Neurologic Emergencies Flashcards
Normally, ___ accounts for up to 85% of the contents of the cranial vault
Brain parenchyma
CSF pH that can produce cerebral ischemia
Increase in pH
Hallmark of severe TBI
Coma (GCS 3-8)
GCS indicating moderate TBI
9-12
In TBI, ICP should be maintained at
<20mmHg
Reasonable indications for CT imaging in TBI
LOC or amnesia >5 min, persistent dizziness, mental status changes, focal neurologic defects, depressed skull fracture, signs of a basilar skull fracture, drug or alcohol use, age <2, suspected child abbuse, falls from >3m, high speed injuries
MCC of death from TBI in infants
Abusive head trauma
Leading cause of hypoxic-ischemic insults leading to HIE in infants and children
Asphyxia arrest
These define the need for neuroprotective interventions in perinatal asphyxia (3) e.g. therapeutic hypothermia
1) Fetal acidosis 2) 5-min APGAR of 0-3 3) Neurologic dysfunction and/or abnormal EEG findings
First goal in HIE
Optimize cardiac output and cerebral perfusion
Seizure of sufficient duration to provide an enduring epileptic focus
Status ep
Diagnosis of status ep is made with
EEG
Development of epilepsy after status ep occurs in up to ___% of children
30
Predominant causes of ischemic stroke in children responsibble for ~50% of strokes after the neonatal period
1) Sickle cell disease 2) Heart disease
Ischemic strokes in children are generally the result of
Damage to the intima of cerebral arteries which can form a thrombotic nidus
Predominant presentation of children with stroke
Abrupt onset of focal neurologic deficits
Predominant presentation of children with intracerebral hemorrhage
Coma
Major complication of stroke
Hemorrhagic transformation
Major complication of aneurysmal SAH
Vasospasm
The only approved acute therapy for stroke
rTPA within 3 hours IV or within 6 hours intrarterially into the occlusion
Guidelines for the management of pediatric stroke
1) ICP monitoring 2) RBC exchange/transfusion therapy for children with sickle cell disease 3) Anticoagulation and/or thrombolytics IF ICP MANAGEMENT IS NOT WARRANTED 4) Continuous EEG monitoring for children with tracheal intubation 5) Thrombolytics for children with cerebral venous sinus thrombosis
Herniation syndromes: Supratentorial to infratentorial
Transtentorial or uncal
Herniation syndromes: Increased ICP in one hemisphere
Subfalcine
Herniation syndromes: Cerebellar mass or edema
Foramen magnum
Herniation syndromes: Compression of the cerebral peduncles
Transtentorial or uncal
Herniation syndromes: Compression of the anterior cerebral artery
Subfalcine
Herniation syndromes: Compression of the midbrain
Transtentorial/uncal
Herniation syndromes: Compression of the cerebellar tonsils
Foramen magnum
Herniation syndromes: Compression of CN III
Transtentorial/uncal
Herniation syndromes: Compression of the posterior circulation
Transtentorial/uncal
Herniation syndromes: Compression of the medulla oblongata
Foramen magnum
Herniation syndromes: Dilated ipsilateral pupil
Transtentorial/uncal
Herniation syndromes: Hemiparesis
Transtentorial/uncal
Herniation syndromes: Bladder incontinence
Subfalcine
Herniation syndromes: Bradycardia, bradypnea, htn, death
Foramen magnum
Herniation syndromes: Hemiparesis
Transtentorial/uncal
Herniation syndromes: Cushing triad
Transtentorial/uncal
Herniation syndromes: Decerebrate posturing
Transtentorial/uncal
In children, brain death most commonly follows
TBI or asphyxia
Standard for diagnosis of brain death
Repeat clinical exam (it is a CLINICAL DIAGNOSIS)
3 key components of clinical brain death
1) Irreversible coma/unresponsiveness 2) Absence of brainstem reflexes 3) Apnea
Extension of the upper extremities followed by flexion of the arms with the hands reaching to midsternal level
Lazarus sign
What does the apnea test assess
Function of the medulla in driving ventilation
How do you do the apnea test
Preoxygenate with 100% O2 ~10mins > adjust ventilation to achieve pCO2 of about 40 > CPAP > assess for breathing efforts through observation and auscultation > ABG 10 mins into the test and every 5 mins thereafter until target pCO2 is surpassed
Positive apnea test
Absence of respiratory efforts with pCO2 >60 or more than 20 from baseline
To establish diagnosis of brain death, findings must remain consistent over a period of observation: For 7 days to 2 mos
2 exams separated by at least 48 hours
To establish diagnosis of brain death, findings must remain consistent over a period of observation: For 2 mos to 1 year
2 exams separated by at least 24 hours
To establish diagnosis of brain death, findings must remain consistent over a period of observation: Older than 1 y/o
2 exams separated by at least 12 hours
Confirmatory testing of brain death should be performed on what population
All children <1 y/o
Confirmatory testing of brain death
EEG, nuclear medicine cerebral flow scans etc.
EEG finding that supports diagnosis of brain death
Electrocerebral silence
