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Emergency Medicine Clerkship > Neurologic Emergencies > Flashcards

Neurologic Emergencies Flashcards

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1
Q

Initial actions and primary survey in a patient with AMS?

A 
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
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2
Q

DDx for AMS - AEIOU TIPS

A 
Alcohol
Epilepsy, Electrolytes, Encephalopathy
Insulin
Opiates and O2
Uremia
Trauma and Temperature
Infection
Poisons and Psychogenic
Shock, Stroke, SAH, Space-occupying lesion, Seizure
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3
Q

Glasgow Coma Scale?

A

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)
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4
Q

Diagnostic testing options for AMS 2/2 suspected metabolic or endocrine cause?

A 
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
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5
Q

Diagnostic testing options for AMS 2/2 suspected toxic or medication causes?

A

Levels of medications (anticonvulsants, digoxin, theophylline, lithium, etc.)
Drug screen (benzos, opioids, barbiturates, etc.)
Alcohol level
Serum osmolality (toxic alcohols)

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6
Q

Diagnostic testing options for AMS 2/2 suspected infectious causes

A 
CBC with diff
UA and culture
BCx
CXR
LP with opening pressure (CT first if suspecting increased ICP)
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7
Q

Diagnostic testing options for AMS 2/2 suspected traumatic cause

A

Head CT/cervical spine CT

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8
Q

Diagnostic testing options for AMS 2/2 suspected neurologic cause

A

Head CT (non-con to start)
MRI (if brainstem/posterior fossa pathology suspected)
EEG (if non-convulsive status suspected)

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9
Q

Diagnostic testing options for AMS 2/2 suspected hemodynamic instability?

A

EKG
Cardiac enzymes (silent MI)
Echo
Carotid/vertebral artery US

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10
Q

Rx hypoglycemia

A

Dextrose

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11
Q

Rx opioid toxicity

A

Naloxone

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12
Q

Rx agitated withdrawal states

A

Supportive care and sedation

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13
Q

Rx dehydration, hypovolemic, hypotension, or hyperosmolar states such as HHNS or hypernatremia?

A

IV fluids

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14
Q

Rx suspected meningitis, urosepsis, pneumonia, etc.

A

Empiric ABX

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15
Q

Rx temperature extremes

A

Rewarming or aggressive cooling

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16
Q

Rx hypertensive encephlopathy

A

Controlled reduction of BP with nitroprusside, labetolol, or fenoldepam

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17
Q

Rx profound hyponatremia with seizures or AMS

A

Hypertonic saline

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18
Q

Rx metastatic CNS lesions with vasogenic edema

A

Glucocorticoids

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19
Q

4 types of ICH?

A

Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intracerebral hemorrhage

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20
Q

Common presenting symptoms among all ICH?

A

Headache, N/V, confusion, somnolence, seizure

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21
Q

Classic presentation of SAH?

A

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

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22
Q

Hunt and Hess Grading System for SAH?

A

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

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23
Q

Risk factors for all intracranial bleeds?

A 
Recent exertion
HTN
Excessive alcohol consumption
Sympathomimetic use
Cigarette smoking
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24
Q

Strongest risk factor for SAH?

A

Family history (3-5x risk)

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25
Q

Most SAH are due to what cause?

A

Rupture of saccular aneurysms

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26
Q

What is an epidural hematoma? What causes them?

A

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

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27
Q

Classic presentation of epidural hematoma?

A

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]

28
Q

What are subdural hematomas? What causes them?

A

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

29
Q

Presentation of SDH?

A

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

30
Q

In pediatric populations, acute or chronic SDH should raise suspicion for ___.

A

Child abuse

31
Q

Initial actions and primary survey in suspected ICH?

A

ABCDs (secure the airway, document neuro exam)

Glucose

32
Q

Cushing’s triad?

A

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

33
Q

Dx ICH?

A

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)

34
Q

Large volumes of blood in the cranium can cause radiologic signs of increased CIP, including… ?

A

Midline shift
Ipsilateral compression of the ventricles with or without contralateral ventricle enlargement
Obliteration of the sulci
Blurring of the grey-white junction

35
Q

Appearance of subdural hematoma?

A

Convex/crescent shaped, may cross suture lines

36
Q

Appearance of epidural hematoma?

A

Convex/lens-shaped, do not cross suture lines

37
Q

2 important CSF features to look for in SAH?

A

Absence or clearing of blood (label ‘traumatic’ tap only if the fourth tube is almost completely free of blood (<5 RBCs/HPF)
Xanthochromia

38
Q

Next step if CT or LP is concerning for SAH?

A

Angiography (DSA is the gold standard, CTA or MRA is fine)

39
Q

Canadian head CT rules - high risk for neurosurgical interventions?

A

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

40
Q

Canadian head CT rules - medium risk for neurosurgical interventions?

A 
Amnesia before impact >30 minutes
Dangerous mechanism (pedestrian stuck by vehicle, occupant ejected from MV, fall from elevation >3 feet or 5 stairs)
41
Q

Canadian head CT rules not applicable if…

A 
Non-trauma cases
GCS <13
Age <16
Coumadin or bleeding disorder
Obvious open skull fracture
42
Q

Medical Rx of all ICH?

A

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)

43
Q

How is ICP controlled?

A

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)

44
Q

Define status epilepticus

A

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

45
Q

Patients with a primary seizure disorder are more prone to seize in the setting of what?

A
  1. Medical non-compliance (most common cause)
  2. Sleep deprivation
  3. Emotional or physical stress
46
Q

Etiologies of secondary, or reactive seizures?

A 
Hypoglycemia (most common cause of reactive seizure)
Hyponatremia
Alcohol withdrawal
Trauma
Drugs/Toxins
Tumor
Infections (eg, meningitis, encephalitis, CNS abscess)
Eclampsia
47
Q

2 diagnoses that mimic seizure?

A

Pseudoseizure

Syncope

48
Q

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?

A

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

49
Q

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?

A

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

50
Q

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?

A

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

51
Q

Presentation of seizure 2/2 alcohol withdrawal (DT)?

A

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

52
Q

Presentation of seizure 2/2 eclampsia?

A

Vision complaints, edema of hands, face, feet, proteinuria on UA, HTN

53
Q

Toxins/drugs that can cause seizure?

A

Isoniazid, OD on TCAs (look for widened QRS and prominent terminal R wave in aVR on EKG)

54
Q

___% of patients initially thought to have pseudoseizure are diagnosed with a true seizure disorder.

A

25

55
Q

Initial management of seizures?

A

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

56
Q

First, second, and third line medications for seizures?

A

First line - benzodiazepines (usually lorazepam)
Second line - fosphenytoin/phenobarbital/valproic acid
Third line - versed/pentobarbital/propofol infusions

IV is preferred

57
Q

Which benzos can be given IM?

A

Lorazepam
Midazolam
Diazeapm

58
Q

Common doses of benzos?

A

2 mg Lorazepam (or 2 mg midazolam or 5 mg diazepam) PO/IM/IV Q2-5 minutes PRN

59
Q

Dose of phenytoin/fosphenytoin for seizures?

A

15-20 mg/kg PO/IV

15-20 phenytoin equivalents/kg IV

60
Q

Dose phenobarbital for seizures?

A

20 mg/kg IV (use single dose of 60-120 mg PO for oral load)

61
Q

Dose valproic acid for seizures?

A

15-45 mg/kg IV

62
Q

Rx seizure in eclampsia?

A

Magnesium sulfate

63
Q

Rx seizures 2/2 hyponatremia?

A

Hypertonic saline

64
Q

Rx seizures 2/2 isoniazid?

A

Pryoxidine

65
Q

Rx seizures 2/2 hypoglycemia?

A

Dextrose

66
Q

___% of the population with have a seizure sometime during their lifetime

A

1

Emergency Medicine Clerkship (18 decks)

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