)

A

GCS <15

Suspecture open or depressed skull fracture

Signs of basilar skull fracture

New neurologic deficit

Vomits twice

Preexisting bleeding diathesis (coagulopathy)

Anticoagulated

Seizure

60+ years old

Retrograde amnesia to >30 min before traumatic episode

High impact head injury

Intoxicated

Headache

Abnormal behavior
🖕🖕🖕🖕🖕🖕🖕

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35
Q

Who needs to be admitted for a closed head injury?

A

GCS <15

Abnormal head CT

Seizures

Underlying bleeding diathesis (coagulopathy)

Oral anticoagulants

Recurrent vomiting

Neuro deficit

No responsible person at home to take care of them

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36
Q

Who can go home after a closed head injury/

🏠

A

GCS =15

Normal exam and head CT

No bleeding predisposition

Responsible person at home

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37
Q

What is a diffuse axonal injury?

A

Shearing of white matter tracts from traumatic sudden deceleration injury (blunt trauma) —> severe intracranial injury

The axons have disruption, swelling, and cell death

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38
Q

How will someone with diffuse axonal injury present?

A

They are fuccckeddd up

Often in a coma

Vegetative state

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39
Q

What can we do to help someone with Diffuse Axonal Injury

A

NoTHiNG!!

Grave prognosis

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40
Q

What will you see on CT scan if someone has a Diffuse Axonal Injury?

A

Blurring of gray-to-white-matter margin

Cerebral hemorrhages

Cerebral edema

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41
Q

What are the 3 types of “extra axial” (outside the brain) intracranial hemorrhage?

A

Epidural hematoma

Sub dural hematoma

Subarachnoid hemorrhage, bleeding into CSF

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42
Q

What is an intracerebral hemorrhage?

A

Lesions within the brain substance

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43
Q

What is an epidural hematoma?

A

Acute collection of blood between the skull and the dura mater

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44
Q

What age groups usually get epidural hematoma?

A

Adolescents/young adults

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45
Q

What usually causes epidural hematoma?

****

A

Skull fracture and trauma

****

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46
Q

What artery is usually the source of bleeding in an epidural hematoma?

A

Middle meningeal artery

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47
Q

If someone who has an epidural hematoma loses consciousness, and then becomes normal, are you good to go?

A

No they can experience RAPID clinical deterioration

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48
Q

What will you see on CT scan of an epidural hematoma?

⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️

A

Lens shaped

Or

Lenticular (bicoconvex) shaped

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49
Q

What is a sub dural hematoma?

A

Collection of VENOUS blood between the dura mater and arachnoid

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50
Q

What is the source of the bleeding in a sub dural hematoma?

A

Tears of the bridging veins

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51
Q

What can cause a sub dural hematoma?

A

Brain atrophy (old people or heavy drinkers)

Traumatic falls

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52
Q

What will you see on CT scan of a sub dural hematoma?

⭐️⭐️⭐️⭐️⭐️⭐️

A

CRESCENT SHAPE

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53
Q

Lens shaped on CT

A

EDH

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54
Q

Crescent shape on CT

A

SDH

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55
Q

EDH or SDH:

Venous blood

A

SDH

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56
Q

EDH or SDH:

Usually caused by trauma in adolescents and young adults

A

EDH

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57
Q

How do you manage intracranial hematomas (EDH or SDH)

A

Neurosurgical consult

Those people will decide if they wanna do surgery, or do a burr hole evacuation (trephination) to drain the blood

58
Q

What is a subarachnoid hemorrhage?

A

Bleeding within the subarachnoid space.

Can be traumatic or non-traumatic

59
Q

What can cause a non-traumatic subarachnoid hemorrhage?

A

Aneurysm 85%

Vascular malformation

Cerebral venous thrombosis

60
Q

Are subarachnoid hemorrhages a big deal?

A

Yes.

10% die prior to reaching the hospital

Overall mortality is 51%

61
Q

If a patient says that they have the “worst headache of my life,” what is the answer to the test question

A

that is a “Thunderclap headache,” which indicates that they have a **Subarachnoid hemorrhage*

62
Q

Thunderclap headache=

A

Subarachnoid hemorrhage

63
Q

What might someone say they were doing right before they got the worst headache of their life (subarachnoid hemorrhage)

A

Exertion

Valsalva

Something that raised their BP and blew an aneurysm,

64
Q

What might be in someone’s social history that is a risk factor for subarachnoid hemorrhage?

A

Smoking

65
Q

What kind of imaging/diagnostics will you do when you suspect a subarachnoid hemorrhage?

A

Do a CT BEFORE you do an LP

ONLY do an LP if the CT doesn’t show anything and you suspect it

66
Q

Does every patient with a suspected subarachnoid hemorrhage get an LP?

A

NOOOOO!!!! Only do an LP if their CT scan didn’t show anything and you really suspect it

67
Q

What are the possible complications of subarachnoid hemorrhage?

A

INCREASED ICP***

Rebleeding

Vasospasm and delayed cerebral ischemia

Hydrocephalus

Seizures

Hyponatremia (if they have injury to the hypothamalus)

68
Q

Most strokes are (hemorrhagic/ischemic)

A

Ischemic (70%)

69
Q

What kind of imaging do you need to do IMMEDIATELY when you suspect intracerebral hemorrhage?

A

CT withOUT contrast**

If negative and you still suspect, THEN you do an MRI

Angiography if you want to look for vascular malformation

70
Q

What are the possible non traumatic etiologies of intracerebral hemorrhage?

A

Hypertension ** most common!

Ruptured saccular aneurysm

Vascular malformation

Hemorrhagic infarction (starts ischemic and then bleeds)

Bleeding disorders

Tumor

CNS infection

Drugs (crack, meth)

71
Q

How will someone with intracerebral hemorrhage present?

A

Acute onset of a focal nerurological deficit corresponding to area of brain affected

ICP symptoms- headache, vomiting, decreased LOC, seizures

72
Q

Do people with intracerebral hemorrhage usually die

A

Yes

73
Q

How do you manage a patient that come in with intracerebral hemorrhage?

A

CT withOUT contrast or MRI

Neuro consult

Admit to ICU*****

Control BP- dont want it too high or too low

Manage elevated ICP

Avoid hyperglycemia. Makes outcome much worse. Keep it between 140-180.

Seizure prevention/treatment

Reversal of anticoagulation

NPO

74
Q

What are some possible causes of ischemic CVA (ischemic stroke)

A

AFib

Valvular disease

Atherosclerosis

Thrombus/emobolus

Arterial dissection

HTN

Diabetes

Vasculitis

75
Q

CODE STROKE!!! WHAT ARE YOU GONNA DO?

A

Rapid assessment and ABCs

NIHSS score for severity (20+ is severe)

Oxygen +/- intubation

EXG and troponins (might be caused by afib)

IV fluids

Labs (coats, CBC, CMP, tox)

FINGERSTICK GLUCOSE**

Noncontrast CT or MRI

Aspirin if CT shows non-hemorrhagic CVA***

Neuro consult

Determine if he’s a candidate for thrombolytics or interventional treatments***

76
Q

Why is it super important to get a fingerstick glucose on someone who you think is having a fucking STROKE

A

Becasue hypoglycemia LOOKS A LOT like stroke !!!!

***

77
Q

What are the three most predictive exam findings that would indicate an ischemic stroke?

A

Facial paresis

Arm drift/weakness

Abnormal speech

78
Q

What will you see on CT scan for:

Hemorrhagic CVA

Vs

Ischemic CVA

A

Hemorrhagic: blood is seen where stroke is occurring

Ischemic: early on it will look NORMAL

79
Q

What is the target BP if someone is having a hemorrhagic stroke?

A

140-160/90

(Too low= no brain perfusion.
Too high= increaseed bleeding)

80
Q

What is the target BP for someone with an Ischemic stroke who is NOT a candidate for thrombolytics?

A

Let them get as high as 220/120 before you intervene

“Permissive hypertension” to perfuse brain

81
Q

What kind of stroke pt is allowed to have BP as high as 220/120?

A

Ischemic stroke pt who is not a candidate for thrombolytics

82
Q

“Permissible hypertension”

A

Ischemic stroke pt who is not a candidate for thrombolytics

83
Q

What is the target BP for an ischemic stroke pt who IS a candidiate for thrombolytics ?

A

185/110 or less

84
Q

What is the specific thrombolytic Ms Sears mentioned in this lecture?

A

Alteplase

85
Q

In order to be a candidiate for IV thrombolysis (Alteplase), the onset of symptoms/last time they were seen normal must be less than _______ hours

A
  1. 5 hours

* *******

86
Q

Current guidelines say that someone who is having a stroke should be in a CT or MRI machine within _____ minutes

A

25

87
Q

IV thrombolysis infusion should be started within _____minutes of them walking through the door

A

60

88
Q

Why is it SUPER important to get informed consent from the patient/their family before giving a stroke patient IV thrombolysis?

A

Risk of HEMORRHAGE that could be MASSIVE and they will be way worse off

89
Q

What is the difference between a primary, secondary, and post-traumatic seizure?

A

Primary seizure- no clear cause

Secondary seizure- caused by an identifiable neuro condition or infection

Post-traumatic seizure- happens within a week after an injury

90
Q

What are the TWO definitions for status epilepticus?

A

Seizure for 5 minutes straight

OR

Multiple seizures without regain of baseline mental status in 30 minutes

91
Q

What are some examples of conditions that can cause secondary seizures?

A

Eclampsia (up to 8 wks post partum)

Anoxic-ischemic injury (MI caused seizure due to hypoxia in brain?)

Trauma

Intracranial hemorrhage

Vascular lesion

Mass lesions

Degenerative Neuro disease

Congenital brain abnormalities

Infection

Metabolic disturbances

Toxins/drugs

Hypertensive encephalopathy

92
Q

If someone is having a seizure right in front of you in the ER what are you supposed to do ?!!

A

Protect them from injuries

ABCs/intubate

Two IVs

CBC, CMP, Tox screen, FINGERSTICK GLUCOSE

Thiamine and glucose wont hurt

93
Q

What specific lab do you need to run if someone starts seizing and they have a known seizure disorder?

A

Check their anticonvulsant levels (make sure they’ve been taking their meds)

94
Q

If someone with eclampsia starts seizing, what do you need to fo

A

OB consult 😑

95
Q

If someone has their FIRST seizure, what tests do you need to get?

A

MRI

EEG

LP in some peopel

(Neuro will be involved)

96
Q

If someone is in status epilepticus, what do you need to do?

A

Correct metabolic abnormalities

Continuous EEG monitoring

97
Q

From her chart:

If someone is in the first 5 minutes of a seizure, what do you need to do?

A

Supportive care: IV access, monitors, maintain airway, give O2, check glucose and give it if needed, protect them from injury

98
Q

From her chart:

If someone is in minutes 5-10 of a seizure, what do you need to do?

A

IV lorazepam or diazepam

+ an anticonvulsant (Phenytoin/Keppra)

+ consider intubating

99
Q

From her chart:

If someone is in refractory status epilepticus, what do you need to fo?

A

IV Midazolam, Propofol, Ketamine, or Phenobarbital

+intubate

+admit to neuro ICU

+EEG monitoring

100
Q

All patients with a NEW seizure get what

A

CT/MRI

101
Q

Patients with a NEW onset seizure can be sent home as long was they meet these 4 conditions:

A

Returned to baseline

Normal CT

Normal labs

No prolonged postitcal period or seizure related injury

102
Q

Does every patient with new seizures need referral to neuro

A

Yes

103
Q

Pattients with established seizure disorders can be sent home as long as they meet these 3 conditions:

A

Returned to baseline

Seizures have not recurred

No acute abnormalities are found

104
Q

What 3 things can ANYONE with a seizure not do until their seizures are controlled?

A

Swimming

Working with heights, hazardous tools/machines

Driving

105
Q

What are the 4 types of cervical spine fractures she went over

A

Jefferson fracture- C1

C2 (axis) fracture at Dens/odontoid

Hangman’s fracture- C2 with bilateral pedicles

Burst fracture- lower cervical vertebrae all over the place

106
Q

What causes a Jefferson fracture?

A

Axial compression

107
Q

Is there usually spinal cord damage with a Jefferson fracture?

A

No

108
Q

What causes a C2 (axis) fracture at the Odontoid (dens))?

A

Forceful flexion or extension

109
Q

What causes a hangman’s fracture?

A

Hyperextension with compression

110
Q

Does a hangman’s fracture transect the spinal cord?

A

It can, and if it does, they die INSTANTLY

111
Q

What causes a burst fracture?

A

Direct axial load (ex: diving)

112
Q

In a complete spinal cord injury, what symptoms will appear in the first 24 hours, and what symptoms appear 1-3 days later?

A

First 24: absent reflexes, flaccid muscles, priapism, loss of sensation, urinary retention

Later: Hyperreflexia, (+) Babinski sign, Spasticity

113
Q

What are the 4 locations of incomplete spinal cord injury that she talked about?

A

Anterior cord syndrome

Central Cord Syndrome

Posterior Cord Sydnrome

Brown Sequard

114
Q

In Anterior Cord Syndrome, where is the damage and what causes it?

A

Anterior 2/3 of cord

Caused by:

Cord infarct

OR

Disc herniation

115
Q

What will be LOST and what will be PRESERVED in Anterior Cord Sydnrome?

A

Lost:
Motor, reflexes, pain, temperature, bladder control

Preserved:
Tactile, proprioception, vibratory sensation

116
Q

In Central Cord Syndrome, where is the damage, and what can cause it?

A

Medial aspect of the cord

Caused by:

extension injury

spinal cord compression

cancer

117
Q

In Central Cord Syndrome, what is lost and what is preserved?

A

Lost:
Motor in ARMS*** (way more than legs)

Some sensory

Bladder control

Preserved:
“Sacral Sparing”

118
Q

In Posterior Cord Syndrome, where is the damage, and what can cause it?

A

Both dorsal columns and corticospinal tracts

Caused by:
MS***

Tumors

Subluxation

119
Q

In Posterior Cord Syndrome, what is lost, and what is preserved?

A

Lost:
Motor strength, hyperreflexia, gait ataxia, paresthesia (i guess some of this is gained???)

Preserved:
Bladder control preserved at first.

120
Q

In Brown Sequard (Incomplete spinal cord injury), where is the damage, and what causes it?

A

Its on ONE HALF of the cord

Usually caused by stabbings/shootings

🔫🔪

121
Q

In Brown Sequard, what is lost, and what is preserved?

A

Lost:
Motor paralysis on one side

Proprioception/vibration

Preserved:
Bladder control

122
Q

What is the prognosis for Brown Sequard spinal cord injury?

A

Excellent (90% walk again)

123
Q

What is the most common case of neurogenic shock?

A

Cervical spine injury

124
Q

What is neurogenic shock?

A

Hypotension and bradycardia within hours of a spinal cord injury

125
Q

What kind of imaging do you need to do for spinal trauma?

A

Plain films

CT

MRI if concerned about ligamentous injury

126
Q

If all 5 Nexus Criteria are met, you don’t need to do any imaging for a spinal cord injury.
What are those 5 criteria?

A

Absence of posterior midline tenderness

Normal level of alertness

Not drunk/high

No abnormal neurologic findings

No other painful injuries

127
Q

What is the Canadian C-spine rule?

A

Condition 1:
These people get a CT no matter what:
Age 65+

Dangerous mechanism of injury

Paresthesia in extremities

Condition 2:
No imaging is needed if these apply:
Simple rear-end car crash

Sitting upright

Ambulatory

No midline pain/delayed onset of neck pain

Can test ROM, and they can rotate their neck to 45 degrees

128
Q

Which is better for looking at disk herniation: MRI or CT

A

MRI

129
Q

Which kind of disc herniateion is an emergency:

Radiculopathy or Myelopathy

A

Myelopathy

130
Q

What symptoms will someone have if they have disc herniation causing radiculopaty?

A

Dermatomal pain or numbness

Remember, this is not an emergency

131
Q

What kind of symptoms will someone have if they have a disc herniation causing myelopathy?

A

Weakness

Loss of bladder control

Loss of balance

(This one IS a surgical emergency)

132
Q

What is cauda equina syndrome, and what can cause it?

A

Nerve compression below the L1-L2 space after the end of the spinal cord

Caused by: disc herniation, abscess, tumor, spinal stenosis, cancer, infection, autoimmune disease

133
Q

What is the presentation of cauda equina Syndrome?

**✔️✔️✔️✔️✔️✔️*****

A

Leg weakness in multiple distributions (L3-S1)

Weak plantar flexion, loss of ankle reflex (S1-S2)

Low back pain radiating to BOTH legs

Perineal sensory loss (S2-S4): SADDLE ANESTHESIA. URINARY INCONTINCENCE. DECERASED ANAL SPHINCTER TONE. SEXUAL DYSFUNCTION.
➿➿➿➿➿➿➿➿➿
🌟🌟🌟🌟🌟🌟🌟🌟

134
Q

What kind of imaging do you need to do if you suspect cauda equina Syndrome?

A

EMERGENT MRI with contrast of the lumbar and sacral spine

If not available, do a CT myelogram of the entire spine

135
Q

Other than get an MRI with contrast, what else do you need to do RIGHT FUCKING NOW when you suspect cauda equina syndrome?

A

IV Dexamethasone 10mg

DO NOT WAIT FOR IMAGING
**

136
Q

What is this:

Acute onset of immune-mediated peripheral neuropathy that starts distally and ascends symmetrically

A

Guillan barre

137
Q

Guillan barre is the most common ___________ neuropathy

A

Demyelination**

138
Q

What will you have a few weeks before you develop guillan barre?

A

Mild viral illness

139
Q

What is the clinical presentation of guillan barre?

A

DTR’s absent or depressed

Cranial nerves affected

Respiratory weakness maybe requiring ventilation

Dysautonomia: alternating HTN/hypotension, tachycardia/bradycardia, loss of sweating

No fever

Elevated protein in CSF

140
Q

What kind of study do you need to do for guillan barre?

A

EMG-NCS (electromyogram-nerve construction study)

Typically done during the course of admission, not in ED

141
Q

How do you treat guillan barre?

A

Admit to ICU

Mechanical ventilation

DVT prophylaxis (these people cant move their legs)

Urinary catheterization

IVIG and plasmapheresis (done during course of admission, not in ED)

142
Q

For every single condition i put in this deck, who do you need to call immediately, even if i forgot to list it?

A

Neurosurgery/neuro experts

Emed/Surg Exam 2 🚑 (ASL) (1 decks)

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