Neuro - mx Flashcards
Viral meningitis management
In all cases manage as though having bacterial meningitis until proven otherwise
- Immediate broad spectrum abx
- Supportive treatment
- IVF, antipyretics, antiemetics
- Treatment of causative organism
- Treatment of complications
Viral meningitis
- Supportive
- analgesia, antipyretics, nutritional support, hydration
- No specific treatment
- Ganciclovir - CMV (renal toxicty)
- Aciclovir - HSV
Subdural haematoma management
Acute haemorrhage
ABCDE + refer to neurosurgeon
If small (<10mm) + no significant neurological dysfunction (GCS >9) + midline shift <5mm
• Observation, monitoring, follow-up CT
• Prophylactic antiepileptics for 7 days (phenytoin, levetiracetam) for all pt [levetiracetam is easier to administer + monitor than phenytoin]
• Reverse/Stop anticoagulation if needed
Vitamin K – warfarin
FFP Plt (goal >100 x 109/L)
Cryoprecipitate – low fibrinogen levels
Protamin – pt on heparin
Activated factor VIIa
• Intracranial pressure lowering regimen if needed (raising the head to 30, analgesic, sedation, IV mannitol, hypertonic saline) if needed
If >10mm, midline shift >5mm, GCS <9, chronic heamatoma
• Surgery
o Burr hole craniotomy – 2 burr holes are made + the clot is irrigated using saline irrigation + suction
o Trauma craniotomy (frontotemporal craniotomy)
o Durotomy + removal of clot
o Hemicraniectomy
- Prophylactic antiepileptics for 7 days (phenytoin, levetiracetam) for all pt [levetiracetam is easier to administer + monitor than phenytoin]
- Correction of coagulopathy if needed
- Intracranial pressure-lowering regimen (raising the head to 30, analgesic, sedation, IV mannitol, hypertonic saline) if needed
Focal seizures mx
Carbamazepine (1st line)
Lamotrigine (2nd line)
Generalised seizures mx
Sodium Valproate (1st line) Carbamazepine (2nd line)
Use lamotrigine if pregnant (sodium valproate is teratoegenic)
Status epilepticus mx
- ABC
Secure airway
Oxygen (100%)
Supportive care (correct hypotension, hyperthermia, glucose, electrolyte abnormalities, potential thiamine deficiency)
Measure BM - if hypoglycaemic give thiamine (100mg) + 50ml of 50% glucose or 250mL of 10% dextrose (treat immediately)
Thiamine (100mg) should be given along with glucose - glucose infusion increases the risk of Wernicke’s encephalopathy in susceptible patients
Benzodiazepines
- if seizure lasts >5 mins
- rectal diazepam in ambulance
- IV lorazepam (REPEAT after 10 mins if seizure doesn’t terminate)
- If no IV access can be obtained, use rectal diazepam or midazolam (IM, intranasal, buccal)
If seizing
>20 mins
- IV Phenytoin (phenobarbitral is 3rd line but sometimes omitted)
If seizing >30 mins
- Generalised anaesthesia + ICU
Bacterial meningitis management
In all cases manage as though having bacterial meningitis until proven otherwise
- Immediate broad spectrum abx
- Supportive treatment
- IVF, antipyretics, antiemetics
- Treatment of causative organism
- Treatment of complications
Bacterial meningitis/non-blanching rash/suspected meningococcal septicaemia
- Emergency
- <16 y/o/ signs of severe sepsis + if >1h needed to get to hospital – IM/IV benzylpenicillin
o Initial blind antibiotic therapy started immediately
CEFTRIAXONE/CEFOTAXIME – empirical treatment before identification of the causative organism
o IV dexamethasone 10mg x4/day for 4/7 to reduce cerebral oedema
If consciousness affected, give IV acyclovir to cover for enephalitis
Prophylaxis to close contacts: Rifampicin or ciprofloxacin
If penicillin-susceptible/β lactamase -ve/non-allergic patient give penicillin
If penicilin resistant/β lactamase +ve/pt allergic to penicillin give ceftriaxone
Abx given IV in all cases
o N. meningitidis –> IV benzylpenicillin or IV ceftriaxone for 5-7 days
o S. pneumoniae –> IV Benzylpenicillin/Ampicillin or IV ceftriaxone/cefotaxime + IV vancomycin
o H. Influenzae –> IV ampicillin (β lactamase -ve) or IV Ceftriaxone/cefotaxime (β lactamase +ve)
o Listeriosis –> IV benzylpenicillin/ampicillin + IV gentamycin
Ischaemic Stroke management
• Before antiplatelet, thrombolytic, anticoagulant therapy - exclude haemorrhage
• Thrombolytic treatment AND thrombectomy - within 4.5h
o IV Alteplase
o Then give aspirin 300mg (24h after alteplase, do not give aspirin in first 24h + need to rule out again haemorrhage with CT scan)
• If >4.5h have passed
o Aspirin 300mg
o Aspirin delayed 24h if patient receives thrombolysis
o Swallow assessment, mantain hydration, oxygenations, monitor glucose
o GCS monitoring
• Anticoagulants (Heparin or warfarin )
o Used if pt has AF
o Considered in certain subgroups where there is a high risk of emboli recurrence or stroke progression (carotid dissection, recurrent cardiac emboli, critical carotid artery stenosis)
o For VTE prophylaxis use LMWH (e.g. dalteparin) only if ischaemic stroke
If AF - warfarin
No AF - aspirin for 2 weeks then switch to LIFELONG clopidogrel
People with acute stroke should have their swallowing screened before being given any oral food, fluid, medication - may need an NG tube
VTE prophylaxis
GCS monitoring
Early mobilisation + rehabilitation
Surgical intervention that might be needed in a stroke patient
o Middle cerebral artery infarction – surgical decompressive hemicraniectomy
o Mechanical clot retrieval
o Proximal anterior circulation affected + less than 6h since symptoms started – Endovascular Thrombectomy (through femoral + internal carotids)
o SAH – operation to fix the leaking artery
o Carotid doppler
Carotid endarterectomy if >50% stenosed + symptomatic or if >70% stenosed
Haemorrhagic stroke management
o Control hypertension and seizures
o IV mannitol and hyperventilation helps lower intracranial pressure
o Evacuation of haematoma or ventricular drainage may be required
o If haemorrhagic stroke + pt is already on anticoagulant medication – Vitamin K, prothrombin complex concentrate transfusion to reverse effect of anticoagulation
o RF reduction to prevent further episodes
o Supportive therapy to aid rehabilitation
What should ischaemic stroke patients be discharged on?
• Discharge on
o Clopidogrel 75mg
daily Aspirin + dipyridamole - If clopidogrel is contraindicated/not-tolerated (combination more effective than aspirin alone)
o Daily statin (even if cholesterol levels are normal)
o Daily ACEi +/or thiazide diuretic
Aim for BP <130/85 mmHg or <120/80 mmHg if diabetic
TIA mx
• Acute neurological symptoms that resolve completely within 24h
o 300mg aspirin immediately
o Assess urgently within 24h unless:
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
• Pt with confirmed TIA - secondary prevention
o Clopidogrel – 300mg loading dose + 75mg thereafter
o High-intensity statin therapy – e.g. atorvastatin 20-80mg
o BP-lowering therapy with a thiazide-like diuretic, long-acting CCB or ACEi
BUT do not treat BP acutely, unless >220/120 or other indication
If AF - anticoagulate asap (warfarin)
Secondary prevention in patients with TIA
Secondary prevention
• Antiplatelets
• Antihypertensives
• Statins
• Management of AF (rate control; β-blocker/digoxin, rhythm control; cardioversion, anti-coagulation; rivaroxaban, dabigatran, warfarin, aspirin)
• Management of other underlying RF e.g. diabetes, hyperlipidaemia etc
Sodium Valproate SE
- Hair thinning/loss
- Tremor
- Weight gain
- Hepatotoxicity (drug induced hepatitis)
- Pancreatitis
- N+V
- Drowsiness
- Dizziness
- Weakness
- Teratogenicity (neural tube defects, spina bifida)
Phenytoin SE
- Increased hair growth
- Gingival hyperplasia + bleeding
- Acne
- Ataxia
- Rash
- Ophtlamoparesis, diplopoia
- Folate deficiency - megaloblastic anaemia
- Vitamin D deficiency - osteomalacia (because of induction of enzymes in liver that metabolise vitamin D)
- Cerebellar features (ataxia, nystagmous, tremor)
- Induces hepatic enzymes - increases metabolism of hepatically metabolized drugs
- Nausea
- Loss of appetite
- Teratogenic (cleft palate + congenital heart disease)
Ethosuximide SE
- Abdominal pain
- Pancytopenia
- SLE
- Suicidal thoughts
- Night terrors
- Paranoid psychosis
- Loss of appetite
- Fatigue
- Steven-Johnson syndrome (affects skin and mucous membranes. It’s usually a reaction to a medication or an infection. Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters)
Carbamazepine SE
o Hyponatramia o Ataxia o Rash o Neutropenia - agranulocytosis o Osteoporosis
o Dizziness o Nausea o Headaches o Drowsiness o Teratogenic
o Induces hepatic enzymes - increases metabolism of hepatically metabolized drugs
Tonic-clonic seizure drug mx
CLV
Carbamazepine
Lamotrigine
Valproate
Tonic-atonic seizure drug management (no loss of consciousness)
Valproate
Absence seizures drug mx
LEV
Lamotrigine
Ethosuximide
Valproate
Myoclonic seizures drug mx
LTV
Levetiracetam
Topiramate
Valproate
Partial seizures drug mx
CLLV
Carbamazepine
Lamotrigine
Levetiracetam
Valproate
Subdural haematoma management
Chronic haematoma
- Antiepileptics (phenytoin, levetiracetam) for all pt
- Elective surgery if needed
- Correction of coagulopathy if needed
- Intracranial pressure-lowering regimen if needed
Migraine mx
Conservative
- Headache diaries
- Avoid triggers
Acute medical
1) paracetamol, ibuprofen, NSAIDs
2) Triptans
Preventative
1) propanolol (BB) or topiramate (anti-epileptic)
2) amitriptyline
capsule GP 371 also says diltiazem can be used in acute attacks
if PMH of IHD triptans are contra indicated - use analgesia + anti-emetics
Cluster headaches - acute attack mx
SC Sumitriptan
High flow oxygen at least 12l/min
passmed
if PMH of IHD triptans are contra indicated - use analgesia + anti-emetics
Cluster headaches - long term prophylaxis
Verapamil
passmed
Tension headaches mx
Conservative
- Headache diaries
- Avoid triggers
Acute medical
- Simple analgesics incl aspirin, paracetamol, NSAIDs
Preventative
- Amitryptiline
- Acupuncture
capsule GP 535
Red clots mx
White clots mx
red clots
anti-coagulation - AF, ventricular thrombi (warfarin, DOACs)
red clots = fibrin + trapped erhythrocytes
White clots
Anti-platelets - stroke due to atherosclerosis, TIA (aspirin, clopidogrel)
white clots = platelets
stroke usually give anti-platelets only when certain that stroke is due to AF/ventricular thrombi/cardioembolic causes give anti-coagulation
Contraindications to thrombolysis
> 4.5h
Haemorrhagic stroke
CT reveals acute trauma or haemorrhage
Symptoms suggestive of SAH (meningism, headache)
High INR, APPT, PT
Low GCS
BP >180/110 mmHg (high risk of haemorrhage post thrombolysis)
Cerebral venous sinus thrombosis mx
Anticoagulation (first line therapy)
Even in the presence of hemorrhagic transformation of the infarction
Drugs that induce the hepatic enzymes + significance
Phenytoin
Carbamazepine
Barbiturates
Increase metabolism of OCP - need to 2x the dose of OCP
Increase metabolism of warfarin - need more warfarin for the same target INR
SE of anti-epileptic drugs
Weigh gain
Psychiatric SE e.g. Depression
Mechanism of action of Phenytoin
Block action potential (Na+ channel - depolarisation)
Mechanism of action of Carbamazepine
Block action potential (Na+ channel - depolarisation)
Mechanism of action of Lamotrigiene (LTG)
Block action potential (Na+ channel - depolarisation)
Mechanism of action of Levetiracetam (LEV)
Reduce glutamate- mediated excitation (pre-synaptic)
Mechanism of action of benzodiazepines
Enhance GABA inhibition (increase frequency of Cl channel opening)
SE of lamotrigiene
- Rash
- Headaches
- Dizziness
- Insomnia
- Vivid dreams
- Steven Johnson syndrome (affects skin and mucous membranes. It’s usually a reaction to a medication or an infection. Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters)
Where is the lesion in
Spinal cord compression
Cauda equina
Radiculopathy
Spinal cord compression - spinal cord
Cauda equina - cauda equina
Radiculopathy - nerve root
When is carotid entarterectomy recommended?
o Carotid endarterectomy if >50% stenosed carotid artery on doppler
o Surgery isn’t recommended in cases where there’s minor stenosis (less than 50%).
o This is because surgery is most beneficial for people with moderate and severe stenosis (more than 50%).
o The maximum benefit is seen in those with severe stenosis (70 to 99%).
Bell’s palsy mx
- High dose corticosteroids – prednisolone
- Eye protection
For some patients
• Antiviral agents - reduce long-term sequelae of Bell’s palsy compared with a corticosteroid alone
o If severe palsy/complete paralysis on presentation
o Valaciclovir, acyclovir
• Surgical decompression – consider if positive ENoG and needle EMG
How do you manage head injuries? What do you avoid using?
Manage using paracetamol, naproxen
Prochlorperazine
Benzodiazepines enough to calm them down but not to cause them to fall asleep as you need to monitor their GCS
Prophylactic antiepileptics for 7 days(phenytoin, levetiracetam) [levetiracetam is easier to administer + monitor than phenytoin]
GCS <13 - tranexamic acid
think of reducing ICP (monro-kellie doctorine)
Avoid using opioids because they make the vomiting and the dizziness worse
Steroids are contra-indicated in acute traumatic injury - higher risk of complications
What is the monro-kellie doctorine?
The Monro–Kellie hypothesis states that the cranial compartment is inelastic and that the volume inside the cranium is fixed
therefore in brain injuries if there is increase in volume of either the brain/blood/CSF something else must decrease to compensate for that increase in volume
How to reduce ICP using the monro-kellie doctorine
to reduce the volume of
CSF - ventricular drain
blood
improve venous return by sitting them up, remove anything from around the neck that compresses the jugular veins
make sure they are not constipated/bowel obstruction/chest infection (increased intrathoracic pressure resulting from bloated abdo
means decreased venous return)
make sure pt is intubated –> so that they have a normal pCO2 4.5-5 kpa to avoid cerebral vasodilation
brain
sedation, analgesia, anti-epileptics to reduce the metabolic demand of the brain
if these conservative measures do not work - use mannitol or hypertonic saline to decrease the ICP
if medical measures do not work - craniotomy
Unconscious pt think of
unprotected airway therefore might need intubation
ABC in trauma
Airway + c-spine control
Breathing - will need intubation if <8
Circulation
penetrating brain injuries/serious skull fractures
Damage control Getting rid of the foreign body seizure control ICP control Pt in ICU until he is stable
then take him to surgery
