NEURO PACKET 2

Question 1

TX OF HEMORRHAGIC STROKE

TREATMENT of HEMORRHAGIC **these pts don’t get ____ ***acute management (hospital)
- Admitted to ICU for observation and supportive care
- Systolic BP lowered to 140mg HG with ______ (fast acting BB, easy to titrate) or ______
o Platelet transfusion for thrombocytopenia
o ______ reversed with fresh frozen plasma, prothrombin complex concentrates, vitamin K or specific reversal agents
- Monitor ___ and treat with osmotic therapy
- _______ drainage with acute hydrocephalus

Answer 1

TPA
labetalol
nicardipine
coagulopathies
ICP
ventricular

Question 2

TIA

• Medical Measures
  o Hospitalization when patients are seen within a ____ bc risk for early recurrence
  o ABCD2 score  assess recurrence risk
  o A score of _ or more has been suggested as a threshold for hospitalization
   Points are assigned for the following criteria
  • Age __ or older (1 point)
  • BP ___/90 or higher (1 point)
  • Clinical symptoms of ____ weakness ( 2 points) or speech impairment without weakness (1 point)
  • Duration ___ mins or longer (2 points) or 10-59 minutes (1 point)
  • DM (1 point).
  o ABCD21
   Additional 3 points for any abnormal diffusion-weighted MRI finding or any infarct (new or old) on noncontrast CT
   Proposed as better predictor of subsequent stroke risk
  o Admission advisable
   Patients with crescendo attacks
   Symptomatic carotid stenosis
   Known cardiac source of emboli
   hypercoagulable state
   Hospitalization facilitates early intervention for any recurrence and rapid institution of secondary prevention measures
  o Aimed at preventing further attacks and strokes
   Treat ____; hematologic disorders and HTN (ACEI, or ARB)
   ____ no matter what LDL is
   Stop smoking
   Cardiac sources of embolization should be treated
   Regular physical activity.
  o Anticoagulation
   Chief indicator is ___
   Patients with metal heart valves, left ventricular thrombus, antiphospholipid antibody syndrome
   If indicated should be started immediately if their use is not contraindicated and that is an acute cerebral infarct occurred it is small
   _____ (target INR 2-3); bridging with heparin not necessary but some advocate for ASA until therapeutic warfarin levels.
   Long term with Afib; not usually started in the acute setting
  • Dabigatran, rivaroxaban, apixaban, are options
   Combination antiplatelet-anticoagulation
  • Mechanical heart valves
  • Separate indication for antiplatelet therapy such as cardiac stent.
  o Antiplatelet Therapy
   All patients in whom anticoagulation is not indicated to reduce the frequency of TIAs and the incidence of stroke
   ____ (81mg daily)
   Extended-release dipyridamole (200 mg BID)
   Clopidogrel (75mg daily)
   Cilostazol (100mg BID) similar efficacy as ASA in Asian population with less hemorrhagic risk
   ASA and clopidigrel increase risk of hemorrhage but short-term therapy may be beneficial
  o Surgical or Endovascular measures
   Surgically accessible high-grade stenosis (70-99%) on the side appropriate to carotid ischemic attacks. Symptomatic stenosis of 50-69% derive moderate benefit; not indicated for mild stenosis (less than 50%)
   Operative treatment
  • Carotid endarterectomy or endovascular intervention reduces the risk of ipsilateral carotid stroke; especially when TIAs are of recent onset (less than 1 month) and when perioperative morbidity and mortality risk is estimated to be less than 6%
  • Endovascular therapy carries a slightly higher procedural stroke risk than endarterectomy in patients older than 70
  o Generally reserved for younger patients whose neck anatomy is unfavorable for surgery

Answer 2

week
4
60
140
focal
60
DM
statin
Afib
Warfarin
ASA

Question 3

CONCUSSION

TREATMENT
- PREVENTION: ____, seatbelts, other protective equipment
- Once acute bleed has been excluded, treatment of mild TBI aimed at promoting resolution of post-concussive symptoms and preventing recurrent injury by avoiding ____ activities, etc. (which increases the risk of chronic neurobehavioral impairment and delays recovery)
- Second impact syndrome: recurrent concussion while a patient is still symptomatic from first concussion  may lead to fatal cerebral edemas
o Patients at risk for recurrent concussion (____) should be held out of risky behavior (until they are asymptomatic from original injury)!!!
- Patients _______ with moderate to severe TBI:
o Multi-disciplinary approach due to concomitant injuries
o Elevated _______ can result from diffuse axonal injury or hematoma (requiring surgical decompression) or other medical issues
 Decompressive craniectomy may reduce otherwise refractory intracranial HTN (does not improve neurologic outcome)
o ______ associated with worsened functional outcomes

SUBDURAL HEMATOMA
o TREATMENT: ____ intervention is indicated when…
 Hematoma is __ mm or more in thickness or there is a midline shift of 5 mm or more
 Decline in GCS of __ or more from injury to hospital admission
 If one or more of the pupils are fixed and ___

• Scalp lacerations and depressed skull fractures: should be treated ______ as appropriate
• Simple skull fractures: require no specific treatment (just _____)
• With leakage of CSF: conservative treatment with elevation of the ____, restriction of fluid, and administration of ________
  o If leak continues for more than a few days, lumbar subarachnoid drainage
  o Abx for infection
  o Vaccination against pneumococcus recommended
  o Occasional intracranial repair of the dural defect because of persistence of the lead or recurrent meningitis

Answer 3

helmets
sports
athletes
hospitalized
ICP
hypothermia

surgical
10
2
dilated

surgical
monitor
head
acetazolamide

Question 4

ACUTE SUBDURAL HEMORRHAGE

______

Answer 4

surgical evacuation

Question 5

STATUS EPILEPTICUS/ACUTE TONIC CLONIC SEIZURES ***This is management for seizure in your ED (treatment for status epilepticus, but also for anyone coming in with an acute seizure)

• Protect the ABCs!
• Start IV _______ in case of hypoglycemia
• IV bolus _______ (benzo) 4mg – repeat after 10 minutes if needed *seizure usually goes away at this point for tonic-clonic seizure
• Load IV ______ to assist with long term control
• IF the above measures fail, general anesthesia with _____ assist is used  anesthetics are paralytic agents SO helps with breaking seizure cycle

Answer 5

dextrose
lorazepam
phenytoin
ventilatory

Question 6

ALCOHOL WITHDRAWAL SEIZURES
TREATMENT
- Give IV _____, magnesium, and _____
- Treat seizures with _______ (ativan, valium)
- Check electrolytes and further correct any imbalances (ex. low magnesium, low calcium)
- Patients at risk for developing Delirum Tremens (DTs)  can be fatal

Answer 6

glucose, thiamine

benzos

Question 7

FEBRILE SEIZURES

treat the ___ and seizures will resolve

Answer 7

fever