Neurologic Emergencies Flashcards
Initial actions and primary survey in a patient with AMS?
Assess ABCs Monitor, pulse ox Supplemental O2 if hypoxic Bedside glucose testing IV access Evaluate for signs of trauma and consider C-spine stabilization Consider naloxone administration
DDx for AMS - AEIOU TIPS
Alcohol Epilepsy, Electrolytes, Encephalopathy Insulin Opiates and O2 Uremia Trauma and Temperature Infection Poisons and Psychogenic Shock, Stroke, SAH, Space-occupying lesion, Seizure
Glasgow Coma Scale?
Eye opening
- Spontaneous (4)
- Loud voice (3)
- To pain (2)
- None (1)
Verbal
- Oriented (5)
- Confused (4)
- Inappropriate words (3)
- Incomprehensible sounds (2)
- No sounds (1)
Motor
- Obeys (6)
- Localizes to pain (5)
- Withdraws to pain (4)
- Abnormal flexion posturing (3)
- Abnormal extension posturing (2)
- None (1)
Diagnostic testing options for AMS 2/2 suspected metabolic or endocrine cause?
Rapid glucose Serum electrolytes (Na, Ca) ABG or VBG (with co-oximetry for carboxy or met-hemoglobinemia) BUN/Cr Thyroid function tests Ammonia level Serum cortisol level
Diagnostic testing options for AMS 2/2 suspected toxic or medication causes?
Levels of medications (anticonvulsants, digoxin, theophylline, lithium, etc.)
Drug screen (benzos, opioids, barbiturates, etc.)
Alcohol level
Serum osmolality (toxic alcohols)
Diagnostic testing options for AMS 2/2 suspected infectious causes
CBC with diff UA and culture BCx CXR LP with opening pressure (CT first if suspecting increased ICP)
Diagnostic testing options for AMS 2/2 suspected traumatic cause
Head CT/cervical spine CT
Diagnostic testing options for AMS 2/2 suspected neurologic cause
Head CT (non-con to start)
MRI (if brainstem/posterior fossa pathology suspected)
EEG (if non-convulsive status suspected)
Diagnostic testing options for AMS 2/2 suspected hemodynamic instability?
EKG
Cardiac enzymes (silent MI)
Echo
Carotid/vertebral artery US
Rx hypoglycemia
Dextrose
Rx opioid toxicity
Naloxone
Rx agitated withdrawal states
Supportive care and sedation
Rx dehydration, hypovolemic, hypotension, or hyperosmolar states such as HHNS or hypernatremia?
IV fluids
Rx suspected meningitis, urosepsis, pneumonia, etc.
Empiric ABX
Rx temperature extremes
Rewarming or aggressive cooling
Rx hypertensive encephlopathy
Controlled reduction of BP with nitroprusside, labetolol, or fenoldepam
Rx profound hyponatremia with seizures or AMS
Hypertonic saline
Rx metastatic CNS lesions with vasogenic edema
Glucocorticoids
4 types of ICH?
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intracerebral hemorrhage
Common presenting symptoms among all ICH?
Headache, N/V, confusion, somnolence, seizure
Classic presentation of SAH?
Acute-onset “thunderclap” headache with LOC, vomiting, neck stiffness, or seizure
Maximum intensity within seconds
Often occipital in location
Significant proportion (30-50%) also have a warning headache
Hunt and Hess Grading System for SAH?
1 - asymptomatic, mild headache, slight nuchal rigidity
2 - moderate to severe headache, nuchal rigidity, no neurologic deficit other than CN palsy
3 - Drowsiness/confusion, mild focal neurologic deficit
4 - Stupor, moderate-severe hemiparesis
5 - Coma, decerebrate posturing
Risk factors for all intracranial bleeds?
Recent exertion HTN Excessive alcohol consumption Sympathomimetic use Cigarette smoking
Strongest risk factor for SAH?
Family history (3-5x risk)
Most SAH are due to what cause?
Rupture of saccular aneurysms
What is an epidural hematoma? What causes them?
Accumulation of blood between the skull and the dura
Significant blunt head trauma -> fracture of the temporal bone -> injury to middle meningeal artery -> high-pressure bleeding in the cranial vault
Classic presentation of epidural hematoma?
Brief LOC after a blow to the head -> lucid period -> LOC deteriorates again -> herniation and death
[in reality, most patients either do not lose consciousness or do not regain it again]
What are subdural hematomas? What causes them?
Extra-axial blood collections between the dura and the arachnoid mater
Acceleration-deceleration injury leading to shearing of bridging veins -> low-pressure bleed with fairly slow growing hematoma
Presentation of SDH?
Wide clinical spectrum
Rapid accumulation of blood, absence of pre-existing atrophy, and the presence of other TBIs correspond to a worse neuro status at presentation
In pediatric populations, acute or chronic SDH should raise suspicion for ___.
Child abuse
Initial actions and primary survey in suspected ICH?
ABCDs (secure the airway, document neuro exam)
Glucose
Cushing’s triad?
Physiologic response to rapidly increasing intracranial pressure and imminent brain herniation -> hypertension, bradycardia, abnormal respiratory patterns
Other signs of imminent herniation - pupillary reaction and pupillary asymmetry
Dx ICH?
Non-contrast CT
(Easy to miss bleeding during days 3-14, as it becomes isodense)
+/- LP if suspecting SAH (not necessarily needed if CT is normal in the first 6 hours after onset of symptoms)
Large volumes of blood in the cranium can cause radiologic signs of increased CIP, including… ?
Midline shift
Ipsilateral compression of the ventricles with or without contralateral ventricle enlargement
Obliteration of the sulci
Blurring of the grey-white junction
Appearance of subdural hematoma?
Convex/crescent shaped, may cross suture lines
Appearance of epidural hematoma?
Convex/lens-shaped, do not cross suture lines
2 important CSF features to look for in SAH?
Absence or clearing of blood (label ‘traumatic’ tap only if the fourth tube is almost completely free of blood (<5 RBCs/HPF)
Xanthochromia
Next step if CT or LP is concerning for SAH?
Angiography (DSA is the gold standard, CTA or MRA is fine)
Canadian head CT rules - high risk for neurosurgical interventions?
GCS score <15 at 2 hours after injury
Suspected open or depressed skull fracture
Any signs of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/rhinorrea, Battle’s sign)
Vomiting >2 episodes
>65 y/o
Canadian head CT rules - medium risk for neurosurgical interventions?
Amnesia before impact >30 minutes Dangerous mechanism (pedestrian stuck by vehicle, occupant ejected from MV, fall from elevation >3 feet or 5 stairs)
Canadian head CT rules not applicable if…
Non-trauma cases GCS <13 Age <16 Coumadin or bleeding disorder Obvious open skull fracture
Medical Rx of all ICH?
Assess and reassess ABCDs
D/C or reverse anticoagulation
Prevent hypotension and hypoxemia
Control ICP
Prevent seizure (PPx may be necessary depending on the type and extenf o bleed)
Rx fever and infection aggressively
Control blood glucose (target 140-185 mg/dL)
How is ICP controlled?
Monitor/lower BP in consultation with neurosurgery
Elevate the HOB to 30 degrees
Provide adequate sedation and analgesia
If signs of rapidly rising ICP or herniation, consider mannitol or mild hyperventilation (target CO2 around 30 mmHg)
Define status epilepticus
Seizure >5 minutes duration OR 2+ seizure in a row without a return to baseline
Note that a prolonged postictal period may also indicate ongoing seizure activity
Patients with a primary seizure disorder are more prone to seize in the setting of what?
- Medical non-compliance (most common cause)
- Sleep deprivation
- Emotional or physical stress
Etiologies of secondary, or reactive seizures?
Hypoglycemia (most common cause of reactive seizure) Hyponatremia Alcohol withdrawal Trauma Drugs/Toxins Tumor Infections (eg, meningitis, encephalitis, CNS abscess) Eclampsia
2 diagnoses that mimic seizure?
Pseudoseizure
Syncope
Work-up for patients presenting after an uncomplicated seizure who are back to baseline and have no complaints and a normal physical include what labs?
New-onset, first-time seizure: BMP (sodium and glucose), pregnancy test
Recurrent: (medication levels - phenytoin, carbamazepine, phenobarbital, etc.), further testing guided by H&P
Status - more complete lab profile including LP to identify possible underlying causes
Work-up for patients presenting after an uncomplicated seizure who are back to baseline and have no complaints and a normal physical include what imaging?
New - CT scan to r/o intracranial lesions, MRI in outpatient setting
Recurrent - CT scan if change in seizure pattern, significant trauma, fever, prolonged post-ictal time, new neruo deficit, other concerning symptoms
Status - all patients get CT
Work-up for patients presenting after an uncomplicated seizure who are back to baseline and have no complaints and a normal physical include what procedures?
LP in any patient with status, severe HA, fever, persistent AMS, or immunocompromise (especially HIV)
Head CT prior to LP
EEG in outpatient setting if new
Emergent continuous EEG if status
Presentation of seizure 2/2 alcohol withdrawal (DT)?
May present with anxiety, tremulousness, AMS, tachycardia, HTN, hyperthermia, tachypnea
Elevated BAL does not r/o this diagnosis, as chronic use may lead to seizure at any blood level
Presentation of seizure 2/2 eclampsia?
Vision complaints, edema of hands, face, feet, proteinuria on UA, HTN
Toxins/drugs that can cause seizure?
Isoniazid, OD on TCAs (look for widened QRS and prominent terminal R wave in aVR on EKG)
___% of patients initially thought to have pseudoseizure are diagnosed with a true seizure disorder.
25
Initial management of seizures?
ABCs, supplemental O2
Keep patient safe from falling/other injuries
Remove restrictive clothing
Do not place anything in the patient’s mouth except possibly a bite block or an oropharyngeal airway
First, second, and third line medications for seizures?
First line - benzodiazepines (usually lorazepam)
Second line - fosphenytoin/phenobarbital/valproic acid
Third line - versed/pentobarbital/propofol infusions
IV is preferred
Which benzos can be given IM?
Lorazepam
Midazolam
Diazeapm
Common doses of benzos?
2 mg Lorazepam (or 2 mg midazolam or 5 mg diazepam) PO/IM/IV Q2-5 minutes PRN
Dose of phenytoin/fosphenytoin for seizures?
15-20 mg/kg PO/IV
15-20 phenytoin equivalents/kg IV
Dose phenobarbital for seizures?
20 mg/kg IV (use single dose of 60-120 mg PO for oral load)
Dose valproic acid for seizures?
15-45 mg/kg IV
Rx seizure in eclampsia?
Magnesium sulfate
Rx seizures 2/2 hyponatremia?
Hypertonic saline
Rx seizures 2/2 isoniazid?
Pryoxidine
Rx seizures 2/2 hypoglycemia?
Dextrose
___% of the population with have a seizure sometime during their lifetime
1
