Neuro Emergencies 🏌️♂️(Lauren🌭) Flashcards
How might someone with increased ICP present?
Headache
NV
Papilledema
Fixed pupil(s)
Decreased consciousness
Decorticate or decerebrate posturing
Cushing’s triad (ominous)
What 3 things are in Cushing’s triad? What does Cushing triad indicate?
Bradycardia
Hypertension
Respiratory depression
Indicates increased ICP
What do you need to do to work up someone you suspect has increased ICP?
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
What kinds of things can cause increased ICP?
TBI/ intracranial hemorrhage
CNS infection
Ischemic stroke (hypoxia—> necrosis —> swelling)
Neoplasm
Vasculitis
Hydrocephalus
When you call neurosurgery for increased ICP, what 2 proceudeures might they do?
Decompressive craniectomy (remove piece of skull)
Ventriculosotiomy ( draw fluid from ventricles)
Why is it important to OXYGENATE patients with increased ICP? (even if their pulse ox is normal)
Because any amount of hypoxia + hypotension will cause a vasodilation response which will increase ICP even more
What can you do as a lowly PA to help someone with increased ICP?
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)
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
AMS
Cranial nerve/neuro deficits
Scalp laceration/contusion
Bony “Step-off” (depressed fracture)
Periorbital or retroauricular ecchymosis
What are the 3 types of skull fracture
Linear
Depressed
Basilar
What is a linear fracture
Single fracture, no big deal
What do you do if someone has a linear Skull fracture but, the CT was normal and they have no neurological deficit?
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
What is a depressed skull fracture?
Segment of the skill is driven below the level of the adjacent skull.
Usually involves injury to Brain
Do depressed skull fractures have a high risk of CNS infection?
Yes (from skin bacteria). Do not probe their fracture lol
What do you need to do to manage a depressed skull fracture?
CT scan
Admit to neurosurgery
Tetanus shot
Prophylactic antibiotics
Anticonvulsants
What is a basilar skull fracture?
A fracture that can produce a dural tear resulting in communication between subarachnoid space, parang Sal sinus, and the middle ear
What is one of the first clues that your patient might have a basilar skull fracture?
Clear/blood tinged fluid coming from their nose or ear
What is this:
Retroauricualur or mastoid ecchymosis
Battle sign
What are battle sign and raccoon eyes indicative of
Basilar skull fracture
How long after suffering from a basilar skull fracture will Battle sign and Racoon eyes show up?
1-3 days later
Which kind of skull fracture may have hemotympanum (blood behind TM)
Basilar
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
Um yes
What are the possible risks of basilar skull fracture?
CSF leak
Infection
Cranial nerve injurty
Epidural hematoma if through temporal bone
What do you need to do to treat a basilar skull fracture?
Admit NO MATTER WHAT
Neuro consult
What causes penetrating skull fractures?
Gunshot
Stab
Blast
What do you need to do if someone has a penetrating injury to their skull?
Call neurosurgery
IV antibiotics
What is a tangential skull fracture, and what do you do about it?
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
For all skull fractures, what kind of imaging needs to be done?
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 *****
Why do you need to do a CT of someone’s C spine if they have a skull fracture?
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
What is a concussion
A mild TBI.
Trauma induced alteration in mental status that may or may not involve loss of consciousness
What is a brain contusion?
Areas of brain bruising associated with localized ischemia, edema, and mass effect
What can cause a brain contusion?
Direct external contact force
Acceleration/deceleration trauma
What effect would a Brian contusion have on a concussion?
Delays recovery from your concussion lol
What is a coup vs contrecoup injury?
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”
Who requires urgent neuroimaginf and neurosurgical consultation?
(Youre gonna love this)
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
🖕🖕🖕🖕🖕🖕🖕
Who needs to be admitted for a closed head injury?
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
Who can go home after a closed head injury/
🏠
GCS =15
Normal exam and head CT
No bleeding predisposition
Responsible person at home
What is a diffuse axonal injury?
Shearing of white matter tracts from traumatic sudden deceleration injury (blunt trauma) —> severe intracranial injury
The axons have disruption, swelling, and cell death
How will someone with diffuse axonal injury present?
They are fuccckeddd up
Often in a coma
Vegetative state
What can we do to help someone with Diffuse Axonal Injury
NoTHiNG!!
Grave prognosis
What will you see on CT scan if someone has a Diffuse Axonal Injury?
Blurring of gray-to-white-matter margin
Cerebral hemorrhages
Cerebral edema
What are the 3 types of “extra axial” (outside the brain) intracranial hemorrhage?
Epidural hematoma
Sub dural hematoma
Subarachnoid hemorrhage, bleeding into CSF
What is an intracerebral hemorrhage?
Lesions within the brain substance
What is an epidural hematoma?
Acute collection of blood between the skull and the dura mater
What age groups usually get epidural hematoma?
Adolescents/young adults
What usually causes epidural hematoma?
****
Skull fracture and trauma
****
What artery is usually the source of bleeding in an epidural hematoma?
Middle meningeal artery
If someone who has an epidural hematoma loses consciousness, and then becomes normal, are you good to go?
No they can experience RAPID clinical deterioration
What will you see on CT scan of an epidural hematoma?
⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️
Lens shaped
Or
Lenticular (bicoconvex) shaped
What is a sub dural hematoma?
Collection of VENOUS blood between the dura mater and arachnoid
What is the source of the bleeding in a sub dural hematoma?
Tears of the bridging veins
What can cause a sub dural hematoma?
Brain atrophy (old people or heavy drinkers)
Traumatic falls
What will you see on CT scan of a sub dural hematoma?
⭐️⭐️⭐️⭐️⭐️⭐️
CRESCENT SHAPE
Lens shaped on CT
EDH
Crescent shape on CT
SDH
EDH or SDH:
Venous blood
SDH
EDH or SDH:
Usually caused by trauma in adolescents and young adults
EDH
How do you manage intracranial hematomas (EDH or SDH)
Neurosurgical consult
Those people will decide if they wanna do surgery, or do a burr hole evacuation (trephination) to drain the blood
What is a subarachnoid hemorrhage?
Bleeding within the subarachnoid space.
Can be traumatic or non-traumatic
What can cause a non-traumatic subarachnoid hemorrhage?
Aneurysm 85%
Vascular malformation
Cerebral venous thrombosis
Are subarachnoid hemorrhages a big deal?
Yes.
10% die prior to reaching the hospital
Overall mortality is 51%
If a patient says that they have the “worst headache of my life,” what is the answer to the test question
that is a “Thunderclap headache,” which indicates that they have a **Subarachnoid hemorrhage*
Thunderclap headache=
Subarachnoid hemorrhage
What might someone say they were doing right before they got the worst headache of their life (subarachnoid hemorrhage)
Exertion
Valsalva
Something that raised their BP and blew an aneurysm,
What might be in someone’s social history that is a risk factor for subarachnoid hemorrhage?
Smoking
What kind of imaging/diagnostics will you do when you suspect a subarachnoid hemorrhage?
Do a CT BEFORE you do an LP
ONLY do an LP if the CT doesn’t show anything and you suspect it
Does every patient with a suspected subarachnoid hemorrhage get an LP?
NOOOOO!!!! Only do an LP if their CT scan didn’t show anything and you really suspect it
What are the possible complications of subarachnoid hemorrhage?
INCREASED ICP***
Rebleeding
Vasospasm and delayed cerebral ischemia
Hydrocephalus
Seizures
Hyponatremia (if they have injury to the hypothamalus)
Most strokes are (hemorrhagic/ischemic)
Ischemic (70%)
What kind of imaging do you need to do IMMEDIATELY when you suspect intracerebral hemorrhage?
CT withOUT contrast**
If negative and you still suspect, THEN you do an MRI
Angiography if you want to look for vascular malformation
What are the possible non traumatic etiologies of intracerebral hemorrhage?
Hypertension ** most common!
Ruptured saccular aneurysm
Vascular malformation
Hemorrhagic infarction (starts ischemic and then bleeds)
Bleeding disorders
Tumor
CNS infection
Drugs (crack, meth)
How will someone with intracerebral hemorrhage present?
Acute onset of a focal nerurological deficit corresponding to area of brain affected
ICP symptoms- headache, vomiting, decreased LOC, seizures
Do people with intracerebral hemorrhage usually die
Yes
How do you manage a patient that come in with intracerebral hemorrhage?
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
What are some possible causes of ischemic CVA (ischemic stroke)
AFib
Valvular disease
Atherosclerosis
Thrombus/emobolus
Arterial dissection
HTN
Diabetes
Vasculitis
CODE STROKE!!! WHAT ARE YOU GONNA DO?
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***
Why is it super important to get a fingerstick glucose on someone who you think is having a fucking STROKE
Becasue hypoglycemia LOOKS A LOT like stroke !!!!
***
What are the three most predictive exam findings that would indicate an ischemic stroke?
Facial paresis
Arm drift/weakness
Abnormal speech
What will you see on CT scan for:
Hemorrhagic CVA
Vs
Ischemic CVA
Hemorrhagic: blood is seen where stroke is occurring
Ischemic: early on it will look NORMAL
What is the target BP if someone is having a hemorrhagic stroke?
140-160/90
(Too low= no brain perfusion.
Too high= increaseed bleeding)
What is the target BP for someone with an Ischemic stroke who is NOT a candidate for thrombolytics?
Let them get as high as 220/120 before you intervene
“Permissive hypertension” to perfuse brain
What kind of stroke pt is allowed to have BP as high as 220/120?
Ischemic stroke pt who is not a candidate for thrombolytics
“Permissible hypertension”
Ischemic stroke pt who is not a candidate for thrombolytics
What is the target BP for an ischemic stroke pt who IS a candidiate for thrombolytics ?
185/110 or less
What is the specific thrombolytic Ms Sears mentioned in this lecture?
Alteplase
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
- 5 hours
* *******
Current guidelines say that someone who is having a stroke should be in a CT or MRI machine within _____ minutes
25
IV thrombolysis infusion should be started within _____minutes of them walking through the door
60
Why is it SUPER important to get informed consent from the patient/their family before giving a stroke patient IV thrombolysis?
Risk of HEMORRHAGE that could be MASSIVE and they will be way worse off
What is the difference between a primary, secondary, and post-traumatic seizure?
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
What are the TWO definitions for status epilepticus?
Seizure for 5 minutes straight
OR
Multiple seizures without regain of baseline mental status in 30 minutes
What are some examples of conditions that can cause secondary seizures?
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
If someone is having a seizure right in front of you in the ER what are you supposed to do ?!!
Protect them from injuries
ABCs/intubate
Two IVs
CBC, CMP, Tox screen, FINGERSTICK GLUCOSE
Thiamine and glucose wont hurt
What specific lab do you need to run if someone starts seizing and they have a known seizure disorder?
Check their anticonvulsant levels (make sure they’ve been taking their meds)
If someone with eclampsia starts seizing, what do you need to fo
OB consult 😑
If someone has their FIRST seizure, what tests do you need to get?
MRI
EEG
LP in some peopel
(Neuro will be involved)
If someone is in status epilepticus, what do you need to do?
Correct metabolic abnormalities
Continuous EEG monitoring
From her chart:
If someone is in the first 5 minutes of a seizure, what do you need to do?
Supportive care: IV access, monitors, maintain airway, give O2, check glucose and give it if needed, protect them from injury
From her chart:
If someone is in minutes 5-10 of a seizure, what do you need to do?
IV lorazepam or diazepam
+ an anticonvulsant (Phenytoin/Keppra)
+ consider intubating
From her chart:
If someone is in refractory status epilepticus, what do you need to fo?
IV Midazolam, Propofol, Ketamine, or Phenobarbital
+intubate
+admit to neuro ICU
+EEG monitoring
All patients with a NEW seizure get what
CT/MRI
Patients with a NEW onset seizure can be sent home as long was they meet these 4 conditions:
Returned to baseline
Normal CT
Normal labs
No prolonged postitcal period or seizure related injury
Does every patient with new seizures need referral to neuro
Yes
Pattients with established seizure disorders can be sent home as long as they meet these 3 conditions:
Returned to baseline
Seizures have not recurred
No acute abnormalities are found
What 3 things can ANYONE with a seizure not do until their seizures are controlled?
Swimming
Working with heights, hazardous tools/machines
Driving
What are the 4 types of cervical spine fractures she went over
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
What causes a Jefferson fracture?
Axial compression
Is there usually spinal cord damage with a Jefferson fracture?
No
What causes a C2 (axis) fracture at the Odontoid (dens))?
Forceful flexion or extension
What causes a hangman’s fracture?
Hyperextension with compression
Does a hangman’s fracture transect the spinal cord?
It can, and if it does, they die INSTANTLY
What causes a burst fracture?
Direct axial load (ex: diving)
In a complete spinal cord injury, what symptoms will appear in the first 24 hours, and what symptoms appear 1-3 days later?
First 24: absent reflexes, flaccid muscles, priapism, loss of sensation, urinary retention
Later: Hyperreflexia, (+) Babinski sign, Spasticity
What are the 4 locations of incomplete spinal cord injury that she talked about?
Anterior cord syndrome
Central Cord Syndrome
Posterior Cord Sydnrome
Brown Sequard
In Anterior Cord Syndrome, where is the damage and what causes it?
Anterior 2/3 of cord
Caused by:
Cord infarct
OR
Disc herniation
What will be LOST and what will be PRESERVED in Anterior Cord Sydnrome?
Lost:
Motor, reflexes, pain, temperature, bladder control
Preserved:
Tactile, proprioception, vibratory sensation
In Central Cord Syndrome, where is the damage, and what can cause it?
Medial aspect of the cord
Caused by:
extension injury
spinal cord compression
cancer
In Central Cord Syndrome, what is lost and what is preserved?
Lost:
Motor in ARMS*** (way more than legs)
Some sensory
Bladder control
Preserved:
“Sacral Sparing”
In Posterior Cord Syndrome, where is the damage, and what can cause it?
Both dorsal columns and corticospinal tracts
Caused by:
MS***
Tumors
Subluxation
In Posterior Cord Syndrome, what is lost, and what is preserved?
Lost:
Motor strength, hyperreflexia, gait ataxia, paresthesia (i guess some of this is gained???)
Preserved:
Bladder control preserved at first.
In Brown Sequard (Incomplete spinal cord injury), where is the damage, and what causes it?
Its on ONE HALF of the cord
Usually caused by stabbings/shootings
🔫🔪
In Brown Sequard, what is lost, and what is preserved?
Lost:
Motor paralysis on one side
Proprioception/vibration
Preserved:
Bladder control
What is the prognosis for Brown Sequard spinal cord injury?
Excellent (90% walk again)
What is the most common case of neurogenic shock?
Cervical spine injury
What is neurogenic shock?
Hypotension and bradycardia within hours of a spinal cord injury
What kind of imaging do you need to do for spinal trauma?
Plain films
CT
MRI if concerned about ligamentous injury
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?
Absence of posterior midline tenderness
Normal level of alertness
Not drunk/high
No abnormal neurologic findings
No other painful injuries
What is the Canadian C-spine rule?
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
Which is better for looking at disk herniation: MRI or CT
MRI
Which kind of disc herniateion is an emergency:
Radiculopathy or Myelopathy
Myelopathy
What symptoms will someone have if they have disc herniation causing radiculopaty?
Dermatomal pain or numbness
Remember, this is not an emergency
What kind of symptoms will someone have if they have a disc herniation causing myelopathy?
Weakness
Loss of bladder control
Loss of balance
(This one IS a surgical emergency)
What is cauda equina syndrome, and what can cause it?
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
What is the presentation of cauda equina Syndrome?
**✔️✔️✔️✔️✔️✔️*****
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.
➿➿➿➿➿➿➿➿➿
🌟🌟🌟🌟🌟🌟🌟🌟
What kind of imaging do you need to do if you suspect cauda equina Syndrome?
EMERGENT MRI with contrast of the lumbar and sacral spine
If not available, do a CT myelogram of the entire spine
Other than get an MRI with contrast, what else do you need to do RIGHT FUCKING NOW when you suspect cauda equina syndrome?
IV Dexamethasone 10mg
DO NOT WAIT FOR IMAGING
**
What is this:
Acute onset of immune-mediated peripheral neuropathy that starts distally and ascends symmetrically
Guillan barre
Guillan barre is the most common ___________ neuropathy
Demyelination**
What will you have a few weeks before you develop guillan barre?
Mild viral illness
What is the clinical presentation of guillan barre?
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
What kind of study do you need to do for guillan barre?
EMG-NCS (electromyogram-nerve construction study)
Typically done during the course of admission, not in ED
How do you treat guillan barre?
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)
For every single condition i put in this deck, who do you need to call immediately, even if i forgot to list it?
Neurosurgery/neuro experts
