Neurological Emergenciea Flashcards
Stroke? ISCHAEMIC STROKE = most common — this flash card focuses on ISCHAEMIC .
OVERVIEW:
COMMON SERIOUS NEUROLOGICAL CONDITION (BEAR THIS IN MIND) ACCOUNTS FOR 11% of all deaths within the UK/YEAR.
-rapidly developing focal or neurological disturbances , lasts more than 24 hours or leads to death.
RISK FACTORS:
- smoking
- alcohol & drug misuse
- sedentary lifestyle and poor diet
- Hypertension
- AF
- Valvular disease
- Carotid Artery Disease
- Congestive heart Failure
- Congenital or Structural Heart disease
- Age
- Gender
- Hyperlipidemia
- Diabetes
- Sickle cell syndrome
SYMPTOMS:
- Confusion, altered LoC and Coma
- Headache; sudden onset , severe , unusual and neck stiff in SAH —> pain usually not present if Ischaemic stroke
- weakness
-sensory loss; parasthesia or numbness - speech problems; Dysphasia
- visual problems such as Diplopia
- Dizzieness/ vertigo / loss of balance
- cranial nerve deficits
- difficulty with motor coordination
DIFFERENTIAL DIAGNOSIS:
- Hyperglycaemia
- Sepsis
-hyperglycaemia - dizziness/fainting
- migraine
- neurological abnormalities
- functional neurology
- physiological disorders including anxiety
- mass lesions such as subdural harmonica or tumours
- seizures
- physical trauma (Concussion)
TREATMENT:
1) manage ABCD
2) 02 if necessary (use normal parameters)
3) Aspirin can be used if stroke is Ischaemic
TIA?
TIA OVERVIEW:
- AFFECTS APPROX 50/100,000 PPL/YEAR
Transient episode of neurologic dysfunction due to FOCAL brain, SPINAL cord or RETINAL Ischaemia, WITHOUT acute INFARCTION OR TISSUE INJURY
RISK FACTORS:
- smoking
- alcohol & drug misuse
- sedentary lifestyle and poor diet
- Hypertension
- AF
- Valvular disease
- Carotid Artery Disease
- Congestive heart Failure
- Congenital or Structural Heart disease
- Age
- Gender
- Hyperlipidemia
- Diabetes
- Sickle cell
More specific to TIA:
- Crescendo TIA’s - more than 1 TIA in a week
- prescribed Anticoagulants
- diagnosed clotting disorders
- diagnosis of AF or AF on an ECG
- ABCD2 of 4+
ESSENTIALLY THE SAME AS STROKE
ABCD2 used for TIA:
- Age - above 60 = 1 point
- blood pressure = above 140 = 1 point , above 90 = 1 point
- Clinical ; unilateral weakness = 2 point , speech affected = 1
Duration/Disability; lasting 60+ mins = 1 point , Hx of Diabtetes = 1
TREATMENT:
- if ABCD2 is above 4 then seen within 24 hours, if below 4 refer to TIA clinic
- 300mg Aspirin taken once daily until seen by specialist or 7 days maximum —> given under PGD —> strict inclusion/exclusion criteria
DIFFERENTIAL DIAGNOSIS:
- Seizures ~ can cause sudden weakness, numbness or LoC
- Migraines with Aura ~ temporary visual disturbances mimic TIA visual disturbances
- Syncope ~ temporary LoC mimics TIA
- Peripheral Vestibular disturbances ~ issues with inner ear can cause vertigo , dizziness and balance problems , mimicking stroke and TIA , however speech would not be affected
- Functional Neurological Disorders
-HYPO/HyperGylcemia
Sub-Arachnoid Haemorrhage (SAH) - TYPE OF STROKE
EPIDEMIOLOGY/OVERVIEW:
- AFFECTS APPROX 6-12/100,000 PPL/YEAR (less common)
SAH IS MOST COMMONLY —> SOURCE OF BLEEDING IS INTER-CRANIAL ANEURYSM IN 85% OF BLEEDING.
It is a NON-ANEURYSMAL PERI-MESENCEPHALIC HAEMORRHAGE in 10% of people
VASCULAR ABNORMALITIES IN 5% of people
RISK FACTORS:
essentially same as stroke and TIA , stimulant drug use is a big risk factor.
SYMPTOMS:
- Severe headache “thunderclap headache” <— indicates SAH over a stroke; stroke caused by ischamia is less likely to present with pain
- stiff neck
- nausea/ vomiting
- photophobia
- blurred/ double vision
- focal Neurological differences
- confusion
- reduced level of consciousness
- EYES: Papilledema (optic disk swelling) , pupillary changes, impaired eye movement.
- POSTURING: Deceberate, Decorticate , Flaccid
Hx for PT’s with SAH is critical as Prodromal signs/symptoms are common, occurring approx. 10-20 days prior to rupture (Haemorrhage);
-Headache
- Dizziness
- Orbital Pain
- Diplopia
- Visual loss
Common indicator of SAH =
- single fixed and displayed pupil (bad)
-Bilateral fixed and dilated pupil (worse)
This can be caused by other things such as drug use.
ASSESSMENT of SAH:
1) ABCD
2) DISABILITY; GCS, Pupil examination and PERRLA/PEARL
TREATMENT:
1) MANTAIN ABCD
2) Rapid transport to ED with ATMIST/SBAR pre-alert
3) Actively treat any seizures
Seizures
EPIDEMIOLOGY/OVERVIEW:
- EFFECTS APPROX 23-61/100,000 PPL/YEAR (2nd most common neurological condition)
- A seizure is caused by a sudden burst of excess electrical activity in the brain,causing a temporary disruption in the normal message passing between the brain cells.
RISK FACTORS:
Essentially any brain injury:
- born premature/small
-brain deformity - brain haemorrhage
-brain injury/hypoxia - brain tumour
-infections of brain ; meningitis - stroke
-cerebral palsy - Family Hx
-Alzheimer’s disease family Hx
CAUSES:
- Syncope
- Epilepsy
- Head injury
- Hypoglycaemia
-Alcohol/drug withdrawal , drug misuse - Acute alcohol intoxication
Classifications of Seizures?
- Focal onset ~ PT aware/ impaired awareness , motor = non motor , facial to bilateral tonic-conic
- Generalised onset ~ PT has impaired awareness , Tonic-Clonic, other motor and non-motor absence
- unknown onset ~ Motor , tonic- clinic, other motor and non motor absence
STAGES OF SEIZURE:
1) PRODROMAL symptoms ~ occurs hours/days prior to seizure; confusion, anxiety, irritability, headache, tremor or mood disturbances.
2) EARLY ICTAL symptoms ~ Aura, huge variety of symptoms
3) ICTAL ~ arm/leg stiffening, repeated movement (uncontrollable) , loss of bladder control
4) POST- ICTAL ~ symptoms include malaise, confusion, headache, memory loss, nausea , dysphasia , drowsiness and body soreness
Tonic and clinic phase????
TONIC = LoC, muscle stiff (fall) , bite tongue
CLONIC = limbs jerk, loss of bladder/bowel control, Cyanosis.
TREATMENT:
1) ABCD
2) 02 if hypoxic
3) treat underlying cause
4) use Midazolam 5-10mg / potentially diazepam if seizing for over 5 minutes , administer a second dose after 10 mins if still convulsing , if convulsing after 10 minutes from 2nd dose , seek senior clinical advise to administer 3rd dose.
IT IS CRITICAL TO DETERMINE IF SEIZURE IS PNES (Psychogenic Non-epileptic seizures) or EPILEPSY, AS THIS WILL AFFECT DECISION REGARDING ADMITTING PATIENT TO HOSPITAL OR LEAVING AT HOME.
SYNCOPE
EPIDEMIOLOGY/OVERVIEW:
- common LESS SERIOUS NEUROLOGICAL medical problem 18-39.7/100,000 patients affected/year.
CAUSE:
Reduction in Systemic BP that causes a decrease in global cerebral blood flow , causing LoC
Cardiac VS non-Cardiac Syncope?
Cardiac=
- arrhythmia
-structural cardiac diseases
Non-Cardiac=
- reflex
-vasovagal
- situational
-orthostatic hypotension
Syncope symptoms will vary based on the type of SYNCOPE .
What are red flags in a PT who has experiences Syncope?
- New ECG abnormalities
- physical signs of heart failure
- TLoC during exertion
- FHx of sudden cardiac death age below 40
- new or unexplained breathlessness (Dyspnea)
- Heart murmur
TREATMENT:
3 P’s = Posture , provocation factors and Prodromal
If uncomplicated Syncope ~ indicated by 3 P’s , if full recovery observed, PT can normally be discharged on scene if they are with responsible adult ,
If PT has red flags, conveyance to ED is appropriate.
Cauda Equina Syndrome (CES)
EPIDEMIOLOGY/OVERVIEW:
-collection of nerves at end of spinal cord become compressed , these nerves are responsible for sending/ receiving messages to lower limbs and pelvic organs.
RED FLAGS?
Lower back/sciatic pain;
- saddle anaesthesia
- Bowel/ bladder incontinence
These can indicate surgical emergency and can lead to permanent paralysis of untreated.
SYMPTOMS:
- severe back and leg pain
- parasthesia or weakness in legs and feet
- bowel and bladder dysfunction
- saddle anaesthesia.
Most common indicators of NUEROLOGICAL INVOLVEMENT?
- LoC/TLoC
- Paraesthesia
- weakness or paralysis
- Seizures or Convulsions
- visual disturbances ; Diplopia , visual loss
- slurred speech
- loss of coordination
- tingling
