Neurological Flashcards
What is the best initial test to order in the setting of acute stroke?
fingerstick glucose
What is the most common territory involved in ischemic stroke?
- MCA
PCA strokes present with this primary symptom.
dizziness
What is the immediate ED work up for acute stroke? (3 part)
- ABCs
- fingerstick glucose
- last seen well
*hypoglycemia is an absolute contraindication for tPA
What is the best neuroimaging test to order in the setting of an acute stroke?
- noncontrast CT head/CTA concurrently
If the noncontrast/CTA is negative what is the next imaging test do we order for an acute stroke?
MRI with DWI sequence
What is the time window for tPA vs. thrombectomy?
- tPA = <4.5 hours
- thrombectomy = <24 hours
- thrombectomy only for LVO
- will need to go to ICU
- What is the upper limit for permissive hypertension before you should intervene for an acute stroke?
- What if the patient got tPA?
- 220 SBP
- if patient got tPA = 180 SBP
What medication can be used for blood pressure control in the setting of an acute stroke?
- B-blockers or CCBs IV
* remember permissive HTN rule*
- What is the upper limit for permissive hypertension for a hemorrhagic stroke?
- 140 SBP
A patient presents with stroke deficits and vomiting. You should immediately consider this type of stroke.
hemorrhagic stroke
What is the reversal agent for coumadin?
- FFP (immediate reversal) and Vitamin K (long-term)
What is the reversal agent for a DOAC?
- very difficult to reverse
- Kcentra looks promising
What is the reversal agent for aspirin?
- hold aspirin
- DO NOT give back platelets
What is the reversal agent for therapeutic lovenox?
- protamine
Hypoglycemia is an absolute contraindication to what?
tPA
Sudden onset, severe, “thunderclap” headache is pathognomonic for what?
subarachnoid hemorrhage
What are sentinel headaches and what are they concerning for?
- transient headaches a few weeks or days before a ruptured aneurysm
- concerning for subarachnoid hemorrhage
What is the biggest modifiable risk factor for SAH?
- smoking
Cocaine is a known risk factor for what brain bleed?
- SAH
What is the average mortality for a ruptured cerebral aneurysm?
50%
What size increases the risk for cerebral aneurysm?
7 mm is when the risk of rupture becomes so great we need to intervene
What are the 2 interventions for a ruptured cerebral aneurysm?
- coiling
- clipping
After a negative head CT, a lumbar puncture is performed. What LP results would most likely confirm a SAH?
blood in tube 1 and 4 AND/OR xanthochromia
this is diagnostic for SAH
What is the best neuroimaging test for SAH?
How soon does it have to be done to be accurate?
- noncontrast CT if obtained with 6 hours of headache
What medication is indicated for pain control for SAH?
IV narcotics
What is the goal for blood pressure control in SAH?
<160 BPM
What medication is indicated for seizure prophylaxis in the setting of a SAH?
Keppra
ED management of SAH involves these 5 things.
- STAT neurosurgery consult
- pain control
- BP control
- reverse a/c as needed
- seizure prophylaxis
An epidural hematoma is associated with a laceration of what artery?
- medial meningeal artery d/t trauma associated with skull fracture
This is defined as blood collections between the dura and the arachnoid membranes
subdural hematoma (SDH)
This is defined as blood collections between skull and dura
epidural hematoma (EDH)
Which physical exam finding is the most specific for confirming a tonic-clonic seizure?
Biting side of tongue
What are the 4 causes of seizures?
- electrolyte abnormalities
- withdrawal
- brain mass/bleed/stroke
- epilepsy
What are the 4 triggers of seizures?
- flashing lights
- lack of sleep
- medication
- infection
What are the 2 electrolyte abnormalities that can cause seizure?
- hyponatremia
- hypoglycemia
Withdrawal from any of these 2 substances can cause a withdrawal seizure
- alcohol
- benzodiazepines
A first-time seizure over the age of 50 should be concerning for this.
brain mass/bleed/stroke
What medication is well known to lower seizure threshold?
Wellbutrin
The vast majority of seizure are < ____ minutes.
<2 minutes
How can you discern between a seizure and syncope?
the presence of a post-ictal phase is consistent with a seizure
What is the immediate ED workup for seizures in adults? (3 part)
- ABC, fingerstick glucose, O2
What labs do you want to order when working a seizure in adults?
- CBC, chem, tox screens, urinalysis, lactate
* lactate markedly high d/t to patient not breathing
What is the neuroimaging test of choice for a first time seizure?
noncontrast CT
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.
- check anti-epileptic drug levels
Management of seizures involves these 4 things.
- high flow oxygen
- abort active seizure
- antiepileptic drugs
- patient education
Does a patient need antiepileptic drugs for a first time seizure?
no
- follow up with neurologist for work-up
What medication is used to abort an active seizure?
ativan 2 mg IM
A patient who suffered a seizure cannot drive for how many months?
6 months
and must be cleared by neurologist
What is status epilepticus?
- persistent seizure >5 min or more than one seizure without recovery
In status epilepticus, what do you need to do to maintain oxygen to the brain?
need to intubate with normal RSI
This is a condition in which a seizure is followed by a brief period of temporary paralysis
Todd’s paralysis
How do you manage Todd’s paralysis?
need to do a stroke work-up
What is the most common reported trigger for a migraine?
stress
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?
migraine
What are your red flags for migraine necessitating further work-up? (think: SNOOP)
- systemic symptoms (fever)
- neuro deficit/neoplasm
- onset (sudden onset)
- older age >50
- pattern change
What does the “migraine cocktail” consist of?
- 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
What is the most common bacterial pathogen in acute bacterial meningitis?
- strep pneumo
What is the bacterial pathogen we worry about in acute bacterial meningitis in >50 yo?
- listeria monocytogenes
What pathogen gives you the classic petechial rash in the setting of acute bacterial meningitis?
- neisseria meningitides
A fever and headache should have you concerned for this diagnosis until proven otherwise.
- bacterial meningitis
The Kernig and Brudzinski test are _________ for bacterial meningitis
specific
What is the diagnostic test of choice in bacterial meningitis?
lumbar puncture
What is the antibiotic of choice for bacterial meningitis if the patient is >50 vs. <50 years old?
- 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
