Neuro MDT Flashcards
Headache DANGER SIGNS
- Thunderclap
- Absence of prior headache
- Focal neurosigns
- Fever
- Rapid onset with exercise
- Nasal congestion
- Papilledema
Thunderclap headache could be:
SAH
Absence of prior headache danger sign could be:
CNS infection
Focal Neurosigns other than auras could be
stroke or tumor
Fever with headache could be:
Meningitis
Rapid onset headache with exercise could be:
IC Hemmo./ Brain Aneurysm
Headache with nasal congestion could be:
Sinusitis
Headache with papilledema could be:
Increased ICP
Headache reasons to refer for imaging: (8)
change in pattern worsening despite tx neuro. deficit scalp tenderness onset with exertion visual changes 40 years or older hx of trauma/ HTN
Tension Headache characteristics
most prevalent bilat daily "vice-like" stress/fatigue/glare No dx tests*
Tension Headache Tx
NSAIDS: Motrin 400-800mg Q4-6H/2400mg in 24H max
Tension Headache Tx
NSAIDS: Motrin 400-800mg Q4-6H/2400mg in 24H max
Naproxen 250-500mg PO Q12
Non-Sal: Tylenol 325-1000mg PO Q4-6H/ 4G in 24H max
Cluster Headache Sx
- middle aged males
- unilateral px
- restless agitated
- 15 min-3 hours
Cluster Headache Additional sx
- ipsilateral congestion
- lacrimation
- Horner Syndrome
Homer Syndrome (3)
stop sweating
drooped eyelid
small pupil
Cluster Headache tx + MOA and Contraindications
- O2 100% 15 min*
- Sumatriptan SC 6mg/24h max 12mg
- Zolmitriptan 2.5mg PO/ 10mg 24h max
MOA: Vasoconstriction/Trigeminal assistance
Contra: Cardiac/Bleeding issues
Migraine characteristics (6)
throbbing unilateral or bilateral aura (maybe) visual disturbances Fam Hx NV
Migraine Dx:
Clinically using HPI
Migraine Tx
avoidance rest analgesics Sumatriptan 25/50/100mg or 6mg SC 50mg works best*
Migraine prophylaxis + contraindications
beta blocker
Propranolol 20mg BID: 40-160mg range
CHF Cardio Hypotension
Migraine secondary treatments
Anti-depressant: Amitriptyline 10mg
Anti-emetic: Promethazine 12.5mg-25mg Q4-6H
Post Trauma Headache characteristics
1-2 days after injury
poor memory and concentration
emotional instability
Post Trauma Headache tx
analgesic
Med Overuse headache characteristics
50% of daily headaches
chronic px
heavy analgesic use
treat with med withdraw
Partial Seizures characteristics
dependent on cortical involvement
preictal phase can have auras
Focal Seizure with Retained Awareness
FKA: Simple Partial Seizure*
only 1 part of brain/sx dependent on this
Focal Seizure with Impaired Awareness
FKA: Complex Partial Seizure*
one part of brain
awake/not responding
no memory
Complex Partial Seizure 4 signs
Grimace
Gesturing
Lip Smack
Repeating
General Seizure
entire brain
altered consciousness
Tonic-Clonic aka Grand Mal
Tonic phase
stiffening
Clonic Phase
rhythmic jerking
Todd Paralysis
weakness of limbs
3 Postictal Phase Sx
somnolence
no recollection
Todd Paralysis
Seizure Dx
EEG
Seizure Tx
secure airway
treat sx
MEDEVAC
Seizure labs
electrolyte
LFT
CBC
Glucose
Active Seizure Med
Diazepam 5mg IV/IM Q5-10min; 30mg Max
binds with GABA
Status Epilepticus
seizure that lasts longer than 5 min, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes
Status Epilepticus tx
Diazepam
Valproic Acid 30mg
Intubate
Frontal Lobe Sx
Head and Leg
Jacksonian March
Posturing
Parietal Lobe Sx
Paresthesia
Occipital Lobe Sx
Visual Phenomena
Temporal Lobe
“oh so no head?”
Hallucinations
Epigastric rising
Automatisms
Deja vu
Psychogenic Non Epileptic Seizure
not assoc. with neuronal activity
longer than 2 min
no incontinence
no postictal phase
PNES tx
psychotherapy
Supplies blood to the brain
internal carotid arteries
2 internal carotid branches
Anterior Cerebral Artery
Medial Cerebral Artery
Vertebral artery
Basilar artery
connects cerebral and vertebral arteries
Circle of Willis
Hemorrhagic Stroke
rupture of a blood vessel causing bleeding into the brain and lack of cerebral blood flow leading to ischemia
Ischemic Stroke
blockage of a blood vessel causing lack of blood flow leading to ischemia
Ischemic Stroke 2 subtypes
CVA and TIA
cerebrovascular accident
transient ischemic attack
Thrombotic Ischemic Stroke
obstruction of artery due to blockage in vessel
Embolic Ischemic Stroke
blockage of artery due to debris
Systemic hypoperfusion Ischemic Stroke
lack of blood brain flow due to decreased systemic blood flow
Transient ischemic attack
transient episode of neurologic dysfunction caused by brain, spinal cord, or retinal ischemia, without acute infarction
Only way to differentiate TIA vs CVA
MRI
FASTER mnemonic
Face (drooping numbness) Arms (one limb being weaker) Stability (steadiness on feet) Talking (slurred garbled) Eyes (visual changes) React (MEDEVAC)
ISchemic stroke risk factors
vascular disease A-fib DVT recent MI clotting disorders
Without acute infarction is
TIA
with acute infarction is
CVA
2 hemorrhagic stroke subtypes
ICH
SAH
ICH risk factors
HTN Trauma Bleeding disorders Drug use Aneurisms
Ischemic Stroke tx
> 94% 02
elevate 30 degrees
labs: EKG CBC Glucose O2 sat
Ischemic stroke BP monitoring
do not lower unless 220/120; reduce by 15%
Ischemic Stroke meds + MOA + vitals
Aspirin 325mg
selective beta blocker Labetalol
10-20mg IV
MOA: inhibits B1 to dec HR
BP every 15min
TIA tx
med advice
aspirin
MEDEVAC
states strokes are disqualifying
MANMED 15-106
Stuporous patients respond to
vigorous stimuli
Coma can result from
Seizures Hypothermia Metabolic disturbances Structural lesions Disturbance of circulation Mass causing compression of brain stem
Abrupt onset of coma could suggest
SAH
ICH
stroke
Decorticate
flexion
Decerebrate
extension
Coma ancillary study
NON CONTRAST* CT
Other name for dilated pupils
mydriasis; associated with brainstem compression or drug use
Other name for constricted pupils
miosis; could suggest drug overdose with opiates
GCS scores
Mx 15
Low 3
Intubate 8 or less
Naloxone dose
0.4-2mg
Coup-countercoup
injury at impact as well as opposite side from rebound
Concussion hallmarks*
amnesia
lack of recall
early concussion symptoms
headache dizziness vertigo imbalance nausea vomiting
delayed concussion symptoms
mood/cognitive disturbance
light/noise sensitivity
sleep disturbance
MACE within how long?
48 hours
Direct observation of suspected concussion time
24 hours
Second impact syndrome
diffuse cerebral swelling can develop with 2nd concussion
(2 concussions back to back)
rare but potentially fatal
Post concussion syndrome
headache
dizziness
cognitive impairment
resolves in weeks to months
CTE
chronic traumatic encephalopathy
CTE sx
behavior changes
Parkinson’s
speech and gait abnormalities
thin areas of skull
temporal
nasal sinus
Basilar skull fracture
Battle sign “Raccoon” eyes Hemotympanum CSF rhinorrhea/otorrhea Cranial nerve deficits
ICP tx
elevate head 25-30 degrees
secure airway
ventilate
NS or LR
Mannitol dose
1g/kg IV initial
.25-.5 g/kg IV Q6-8
hypertonic saline dose
7.5% NS 250cc bolus
Epidural hematoma layers
in-between dura mater and skull
Subdural Hematoma layers
between dura mater and arachnoid
Subarachnoid hematoma layers
*in the JEA
between subarachnoid mater and pia mater
*high association with aneurysms and AV malformations
3 ICH type
Epidural hematoma
Subdural hematoma
Subarachnoid Hematoma
Most commonly affected with Epidural Hemmorhage
MMA
middle meningeal artery
Epidural hemorrhage presentation (2)
immediate LOC
Lucid Interval with consciousness
deteriorating neuro function
Seizure/Coma
Epidural hemorrhage acute management
oxygen/intubate
neuro consult
monitor for ICP
MEDEVAC
Subdural Hemorrhage
more common
elderly/EOTH abuse
may occur without impact
likely to die
Subdural Hematoma physiology
venous flow into sinus spaces
may tamponade causing inc flow
Subdural hematoma clinical manifestations
1-2 days after onset
chronic could be 15 days
headaches/light headed/cognitive impairment/somnolence
Subdural Hematoma acute management
Same as epidural hematoma
non-contrast CT to determine
Subarachnoid hemorrhage epidemiology
usually aneurysm
high pressure bleed with CSF
SAH hallmarks
Thunder Clap aka worst headache of my life
sudden/may have meningeal irritation from blood
SAH risk factors
drug use, smoking, HTN, alcohol use
SAH tx
rest
Tylenol
MEDEVAC
Complications of SAH
death rebleeding ischemia ICP seizures
MACE: HEADS
Headache or vomiting? Ear ringing? Amnesia, altered consciousness? Double vision? Something feels wrong?
Recurrent concussion
3 concussions within 1 year. needs neurologist
Recurrent Concussion Evaluation
Comprehensive Neurological Eval
neuroimaging
functional assessment
duty status determination
Spinal cord injury presentation
flaccid paralysis
loss of bowel or bladder control
anesthesia
loss of reflex activity
C3,4 &5…
keep the lungs alive
Spinal cord injury tx
ABC C-collar O2/BP Foley Cath Sedate if necessary MEDEVAC ASAP
Spinal cord injury Med
Methylprednisone 125mg IV Q4-6
Nexus criteria for C-spine
N neuro deficit S spinal tenderness A altered mental status I intoxicated D distracted injuries
Common radiculopathy discs
L5-S1
Radiculopathy
lumbar disk herniation usually due to heavy lifting
Radiculopathy clinical presentation
px with sitting
radiating to leg
lower extremity numbness
L1 radiculopathy
pain, paresthesia, inguinal sensory loss
L2-L4 radiculopathy
acute back px radiates to anterior thigh/knee
weak hips
L5 radiculopathy
most common back pain radiating down lateral aspect of leg into foot
S1 radiculopathy
back pain radiates posterior to foot
Straight leg testing
Lay patient supine and raise patient’s extended leg on the symptomatic side with foot dorsiflexed.
Lasegue’s sign
presence or worsening of radicular pain with straight leg maneuver.
Radiculopathy imaging
radiograph and MRI
Radiculopathy tx
NSAIDs and analgesics
muscle relaxers
Radiculopathy Med
Cyclobenzaprine 5mg PO Q8
Radiculopathy reevaluation
4-6 weeks after
- PT should be considered
- Consult to px management
Cauda Equina
bundle of nerves that spread out from te bottom of the spinal cord
Cauda equina syndrome
cauda equina is squeezed or damaged
Cauda Equine pathophysiology
herniated disc
infection/inflammation
cancer
spinal stenosis
Spinal Stenosis
vertebrae bumps called bone spurs; can compress nerves.
Cauda Equina Clinical Presentation
pain/numb/tingling in lowerback and/or legs
foot drop
bowel problems or incontinence
problems with sex
Cauda Equina tx
MEDEVAC
MRI
treat cause of sx (surgery or meds)
Carpal Tunnel Syndrome
entrapment neuropathy of the median nerve of carpal ligament
caused by repetitive wrist activities
3 predispositions for carpal tunnel
preg
DM
arthritis
Carpal Tunnel presentation
pain burning tingling
bothersome during sleep
late sx: atrophy
Carpel tunnel test
Tinel or Phalen
Carpal Tunnel Tx
splint up to 3 months
Thumb Spica*
NSAIDS/Steroids
Restless Leg Syndrome
Creepy Crawling or Pins and needles in the Limbs
worse at evening or night
hyperalgesia
low px tolerance
akathisia
intense desire to move
Restless Leg Syndrome differential
Volitional movements
Nocturnal Leg Cramp
Class of meds that worsen Restless Leg Syndrome
Antihistamines
Anti-nausea
Antidepressants
Lab for Restless leg syndrome
Iron (serum ferritin)
Restless Leg Syndrome Med
Ferrous Sulfate 325mg with laxative
Bell’s Palsy CN and part of brain
CN 7 (along the pons)
Bell’s Palsy associated diseases
HSV
HIV
Lyme
Bell’s Palsy clinical presentation
unilateral facial paralysis px around ear facial stiffness inability to close eyelid* skin does not wrinkle*
Bell’s phenomenon
upward rolling of the eye on attempted lid closure
Bell’s Palsy vs Stroke
no paralysis of forehead in stroke
intact forehead suggest stroke
Bell’s Palsy tx
protect the affected eye
Prednisone 60mg x7 days
Valacyclovir 1000mg
Bell’s Palsy differentials
HSV
Otitis Media
Lyme
Guillain-Barre Syndrome
Meningitis signs and symptoms
fever
nuchal rigidity (neck stiffness)
altered mental status
Bell’s Palsy hallmarks
forehead paralysis
cannot close eye
Meningitis lab test
Lumbar Puncture
Meningitis tests
Brudzinksi
Kerning
Meningitis med
Ceftriaxone 2g IV
Meningitis Prophylaxis
Ciprofloxacin 500mg
Meningitis associated vaccinations
MGC
S. Pneumonia
FLU
3 classes of chronic px
noncaptive
neuropathic
centralized
Chronic px time
greater than 6-12 weeks
nociceptive pain
caused by stimuli
neuropathic pain
resulting from damage or pathology
centralized pain
reduced ability of the CNS to diminish responses to peripheral stimuli
Chronic pain syndrome tx
Acupuncture
spinal manipulation
Insomnia risk factors
EOTH
stimulant
tobacco
psychiatric
Benign paroxysmal positioning vertigo test
Dix-Hallpike
Peripheral Vertigo presentation
sudden
horizontal nystagmus
tinnitus