Neurologic Emergencies Flashcards
What are the high risk features of headaches?
- age > 50 (tension and cluster HA tend to decrease with age)
- abrupt onset of severe headache
- thunderclap
- change in pattern. frequency, etc etc
Diagnostics for HA:
- CT =
- MRI with and without contrast, MRA, CTA
- LP =
- ICH, SAH, cerebral venous thrombosis, tumor
- meningitis, SAH
SAH is hemorrhaging resulting from rupture of an _________________ only caries a _______________ survival rate.
CT alone MAY not suffice if obtained within _______________.
If beyond this timeframe, the CT is negative, then must do a ________________ to detect __________ or ____________ in the CSF.
intracranial aneurysm
30 day
6 hours
LP, blood, xanthochromia
What imaging is the gold standard for detecting aneurysms?
angiography
What is the definitive treatment for SAH?
surgical clipping or endovascular coiling
prevent the risk of rebleeding (nimodpipine) and seizures (phenytoin)
Intracerebral hemorrhage presents as severe and sudden headache likely with some neurologic deficit indistinguishable from a stroke.
What are the most common causes?
What are the most common bleeding sites?
Diagnostic test?
the most common cause is advancing age and damage of intracerebral arterioles by long standing HTN
common bleeding sites: basal ganglia, thalamus, internal capsule
NON contrast CT
What is the treatment for intracranial hemorrhage?
treat elevated BP (not too aggressive)
if systolic is over 200, then treat with IV nicardipine 5mg/hr or labetalol 20 mg bolus q 10 minute- targets sbp of 140-160
elevate HOB if suspected elevated ICP
What is the initial treatment of migraine headaches?
Which medication is NOT first line therapy?
Which med would be useful in decreasing risk for headache recurrence after ED discharge?
Which meds are contraindicated during pregnancy?
What is the goal ?
- IV with dopamine receptor antagonist
- keterolac 30/60 mg IV
- sumpatriptan 6 mg
not first line = OPIATES
steroids= DEXAMETHASONE
in pregnancy, triptans are contraindicated, no nsaids in 3rd trimester.
to reduce SEVERITY of HA not to reduce it
A non-traumatic spontaneous subdural hematoma presents as ________________ that is more insidious rather than acute in the elderly population. This headache is activation of _____________ within the dura. This is common in patients on _____________________ agents.
These patients may also have signs of….
new headache
nocioceptors
antiplatelet/anticoagulation
signs:
light headedness, cognitive impairment, apathy or depression, parkinsonism, gait ataxia, somnolence, seizures
Carotid/vertebral artery dissection aka cervical artery dissection is a major cause of stroke in __________________ population.
What are the causes?
What are the symptoms?
Internal carotid dissection will present with __________________ symptoms
Vertebral artery dissection will present with ___________________ symptoms
young and middle aged
causes: minor cervical trauma (chiro), coughing, sneezing and physical activity.
symptoms: HA, neck pain, neruo sx, dizziness/vertigo, visual loss,*** HORNER SYNDROME WITH PTOSIS AND MIOSIS OF THE AFFECTED SIDE ****
int carotid: ant circulation sx
vertebral: post circulation
What is the diagnostic study of choice and treatment for patients with carotid artery stroke?
diagnostic: CTA
Tx: treat like stroke pt
thrombolytics or endovascular therapy
Temporal arteritis/giant cell arteritis is an inflammatory condition affecting the small and medium sized ______________ and ____________ vessels. This is primarily a disease of those > _____________ years old, its incidence increases with age. In addition to HA, other symptoms may include…
You want to begin treatment with _________________ daily upon suspicion to minimize morbidity from visual impairment.
intracranial, extracranial
> 50
fever, fatigue, proximal muscle weakness, JAW CLAUDICATION*
or TIA symptoms** especially transient visual loss.
prednisone 60 mg
Cluster headaches have a ________________ and ______________. What is the treatment ?
circadian, circannual pattern: recurring daily for more than a week and remitting for at least 4 weeks.
100% oxygen administed at 12L/min for 15 minutes through a nonebreathing face mask.
Sumatripatin 6 mg
Intranasal lido 10&
Stroke - ischemic - thrombosis vs embolic, majority are from __________________, or hemorrhagic. This results in cerebral ischemia or infarction. A stroke presents as ___________________ or ______________. The door to CT time for a potential stroke patient is within _____________ of ED arrival. Head CT rules out ________________.
atherosclerosis.
focal/global neuro deficits or AMS
20 minutes
hemorrhagic stroke
For patients that had a stroke, the exact time of onset of symptoms is important because thrombolytic window is ___________ and some say __________.
3 hours, 4.5
What is the weakness of the NIH scale?
Max score =
normal =
1-4 =
5-15 =
15-20=
> 20=
score the FIRST response not the best response
identifying posterior circulation- also favors identifying left hemi stroke.
max= 42 signifying devastating stroke
normal = 0
1-4 = minor stroke
5-15= moderate stroke
15-20= mod severe stroke
> 20= severe stroke
For a stroke, the ultimate goal is door to needle time of __________________ of arrival in the ED in greater than or equal to 50% of acute ischemic stroke patients who are treated with thrombolytics.
TPA= 3 hour window
Endovascular therapy for pts who cant get TPA or DO NOT respond to TPA = time limit of 6 hours
less than or equal to 60 minutes
In patients having a stroke, A SBP __________ or DBP ___________ is a contraindication. If a patient is a candidate for thrombolytics, lower BP to meet these entry parameters. Give _____________ within 24-48 hours if NO thrombolytics given.
> 185
110
Aspirin
What is the exclusion criteria for TPA?
- significant head trauma or prior stroke in the previous 3 months
- symptoms suggest SAH
- arterial puncture at noncompressible site in previous 7 days
- hx of previous intracranial hemorrhage, intracranial neoplasm, AVM, aneurysm
- recent intracranial or intraspinal surgery
- elevated BP ( > 185 systolic >110 diastolic)
- active internal bleeding
- acute bleeding diathesis, plt ct <100,000, heparain received withiin 48 hrs
- current anticoag use with INR > 1.7 or PT > 15s
- current use of thrombin/XA inhibitors
- blood glucose <50
- CT= multilobar infarction
Stroke syndromes:
1. anterior circulation
2. middle
3. posterior
4. brainstem
5. cerebellar
6. lacunar
- contralat motor symptoms in LE sparring hands and face
- MOST COMMON, hemiparesis (face and UE)
- ataxia, nystagmus, AMS, vertigo
- ipsilateral CN deficit with contralat motor weakness
5.diziness, nystagmus, N/V, gait instability, HA, limb ataxia, dysarthria, hearing loss, intractable hiccupus. - pure sensory or motor from small penetrating arteries (most favorable prognosis)
TIA is a ___________ episode of neurological dysfunction caused by focal ____________, ____________, or ______________ WITHOUT acute infarction.
What is the workup and the treatment?
1-2 hour
brain
spinal cord
retinal ischemia
workup: CT, EKG
tx: ASA for daily low risk, ASA and clopidogrel for high risk ABCDD score of greater than or equal to 4
For coma’s you can use the GCS scale to measure level of consciousness. What are other measures of brain activity?
pupillary reflex
doll’s head eye reflex
cheyne strokes breathing
posturing
Abrupt coma
Slow coma
What is the workup for coma’s?
abrupt: catastrophic stroke or seizures
slow: progressive CNS lesion such as tumor or subdural hematoma. metabolic causes
liberal use of CT scanning.
How long do you have to wait before calling a patient brain dead?
6 hrs
What is one of the main injuries that you want to asses in a patient with a seizure ?
posterior shoulder dislocation
______________ are expected to be elevated in a patient with a first time seizure because of the seizure itself.
What is NOT part of the ED workup for seizures.
In a patient with a well documented seizure d/o who has had a single unprovoked seizure, check a _________________ and pertinent anticonvulsant seizure patterns. You also want to obtain a _______________ if theres a change in established seizure patterns.
lactate
EEG
glucose
What is the treatment of someone having a seizure?
supportive and patient protective measures
turn on side during sz- afterwards suction and assess airway
most sx abort within 5 min
if over 5 min = status
Status epilepticus is a single seizure lasting __________ or ___________ without recovery of consciousness between seizures. What is the treatment?
greater than or equal to 5 min
two or more seizures
treatment- IM or intranasal midazolam, rectal diazepam
For bacterial meningitis, you ALWASY want empiric treatment and within ____________ of presentation. Adjunctive _______________ should be given shortly before or at the same time as the first dose of antibiotics.
What is the treatment for pts
< 1 mo
1- 23 months
2-50 years
> 50 years
30 min
dexamethasone
amp + cefotaxime
vanco + 3rd gen ceph
vanco + 3rd gen ceph
vanco + amp + 3rd gen ceph
Bells palsy: acute onset is 1-2 days, progressive course, maximal clinical weakness/paralysis within 3 weeks. Recovery takes _____________ months. Unilat facial nerve involvement with NO SIGNS of other nervous system involvement. What is the treatment?
6
artificial tears hourly- 4x/day
prednisone 40-60 mg/day orally for 10 days
In Bell’s palsy…
1. motor fibers that innervate the facial muscles >
2. parasympathetic fibers innervating lacrimal, submandibular, and sublingual salivary glands >
3. afferent fibers from taste receptors from the ant…….
4. somatic afferents from the external auditory canal and pinna >
- facial droop
- decreased tearing
- 2/3 of tongue
- hyperaccusis
Guillan Barre syndrome is preceded by a viral illness (campylobacter jejuni) and ascending symmetric weakness that presents with absence of ________________________. The diagnostic testing is ___________________ *delayed findings. The treatment is:
absence of DTR even BEFORE signs of muscle weakness begins.
elevated protein in CSF
tx: IVIG, plasmapharesis
Syncope is defined as ________________ due to global cerebral ________________with a rapid onset, bried duration, and spontaneous complete recovery. What work up do you want to do to rule out lethal crdiopulm/ectopic pregnancy
transient loss of consciousness
hypoperfusion
labs, uHCG, ECG
What are potential ecg findings related to syncope?
prolonged QT interval and brugada
Which patients are considered high risk/low risk in the case of syncope?
high risk: elderly pt with exertional syncope, abnormal ECG with hx of CHF > should be admitted to the hospital
low risk: young patient with an obvious vasovagal event and normal ECG may be disrcharged
Benign paroxysmal positional vertigo (BPPV)
otoconia are displaced
acute onset- vertigo and nystagmus stops if remains still
Vestibular neuritus is dedicit in one of the ______________ nerves. THERE IS NOOOOO associated ….
it is persistent and lasts for DAYS
It presents with spontaneous
vestibular
ear pain, hearing loss, or tinnitus
nystagmus
Cerebellar/brainstem stroke- life threatning/ edema. The patient may have ______________ deficits and it can be persistent and lasts for days. Spontaneous _____________ is present.
focal deficits
nystagmus
finish slides 51-53
