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EM Exam 2 > Neurological > Flashcards

Neurological Flashcards

1
Q

What is the best initial test to order in the setting of acute stroke?

A

fingerstick glucose

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2
Q

What is the most common territory involved in ischemic stroke?

A
  • MCA
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3
Q

PCA strokes present with this primary symptom.

A

dizziness

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4
Q

What is the immediate ED work up for acute stroke? (3 part)

A
  • ABCs
  • fingerstick glucose
  • last seen well

*hypoglycemia is an absolute contraindication for tPA

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5
Q

What is the best neuroimaging test to order in the setting of an acute stroke?

A
  • noncontrast CT head/CTA concurrently
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6
Q

If the noncontrast/CTA is negative what is the next imaging test do we order for an acute stroke?

A

MRI with DWI sequence

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7
Q

What is the time window for tPA vs. thrombectomy?

A
  • tPA = <4.5 hours
  • thrombectomy = <24 hours
  • thrombectomy only for LVO
  • will need to go to ICU
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8
Q
  • What is the upper limit for permissive hypertension before you should intervene for an acute stroke?
  • What if the patient got tPA?
A
  • 220 SBP

- if patient got tPA = 180 SBP

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9
Q

What medication can be used for blood pressure control in the setting of an acute stroke?

A
  • B-blockers or CCBs IV

* remember permissive HTN rule*

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10
Q
  • What is the upper limit for permissive hypertension for a hemorrhagic stroke?
A
  • 140 SBP
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11
Q

A patient presents with stroke deficits and vomiting. You should immediately consider this type of stroke.

A

hemorrhagic stroke

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12
Q

What is the reversal agent for coumadin?

A
  • FFP (immediate reversal) and Vitamin K (long-term)
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13
Q

What is the reversal agent for a DOAC?

A
  • very difficult to reverse

- Kcentra looks promising

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14
Q

What is the reversal agent for aspirin?

A
  • hold aspirin

- DO NOT give back platelets

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15
Q

What is the reversal agent for therapeutic lovenox?

A
  • protamine
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16
Q

Hypoglycemia is an absolute contraindication to what?

A

tPA

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17
Q

Sudden onset, severe, “thunderclap” headache is pathognomonic for what?

A

subarachnoid hemorrhage

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18
Q

What are sentinel headaches and what are they concerning for?

A
  • transient headaches a few weeks or days before a ruptured aneurysm
  • concerning for subarachnoid hemorrhage
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19
Q

What is the biggest modifiable risk factor for SAH?

A
  • smoking
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20
Q

Cocaine is a known risk factor for what brain bleed?

A
  • SAH
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21
Q

What is the average mortality for a ruptured cerebral aneurysm?

A

50%

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22
Q

What size increases the risk for cerebral aneurysm?

A

7 mm is when the risk of rupture becomes so great we need to intervene

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23
Q

What are the 2 interventions for a ruptured cerebral aneurysm?

A
  • coiling

- clipping

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24
Q

After a negative head CT, a lumbar puncture is performed. What LP results would most likely confirm a SAH?

A

blood in tube 1 and 4 AND/OR xanthochromia

this is diagnostic for SAH

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25
Q

What is the best neuroimaging test for SAH?

How soon does it have to be done to be accurate?

A
  • noncontrast CT if obtained with 6 hours of headache
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26
Q

What medication is indicated for pain control for SAH?

A

IV narcotics

27
Q

What is the goal for blood pressure control in SAH?

A

<160 BPM

28
Q

What medication is indicated for seizure prophylaxis in the setting of a SAH?

A

Keppra

29
Q

ED management of SAH involves these 5 things.

A
  • STAT neurosurgery consult
  • pain control
  • BP control
  • reverse a/c as needed
  • seizure prophylaxis
30
Q

An epidural hematoma is associated with a laceration of what artery?

A
  • medial meningeal artery d/t trauma associated with skull fracture
31
Q

This is defined as blood collections between the dura and the arachnoid membranes

A

subdural hematoma (SDH)

32
Q

This is defined as blood collections between skull and dura

A

epidural hematoma (EDH)

33
Q

Which physical exam finding is the most specific for confirming a tonic-clonic seizure?

A

Biting side of tongue

34
Q

What are the 4 causes of seizures?

A
  • electrolyte abnormalities
  • withdrawal
  • brain mass/bleed/stroke
  • epilepsy
35
Q

What are the 4 triggers of seizures?

A
  • flashing lights
  • lack of sleep
  • medication
  • infection
36
Q

What are the 2 electrolyte abnormalities that can cause seizure?

A
  • hyponatremia

- hypoglycemia

37
Q

Withdrawal from any of these 2 substances can cause a withdrawal seizure

A
  • alcohol

- benzodiazepines

38
Q

A first-time seizure over the age of 50 should be concerning for this.

A

brain mass/bleed/stroke

39
Q

What medication is well known to lower seizure threshold?

A

Wellbutrin

40
Q

The vast majority of seizure are < ____ minutes.

A

<2 minutes

41
Q

How can you discern between a seizure and syncope?

A

the presence of a post-ictal phase is consistent with a seizure

42
Q

What is the immediate ED workup for seizures in adults? (3 part)

A
  • ABC, fingerstick glucose, O2
43
Q

What labs do you want to order when working a seizure in adults?

A
  • CBC, chem, tox screens, urinalysis, lactate

* lactate markedly high d/t to patient not breathing

44
Q

What is the neuroimaging test of choice for a first time seizure?

A

noncontrast CT

45
Q

In a patient with a seizure disorder presenting with an acute seizure you do not need to get a CT. Instead you want to do this.

A
  • check anti-epileptic drug levels
46
Q

Management of seizures involves these 4 things.

A
  • high flow oxygen
  • abort active seizure
  • antiepileptic drugs
  • patient education
47
Q

Does a patient need antiepileptic drugs for a first time seizure?

A

no

  • follow up with neurologist for work-up
48
Q

What medication is used to abort an active seizure?

A

ativan 2 mg IM

49
Q

A patient who suffered a seizure cannot drive for how many months?

A

6 months

and must be cleared by neurologist

50
Q

What is status epilepticus?

A
  • persistent seizure >5 min or more than one seizure without recovery
51
Q

In status epilepticus, what do you need to do to maintain oxygen to the brain?

A

need to intubate with normal RSI

52
Q

This is a condition in which a seizure is followed by a brief period of temporary paralysis

A

Todd’s paralysis

53
Q

How do you manage Todd’s paralysis?

A

need to do a stroke work-up

54
Q

What is the most common reported trigger for a migraine?

A

stress

55
Q

40-year-old female presents to the ED complaining of headache. Her headache is 7/10, right sided, throbbing, worse with loud noises and light, with associated nausea. She has taken several doses of sumatriptan without relief. The neuro exam is normal. What is the most likely diagnosis?

A

migraine

56
Q

What are your red flags for migraine necessitating further work-up? (think: SNOOP)

A
  • systemic symptoms (fever)
  • neuro deficit/neoplasm
  • onset (sudden onset)
  • older age >50
  • pattern change
57
Q

What does the “migraine cocktail” consist of?

A
  • reglan, IV fluids, tylenol, toradol (if no risk of bleed), Benadryl, magnesium
  • benadryl to lessen reglan adverse effects
  • avoid opiates or NSAIDs if head bleed not ruled out
58
Q

What is the most common bacterial pathogen in acute bacterial meningitis?

A
  • strep pneumo
59
Q

What is the bacterial pathogen we worry about in acute bacterial meningitis in >50 yo?

A
  • listeria monocytogenes
60
Q

What pathogen gives you the classic petechial rash in the setting of acute bacterial meningitis?

A
  • neisseria meningitides
61
Q

A fever and headache should have you concerned for this diagnosis until proven otherwise.

A
  • bacterial meningitis
62
Q

The Kernig and Brudzinski test are _________ for bacterial meningitis

A

specific

63
Q

What is the diagnostic test of choice in bacterial meningitis?

A

lumbar puncture

64
Q

What is the antibiotic of choice for bacterial meningitis if the patient is >50 vs. <50 years old?

A
  • Vanco (weight based) and Ceftriaxone (2g) for adults <50
  • Vanco and Ceftriaxone and Ampicillin for adults >50
  • Acyclovir if concern for HSV
  • Steroids is beneficial in those with pneumococcal meningitis, can start before or with the first dose of antibiotics

EM Exam 2 (5 decks)

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