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neurological emergencies Flashcards

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USMLE® Step 1 flashcards
1
Q

special considerations

A
  • recognize the signs and symptoms of altered mental status and abnormal neurologic function
  • perform a basic neurologic exam
  • apply the neurologic exam findings to help formulate a diagnosis
  • consider the appropriate differential diagnosis
  • gather the pertinent historical data
  • recognize the signs that indicate and patient is or may soon be unstable
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2
Q

management of neurological emergencies

A
  • Critical care management of neurologic disorders has evolved significantly over the past decades
  • Damage resulting from primary neurologic emergencies can be attenuated by prompt recognition and intervention
  • Must be able to recognize neurologic emergencies early in development, initiate timely treatment, initiate preventive care
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3
Q

stroke

A
  • brain attack
  • blood flow to brain is obstructed or interrupted
  • ischemic or hemorrhagic stroke
  • CVA- no longer used
  • most common sites of thrombotic stroke: branches of cerebral arteries, circle of willis
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4
Q

ischemic stroke

A
  • thrombus or embolus obstructs a blood vessel
  • thrombus- blood clot or cholesterol plaque that forms in the artery
  • embolus- clot or plague that forms elsewhere and than breaks off, and obstructs blood flow when it becomes lodged in an artery
  • more common
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5
Q

hemorrhagic stroke

A

-diseased or damaged vessel rupture

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6
Q

hemiparesis

A
  • unilateral weakness on opposite side os stroke
  • ischemic stroke on left side of brain -> symptoms of right side
  • strokes in middle cerebral artery produce hemiparesis
  • usually weakness more in arm/face than leg
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7
Q

anterior cerebral artery stroke

A
  • altered mental status
  • impaired judgement
  • contralateral weakness more in leg
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8
Q

posterior cerebral artery stroke

A

-impaired thought/memory, visual field deficits

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9
Q

stroke risk factors

A
  • atherosclerosis leads to turbulent blood flow, increased risk of clot
  • blood disorders- sickle cell anemia, polycythemia
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10
Q

signs and symptoms of stroke

A
  • any pt with acute neurological deficit needs to be evaluated for stroke
  • usually abrupt weakness on one side of face, one arm or leg, or entire side of bodey
  • may have sudden decrease or loss of consciousness, lose vision, nausea/vomiting
  • difficulty speaking- dysarthria
  • hemiplegia
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11
Q

dysarthria

A
  • difficulty speaking

- to them it sounds normal, to us it sounds like giberish

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12
Q

hemiplegia

A

-paralysis on one side of the body

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13
Q

last known well time

A
  • last time patient was seen acting normally and time to symptoms is CRUCIAL
  • TPA- tissue plasminogen activator
  • TPA is a medication that is given to dissolve clot that is causing the stroke
  • TPA can cause bleeding (many risk factors)
  • TPA has to be given within 3 hours of the stroke in order to work effectively
  • if prior history of stroke, need to know baseline functioning and mental status
  • longer the stroke longer the symptoms-> symptoms can be permanent
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14
Q

stroke vs TIA

A
  • TIA symptoms resolve within 24 hours (most within 1 hour)
  • transient ischemic attack
  • 10% of TIA pts suffer stroke within 90 days of TIA
  • other DD’s- hypoglycemic episode, migraine headaches, electrolyte abnormalities, CSF infections, MS, Guillain-Barre, psychiatric disorders
  • if you have a TIA its basically a sign that if you dont change something you will have a stroke soon (hypertension, cholesterol)
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15
Q

stroke treatment

A
  • if stroke suspected, transport to a stroke center ASAP
  • stroke scales indicate presence of stroke and severity
  • FAST mnemonic- quick ID of stroke victim
  • cincinnati stroke scale- compares facial droop and arm drift (also slurred speech)
  • NIH stroke scale- more detailed
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16
Q

FAST stroke scale

A
  • Face drooping
  • Arm weakness
  • Speech Difficulty
  • Time to call 911
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17
Q

cincinnati pre-hospital stroke scale

A
  • facial droop
  • arm drift
  • abnormal speech
  • if one sign out of 3 is abnormal the probability of stroke is 72%
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18
Q

stroke treatment

A
  • evaluate ABC, intervene if necessary
  • check blood and correct glucose level
  • supplemental oxygen if below 94%
  • place pt in low-fowlers or supine position with head slightly raised if ischemic stroke suspected
  • regulate BP to maintain MAP at leaset 60mmHg
  • rapid transport to the hospital of utmost importance
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19
Q

Non-contrast CT scan

A
  • if they use contrast it can make a bleed worse
  • so first they use non contrast -> if there is no bleed use a contrast CT
  • primary imaging modality for the initial evaluation of pts with suspected stroke
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20
Q

fibrinolytic agents at hospital (TPA)

A
  • if administered w/in 3 hours of acting normally: better results w/neuro function, ↓ mortality
  • TPA can restore blood flow to the affected of the brain, thereby significantly reducing the effects of the stroke, and reducing long-term disability
  • doesnt always work
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21
Q

mechanical thrombectomy

A
  • physically and surgically removes the clot
  • large vesicle oclusion
  • surgical procedure to remove clot from arteries or veins in the brain
  • can be performed when outside of the TPA window
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22
Q

neuroanatomy and physiology

A
  • neuroanatomy/physiology extremely complex
  • basic understanding needed to appreciate neuromedical emergencies
  • ***quiz
  • Frontal lobe
  • parietal lobe
  • occipital lobe
  • temporal lobe
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23
Q

cerebrum

A
  • conscious thought, memory storage and processing, sensory processing, regulation of skeletal muscle contraction
  • Cerebrum divided into two cerebral hemispheres
  • Superficial layer of gray matter is the cerebral cortex.
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24
Q

cerebellum

A
  • coordination, balance, modulation of motor commands from cerebral cortex
  • second largest area of brain
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25
Q

diencephalon

A

-link between cerebrum and CNS

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26
Q

brain stem

A
  • processes visual and auditory info maintains consciousness, somatic and visceral motor control, regulates autonomic function
  • autonomic control**
  • midbrain, pons, medulla
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27
Q

fissures

A

-deep groves

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28
Q

gyri

A

-folds that increase surface area

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29
Q

sulci

A

-shallow depressions separating gyri

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30
Q

outer coverings

A

-bone- cranial bones and vertebrae

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31
Q

inner coverings

A
  • meninges- 3 layers of membranes
    1. dura mater- outer, strong white fibrous tissue (inner layer of cranial bones’ periosteum)
    1. arachnoid mater- arachnids: spiders, cobweb-like middle layer.
    1. pia mater- innermost meninge, adheres to the outer surface of brain and spinal cord, contains blood vessels.
32
Q

cerebrospinal fluid (CSF)

A
  • surrounds and bathes exposed surfaces of CNS
  • cushions the brain- prevents having serious brain damage
  • provides a protective cushion around brain and spinal cord
  • utilized by brain to monitor changes in the internal environment
  • found in subarachnoid space in brain and spinal cord and within their cavities and canals
33
Q

cerebral vasculature: communicating arteries

A
  • anterior

- posterior

34
Q

cerebral vasculature: cerebral arteries

A
  • anterior (ACAs)
  • middle (MCAs)
  • posterior (PCAs)
35
Q

circle of willis

A
  • merging of:
  • internal carotid arteries
  • vertebral arteries
  • middle cerebral arteries
  • posterior cerebral arteries
  • anterior communicating arteries
  • posterior communicating arteries
  • collateral circulation
36
Q

diagnosis of neurologic emergencies: detailed neuro assessment

A
  • neurologic examination important diagnostic tool for clinician
  • approach to a patient with a possible neurologic emergency should be systematic and comprehensive
  • build on knowledge of altered mental status
  • altered mental status is often associated with a serious comorbidity (trauma and infection)
  • Any decrease in a patient’s alertness, difficulty w/cognition, or behavior that departs from what is considered normal.
37
Q

altered mental status

A
  • patients may show signs of confusion or changes in their typical behavior
  • often difficult to sort out cause
  • behavioral alteration should be confirmed by family member or other, if possible
  • patient with significantly depressed mental status or comatose, cannot give a history, requires immediate resuscitation
38
Q

delirium

A
  • ACUTE alteration in cognition with impairment of awareness and orientation
  • sometimes associated with hallucinations
  • more often in women and with illness of very young or older than 60
  • patient must be fully evaluated
  • appearance, vitals, hydration, evidence of trauma
  • in addition to normal considers, check serum glucose levels
  • agitated delirium
  • causes: intoxication, infection, trauma, seizure, organ failure, stroke, shock, endocrine disorders or intracranial bleeding, and tumors
  • dementia is CHRONIC loss of brain function (different than delirium)
39
Q

excited (or agitated) delirium

A
  • characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting.
  • typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement.
  • Subjects typically die from cardiopulmonary arrest.
40
Q

syncope/light headed

A
  • syncope- transient loss of consciousness associated with decreased brain perfusion
  • many causes
  • light headedness, near-syncope and syncope have similar differential diagnoses:
  • cardiac conditions, hypovolemia, CNS events, pulmonary embolism, vasovagal reflex
  • neurons fire in brain -> body resets
41
Q

dizziness/vertigo

A
  • dizziness can refer to light headedness or vertigo, depending on pts interpretation
  • proprioception- spatial awareness of ones own body
  • usually patients can relate history of experience
  • TIAs, stroke, vertigo, OD, vertebral artery dissection, electrolyte imbalance may still be symptomatic
42
Q

blood glucose

A
  • stroke mimics- pt who has low blood sugar (hypoglycemic) can mimic the same symptoms of a stroke
  • slurred speech, confusion, weakness
  • hypoglycemic episode
  • priority number one when assessing the patient
  • you dont want to treat someone for a stroke when they just need sugar
43
Q

frontal lobe*

A
  • frontal association area
  • speech
  • motor cortex
44
Q

parietal lobe*

A
  • speech
  • taste
  • somatosensory cortex
  • somatosensory association area
  • reading
45
Q

occipital lobe*

A
  • visual association area

- vision

46
Q

temporal lobe*

A
  • smell
  • hearing
  • auditory association area
47
Q

central vertigo

A
  • may be caused by stroke, concussion, tumors, infection, migraine, MS, toxic ingestion/inhalation
  • vertigo is a symptom- originates in CNS or vestibular organs
48
Q

peripheral vertigo

A
  • disruption in vestibular system or CN VIII
  • feeling of imbalance, difficulty remaining upright, room is spinning, may have nausea/vomiting tinnitus
  • dysfunction in inner ear
  • Symptoms acute, abrupt, shorter and severe than central vertigo and worse or triggered by movement or change in head position.
  • Benign positional vertigo resolves w/cessation of movement
49
Q

causes of vertigo

A
  • benign paroxysmal positional vertigo (BPPV) -> migraine headache
  • menieres disease -> multiple sclerosis
  • labyrinthitis -> mal de debarquement syndrome
  • ototoxicity -> cerebellar hemorrhage and infarct
  • superior canal dehiscence syndrome -> vertebrobasilar insufficiency, vertebral artery dissection, neoplasm
50
Q

peripheral vertigo vs central vertigo

A

PERIPHERAL
-sudden onset
-intermittent with severe symptoms
-affected by head position and movement
-nausea and vomiting more frequent and severe
-motor function, gait and coordination typically intact
CENTRAL
-gradual onset
-constant with milder symptoms
-unaffected by head position and movement
-nausea and vomiting less predictable
-motor function, gait instability and loss of coordination frequent

51
Q

assessing dizziness/vertigo

A
  • question patient about hx of stroke, atrial fibrillation, hypertension
  • Pt may have ↓ LOC or nystagmus (from lesion in brain or vestibular organs)
  • Vertigo more than 24 hours w/loss of balance, difficulty maintaining posture, standing, walking: suspect cerebellar lesion (infarction)
  • W/other cranial nerve deficits: suspect brainstem or cerebellar issues
  • Transient symptoms, not triggered by motion may indicate TIA
52
Q

seizure

A
  • Brief episodes of abnormal or asynchronous neuronal activity in the brain
  • Look for anti-seizure medication or medical alert bracelet
  • Epilepsy, head injury, meningitis, toxins, possible causes
53
Q

epilepsy

A

-A seizure occurs when a burst of electrical impulses in the brain escape their normal limits. They spread to neighboring areas and create an uncontrolled storm of electrical activity. The electrical impulses can be transmitted to the muscles, causing twitches or convulsions. Some of the main causes of epilepsy include: Low oxygen during birth, Head injuries that occur during birth or from accidents during youth or adulthood, Brain tumors, Genetic conditions that result in brain injury, such as tuberous sclerosis, Infections such as meningitis or encephalitis, Stroke or any other type of damage to the brain, Abnormal levels of substances such as sodium or blood sugar.

54
Q

headache

A
  • This can be a vague and puzzling symptom
  • Pay attention to patient’s description of onset, nature, and location of pain
  • Note associated symptoms:
    • > vision changes (ipsilateral may be temporal arteritis)
    • > photophobia, phonophobia, “flashing lights”
  • Trauma followed by headache may indicate subdural/epidural hematoma or vertebral artery dissection
  • Severe h/a w/sudden onset (w/or w/out vomiting) may be subarachnoid bleeding
  • Co-morbidities hypertension, vascular issues, may indicate brain bleeding or aneurysm
  • Look for abnormal vital signs: fever could indicate meningitis
55
Q

red flags in the headache history

A
  • HA accompanied by unconsciousness
  • first-worst HA (appearing suddenly)
  • HA accompanied with neurological abnormalities during and/or after the HA
  • HA associated with fever or stiff neck
  • HA developing after 50 years of age
  • a change in characteristic response to previous treatments of HA
  • HA associated with alterations in behavior and personality
  • HA initiated by Valsalva maneuver
  • gait!
  • were worried about aneurism and hemorrhage
56
Q

focal neurological deficit

A
  • any localized loss of neurological function (ex. weakness or numbers)
  • stroke
  • may also be preceding illness- Guillain-Barre
  • or chronic disorder- ALS, MS
  • ask about bowel/bladder function
57
Q

hypoglycemia

A
  • often present with confusion and abnormal behavior
  • may also seem depressed, sluggish, or mentally slow
  • may have focal weakness or completely unresponsive
  • if pt can swallow without risk of aspiration, give oral glucose
  • if low LOC or unconscious -> give IV dextrose*
  • is the pt diabetic
  • If there is a problem checking blood glucose, give IV dextrose. If IV not available, glucagon by IM injection
58
Q

intracranial hypertension

A
  • ↑ Intracranial pressure (ICP) can compromise brain perfusion
  • May be due to mass effect (hemorrhage or edema) or malfunction of ventriculoperitoneal shunt
  • pupils dilate
  • If ICP gets too high, brain may herniate through foramen magnum (high mortality): with signs of unilateral blown pupil and loss of consciousness
  • A ventriculoperitoneal (VP) shunt is a medical device that relieves pressure on the brain caused by fluid accumulation.
59
Q

intracranial hypertension treatment

A
  • Treating ↑ ICP with hyperventilation: must be performed carefully, with monitoring patient’s neurological status
    1. hyperventilating decreases amount of CO2 in blood which induces cerebral vasoconstriction
    2. vasoconstriction decreases blood volume in brain which reduces ICP
    • however vasoconstriction also ↓ perfusion to brain, so this must be carefully considered
60
Q

causes of decreased LOC- AEIOU-TIPS

A
  • do not need to know acronym
  • A- alcohol, anaphylaxis, acute MI
  • E- epilepsy
  • I-insulin (glucose)
  • O- opiates
  • U- uriema
  • T- trauma
  • I- Intracranial (tumor, hemorrhage, hypertension)
  • P- poisoning
  • S- seizure, stroke, syncope
61
Q

subarachnoid hemorrhage

A
  • Arteries on brain’s surface bleed into subarachnoid space
  • Caused by cerebral aneurysm, trauma or rupture of arteriovenous malformation
  • Sudden & severe h/a, possible loss of consciousness
  • Arteriovenous malformation: genetic vascular defect condition, some arteries connect directly to veins
62
Q

subarachnoid hemorrhage

A

Five grades of hemorrhage:

  1. mild h/a with or w/out meningeal irritation
  2. severe h/a with or w/out pupillary change
  3. mild alteration in neurological exam
  4. depressed level of consciousness
  5. comatose with or w/out posturing
63
Q

subdural hematoma

A
  • Collection of blood between dura and arachnoid meninges
  • May be acute, subacute, or chronic (2-3 weeks post-injury)
  • Mortality rate: 20%, mostly in pt’s over 60 y/o
  • Trauma or deceleration injury: tearing of veins between cerebral cortex & venous sinuses
    • blood clots in subdural space
64
Q

coup-contrecoup injury: subdural hematoma

A
  • coup (blow) causes trauma to brain, brain recoils after blow and is injured on opposite side after it rebounds
    • bleeding/damage to both sides of brain
  • Signs/symptoms: loss of consciousness after head trauma, amnesia, personality changes, h/a, visual changes, vomiting, hemiparesis, hemiplegia
65
Q

epidural hematoma

A

-Accumulation of blood between inner layer of skull and dura mater
-Usually from trauma to subcranial arteries resulting in high-pressure mass effect
-Usually an associated skull fracture
80% in temporo-parietal region
-Prompt surgical decompression for pt’s with significant neurological dysfunction

66
Q

sign and symptoms of epidural hematoma

A
  • patient may not lose consciousness or may lose it and then awaken (lucid interval) before becoming unresponsive
  • may have severe h/a, vomiting, seizures
  • QUIZ
  • increased ICP may cause Cushing’s triad ***(patient unesponsive w/imminent death):
    1. systolic hypertension
    2. bradycardia
    3. irregular respiratory pattern
67
Q

treatment for subarachnoid hemorrhage, subdural and epidural hematoma

A
  • ABC
  • Protect C-spine
  • Transport to trauma center w/ neurosurgical capabilities
  • CT or MRI at hospital
  • May need lumbar puncture: blood in CSF
  • Monitor mental status
  • IV line, administer oxygen, cardiac monitor, do not administer fluids unless BP is low -> mostly for epidural hematoma
68
Q

meningitis

A
  • Inflammation of meninges and infection of CSF
  • Many infectious and non-infectious causes
  • Life-threatening, acute meningitis is usually bacterial infection
  • Usually by bacteria that colonize in nasopharynx, spread to CSF
  • Lack of antibodies and WBC’s in CSF
  • Pressure around brain reverses flow of CSF
  • Meningitis in infants usually caused by group B streptococcus or E. coli
  • After 1 year old, Streptococcus pneumoniae and Neisseria meningitidis become more common
69
Q

signs and symptoms of meningitis

A
  • patients w/ acute bacterial meningitis may decompensate quickly & require emergency care and antibiotics
  • Classic initial symptoms: headaches, nuchal rigidity (neck pain), fever/chills, and photophobia (resistance to light)***
  • seizures, altered mental state, coma, and death can also develop
  • bacterial presents more quickly than viral
  • (+) Kernig’s sign & (+) Brudzinski’s sign
  • meningismus: triad of nuchal rigidity, photophobia, headache
70
Q

kernigs sign

A

-severe stiffness of the hamstrings causes inability to straighten the leg when the hip is flexed to 90 degrees

71
Q

brudzinskis neck sign

A

-severe neck stiffness causes a patients hips and knees to flex when the neck is flexed

72
Q

meningitis: where to suspect it

A
  • Suspect meningitis in older and younger patients
  • Patients with suppressed immune systems
  • Live in crowded places
  • Exposure to others with meningitis
  • Meningitis can be contagious
  • Use protective gear: mask, gloves, gown
  • Pt’s w/suspected meningitis can be treated in most ED’s, head CT to rule out stroke, lumbar puncture to test CSF, IV antibiotics
73
Q

bells palsy

A
  • can mimic strokes
  • Unilateral facial paralysis that may mimic a stroke
  • Cranial nerve VII (Facial)
  • Unknown origin or infection (herpes simplex)
  • In stroke: only lower half of face is weak, forehead and upper eyelid have normal motor function
  • inability to wrinkle brow, drooping eyelid, inability to puff cheeks, drooping mouth
74
Q

guillain-barre syndrome

A
  • A group of acute immune-mediated polyneuropathies
  • Demyelinating disorders causing weakness, numbness, or paralysis throughout body
  • 1-3 per 100,000 people in U.S. affected
  • Can occur at any age
  • Autoimmune response to recent infection
  • Antibodies formed against peripheral nerves
  • starts at legs and goes up -> goes to lung cavity
  • can lead to pneumonia!
  • intubate and ventilate
75
Q

guillain-barre syndrome

A
  • Patients may require mechanical ventilation at some point in their illness to compensate for respiratory muscle weakness (Pneumonia is a common side effect)
  • Lack of deep tendon reflexes is strong indicator of Guillain-Barre
  • Parasthesia in feet and hands
  • Paralysis usually begins in feet and works its way up to the lungs
  • May have loss of vibratory sense, proprioception and touch
  • Most patients at their worst 12 days from onset and improve over next few months
  • degradation of myelin sheath
76
Q

diagnostic criteria for GB syndrome

A

required symptoms
-progressive weakness of 2 or more limbs due to neuropathy
-areflexia
-disease course < 4 weeks
-exclusion of other causes (vasculitis, toxins, botulism, diphtheria, porphyria, localized spinal cord or cauda equina syndrome
supportive symptoms
-relatively symmetrical weakness
-mild sensory involvement
-facial or other cranial nerve involvement
-absence of fever
-typical csf profile (cytoalbumin dissociation)
-electrophysiological evidence of demyelination

77
Q

conclusions

A
  • assessment and management of the neurologic patient requires a detailed assessment
  • meningitis is contagious
  • as a provider you must take contact precautions
  • what are the various exams that can be performed to help diagnose a patient with meningitis
  • time is a key in the stroke patient
  • types of strokes?
  • signs/symptoms and assessment technique to diagnose someone having a stroke
  • door to CT scan and possible TPA administration within 3 hours to increase survivability
  • bells palsy
  • what does it mimic?
  • what cranial nerve is usually effected?
  • seizures
  • how do you treat this type of patients?
  • what are the various classifications for seizures?
  • elevated intracranial pressure
  • what is cushing’s triad?
  • guillain-barre syndrome
  • what signs/symptoms would you anticipate

Medical Emergencies (16 decks)

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