Neurologic Emergencies Flashcards
In the presence of HA, the below are indicative of…
Nausea/vomiting Papilledema Unilateral or bilateral fixed pupil consciousness Decorticate or decerebrate posturing
elevated ICP
Ominous finding of elevated ICP…
Cushing’s triad
bradycardia, hypertension, resp. depression
Lab workup for elevated ICP
type and cross CBC CMP Osmolality BAL/Tox Screen Glucose Coags
CT/MRI
Initial Tx of elevated ICP… (5)
Head of bed 30 degrees O2 hyperventilation BP control/NS Mannitol
Gold standard of ICP monitoring…
Intraventricular monitor
The below are indications for what ICP intervention?
at risk
GCS < 8
aggressive medical care
Intraventricular monitor
In increased ICP hyperventilation, what is the target PCO2?
26-30 mmHg
Neuro presentation of linear skull fx?
no neuro sxs
3 MC regions of linear skull fx
temporoparietal
frontal
occipital
A linear skull fx on the _____ bone can disturb vascular structures and cause bleeding…
temporal bone
Linear skull fx can be managed with ED observation for 4-6 hours if what two things are present…
neg CT
no neuro deficit
_____ skull fx often involves injury to brain parenchyma
depressed
mgmt of depressed skull fx…
CT
neuro admit
+/- Td
What skull fx can tear the dura, causing communication in subarachnoid space, sinuses, and middle ear?
basilar skull fx
A basilar skull fx of the ______ increases risk of epidural hematoma
temporal bone
What is an important facet of mTBI assessment?
mental status testing
Closed head injury home disposition…4 factors…
GCS 15
normal CT
no bleeding risk
can monitor at home
The below are ED precautions for…
Unable to awaken the patient Severe or worsening headaches Somnolence or confusion Restlessness, unsteadiness, or seizures Vison changes Vomiting, fever, or stiff neck Urinary or bowel incontinence Weakness or numbness involving any part of the body
closed head injury
This is the shearing of white matter tracts from traumatic deceleration/blunt trauma
diffuse axonal injury
this is a cause of persistent vegetative state
diffuse axonal injury
CT shows blurring of grey-to-white margin, small lesions in white tracts, cerebral hemorrhage and/or edema
diffuse axonal injury
surgery for diffuse axonal injury?
no
Brief LOC –> lucid interval
–> rapid clinical
deterioration
epidural hematoma
this intracranial hematoma is associated with adolescents and young adults w/ skull fx and trauma
epidural hematoma
middle miningeal artery
most subdural hematomas occur via…
falls
bridging vein tear
The below describes what “rule”:
Age ≥40 years Neck pain or stiffness Limited neck flexion on examination Witnessed loss of consciousness Onset during exertion Thunderclap headache (instantly peaking pain)
Ottowa SAH rule
If CT is negative and SAH is suspected, what diagnostic is mandated?
LP
what can be done in lieu of LP in SAH?
CTA
Pt. p/w:
Acute onset of focal neurologic deficit Increasing neurologic signs/symptoms over time Headache Vomiting Decreased LOC Seizures
ICH
MC etiology of ICH?
HTN
Imaging for ICH?
stat non-contrast CT or MRI (smaller lesions)
important facet of ICH management
BP 140-160/90
Labs for CVA… (5)
coags CBC CMP Tox fingerstick glucose
Imaging for CVA…
state noncontrast CT w/in 20 min
If non-hemorrhagic CT, what can be administered?
ASA
3 MC findings for Ischemic Stroke…
facial paresis
arm drift/weakness or paresis
abnormal speech
tPA infusion should be _____ from time of arrival in ED and ______ from onset of sxs
less than 60 min
less than 4.5 hours
2 criteria for status epilepticus
5+ minutes
2+ seizures w. incomplete recovery
Initial mgmt of status epilepticus…
BZ + anticonvulsants x 2 dose max
If continued seizure activity after administration of BZs and anticonvulsants?
IV midazolam/propofol/pentobarbital
continuous _____ monitoring is required for status epilepticus
EEG
C-spine nexus criteria (5)…(no imaging needed)
no midline tenderness, intoxication, painful injury
normal LOC, neuro exam
What type of c-spine fx?
vertical compression transmitted to lateral masses of atlas…
fx of arches of c1
Jefferson/Burst fx
Imaging for Jefferson/Burst fx…
X-Ray –> CT
What type of c-spine fx?
MOI: extreme hyperextension via abrupt deceleration
bilateral pedicle fx
C2 pedicle fx (hangman’s)
Why minimal spinal cord damage in pedicle fx?
AP diameter at C2 is greatest
what is the MOI of an odontoid fx?
forceful flexion or extension
What type of C2 fx?
Stable
occurs above transverse ligament
Type 1
What type of C2 fx?
unstable
base of dens at C2 attachment
non-union in 50%
Type 2
What type of c-spine fx?
Fx thru upper body of C2
unstable
Type 3
What type of c-spine fx?
MOI: direct axial load
fragment displacement
burst fx
What time of complete SCI?
Absent reflexes Flaccid muscles Loss of sensation Priapism in men Urinary retention
acute ( < 1 day)
What time of complete SCI?
Hyperreflexia \+Babinski Spasticity
1-3 days post injury
Patient presents with:
motor impairment
loss of reflexes
bilateral loss of pain/temp sensation
bladder dysfunction
Anterior cord syndrome
What sensations are preserved in anterior cord syndrome?
tactile, proprioception, vibratory
Etiology: cord infarct, disc hernation
anterior cord syndrome
Patient p/w:
motor impairment UE > LE
variable sensory loss below injury
+/- bladder dysfunction…
central cord syndrome
What is preserved in central cord syndrome?
vibration, proprioception
MOI extension injury, compression, slow growing lesion
central cord syndrome
Pt. p/w:
motor weakness
hyperreflexia
gait ataxia
paresthesia
posterior cord syndrome
what is initially preserved in posterior cord syndrome?
bladder function
MOI: MS, tumors, subluxation
Etiology: bilateral dorsal column, corticospinal tract involvement
posterior cord syndrome
Pt. p/w:
ipsilateral motor paralysis and loss of proprioception/vibration
contralateral loss of pain/temp
brown sequard
What is preserved in brown sequard?
bladder fxn
MOI: penetrating injury
etiology: lateral hemi section, dorsal column unilateral
brown sequard
prognosis of brown sequard?
good
Which imaging for spinal alignment/fracture?
radiograph
Which imaging for ligamentious/spinal cord injury?
high res CT or MRI
Roots of the phrenic nerve emerge where? (diaphragm innervation)
C3/4/5
“C3,4,5 keep the diaphragm alive”
Unstable lesions above ____ may cause immediate respiratory paralysis
C3
The below can cause…
Intervertebral disc herniation Epidural abscess Tumor Lumbar spinal stenosis Metastatic disease Infectious Autoimmune
cauda equina syndrome
patient presents with:
LBP + LE radiation
LE weakness
Atrophy of calves
Perineal sensory loss
cauda equina
Imaging for cauda equina syndrome
stat non-contrast MRI
Clinical suspicion of cauda equina warrants immediate admin of…
dexamethasone 10mg IV x 1
What preceeds onset of guillen barre?
URI/gastroenteritis 1-3 weeks prior
c. jejuni mc
pt p/w:
absent/depressed DTRs CN involvement gait problems paralysis/paresthesia Dysautonomia
guillen barre
is there fever with guillen barre?
no
30% of guillen barre results in…
severe respiratory involvement
Diagnostics for guillen barre
CSF studies
EMG-NCS (not in ED)
CSF findings in guillen barre
elevated protein
normal WBCs
Tx for guillen barre that usually occurs outside of ED
IVIG or plasmapheresis