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ED > Neurological Emergencies > Flashcards

Neurological Emergencies Flashcards

1
Q

What percentage of strokes are preventable

A

80%

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2
Q

Name some modifiable risk factors of a stroke

A

DM, HTN, smoking, ETOH, obesity, Afib, High cholesterol

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3
Q

Name some non-modifiable risk factors

A

Age, race (African American, Hispanic, Native American), Gender (Men), Previous TIA/CVA, family Hx

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4
Q

Signs and symptoms of a stroke

A

Sudden onset garbled/inability to speak, unilateral arm or leg weakness or numbness, facial droop, severe HA, LOC, loss of balance, visual field cut

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5
Q

Most common artery to be affected in a stroke

A

Middle Cerebral artery

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6
Q

Percentage of Ischemia vs hemorrhagic

A

84%- Ischemic

16%- hemorrhagic

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7
Q

Types of Ischemic strokes

A

Thrombolitic- 53%
Embolic- 31%
Lacunar

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8
Q

What is the biggest risk factor for having an embolic stroke

A

A-fib

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9
Q

What is a TIA

A

Stroke symptoms that clear within 24 hours

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10
Q

What is the ischemic penebmbra

A

The “At risk” portion of the brain that is potentially reversable

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11
Q

Symptoms of anterior cerebral artery stroke

A

Most die immediately
Frontal lobe portion, poor judgment, altered MS
Uncommon presentation

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12
Q

Middle cerebral artery stroke

A

Contralateral hemiparesis, dysarthria, aphasia/apraxia, homonymous hemianopsia, facial droop

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13
Q

Posterior cerebral artery stroke

A

contralateral homonymous hemianopsia
Unilateral cortical blindness
Memory loss
Unilateral 3rd nerve palsy

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14
Q

Vertebrobasilar stroke

A 
close to brain stem
Unilateral or bilateral CN deficits
Coma, death, respiratory insufficiency 
Tachycardia
Liable BP
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15
Q

Opthalmic artery strokes

A

Amaurosis Fugax

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16
Q

Lucunar infarcts

A

isolated hemiparesis, dystonia, dysarthria, sensory defects, unilateral parkinsonian signs

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17
Q

What is the Cincinnati pre-hospital stroke scale

A

Identifies 3 areas- facial droop, pronator drift, speech

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18
Q

What is the NIH stroke scale

A

measures sensory, motor, speech, gaze, LOC to identify stroke outcomes

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19
Q

Why do we use CT in a stroke

A

to rule out other causes, or to identify bleeding

Infarcts will not show for 24 hours on CT

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20
Q

What BP do we need to keep people with a suspected stroke below?

A

220 or less

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21
Q

What could mimic a stroke

A

Hypogycemia

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22
Q

What are the inclusion criteria to give thrombolitic therapy to a ishemic stroke patient

A

1) Age of at least 18
2) Within 180 minutes of onset of sx’s—NOW EXPANDED TO 4.5 HOURS FROM 3 IN SOME PTS
3) Stroke sx’s acutely
4) BP systolic less than 185, diastolic less than 110
5) No assoc seizures
6) Not minor sx’s or rapidly resolving sx’s
7) No Coumadin use**CHANGED, NOW RELATIVE
8) PT less than 15, INR less than 1.7
9) No Heparin during last 48 hours, normal APTT
10) Platelet count grt than 100,000
11) Glucose grt than 50, less than 400
12) No MI
13) No hx AVM, aneurysm, ICH in past
14) No major surgeries in last 14 days
15) No CVA or serious head injury within 3 months
16) No GI/GU bleeding in last 21 days
17) No lactation or pregnancy within the last 30 days

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23
Q

Can you give TPA within 4.5 hours instead of 3?

A

Yes as long as not…
AGE GRT THAN 80
ORAL ANTICOAGS WHO HAVE INR25
PRIOR CVA OR DIABETES

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24
Q

What are some adjunct therapies for ischemic stroke treatment

A

ASA, other antiplatelets, Heparin

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25
Q

If you use a catheter to administer TPA how long do you have for it to be effective

A

6 hours

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26
Q

If I have A fib what should you give me?

A

heparin

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27
Q

What are the steps of endovascular retrieval?

A

1) Catheter is inserted into groin after angiography showing location of cerebral clot
2) Catheter is fed into cerebral location
3) Clot is snared, and sucked up into balloon
4) Catheter is than removed, and clot removed from body

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28
Q

If you have had a TIA what is the probability you will have another within 24 hours? Within 30 days?

A

A) 30-50%

B) 75%

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29
Q

What are the types of Hemorrhagic strokes?

A

ICH (10%)
SAH (6%)
IVH

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30
Q

What is often the culprit of an SAH

A

Trauma or Berry Aneurysm

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31
Q

What is the number one cause of Intracranial Hemorrhage?

A

Hypertension

Other cause= Cocaine

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32
Q

What is the cause of an inraventricular hemorrhage?

A

Consequence of other bleeding

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33
Q

What is the modality of choice in diagnosing a hemorrhagic stroke?

A

CT- Non contrast

34
Q

If you suspect an aneurysm what should you get?

A

CT/MR angiography r formal cerebral angiogram

35
Q

Management of a hemorrhagic stroke?

A

Control BP- SBP less than 180
Seizure meds
Frequent neruo monitoring

36
Q

Should you slowly or rapidly decrease the blood pressure in a hemorrhagic stroke patient?

A

SLOWLY

37
Q

What type of medications should you use to decrease the blood pressure in an hemorrhagic stroke?

A

Titratable BP meds–> cortarone, labetalol, nitropuriside

38
Q

Can you use a beta blocker ALONE to decrease the blood pressure in a hemorrhagic stroke?

A

NO- too rapid of a descent

39
Q

What is a new drug being studied for use in hemorrhagic stroke patients?

A

Recombinant Factor VIIa/Novo 7

40
Q

What are the layers of the scalp?

A 
S- Skin
C- Connective tissue/fat
A- Aponerosis (Galea)-- blood vessels 
L- Loose connective tissue
P- Periosteum/pericranium
41
Q

If you do not ensure that the Galea is closed fully while suturing the scalp closed what can result?

A

Expanding/subgaleal hematoma

42
Q

IF the temporal bone fractures what are you at risk for?

A

EDH- Middle menigral artery is deep to this

43
Q

When do you need surgical intervention for a depressed skull fracture

A

If is depressed more than the thickness of the skull

44
Q

What is the danger or a basilar fracture?

A

CSF leaks out!

45
Q

What are some signs on clinical exam that indicate a basilar fracture?

A

Hemotympanum
Battle sign
CSF oto/rhinorrhea
Rccoon eyes

46
Q

What is a concussion?

A

Breif LOC secondary to non-penetrating trauma, with GSC greater than 12 and negative CT

47
Q

Symptoms of a concussion

A

HA, N?V, brief AMS,

48
Q

If I have a GCS of 11 could I have a concussion?

A

No –> can get as low as 13 but thats it

49
Q

Treatment of concussions

A

observation in hospital or at home, limited cognitive activity (HW, TV), No sports, cognitive follow up

50
Q

How long to concussion patients need to be followed up for?

A

until the symptoms are gone

51
Q

What is a cerebral contusion?

A

Brain bruise

52
Q

What imaging modality is best to look for cerebral contusions, and what would it show

A

CT- small punctate hemorrhage that may enlarge over time

53
Q

What is the treatment of a cerebral hemorrhage

A

close observation

Repeat CT in 24 hrs

54
Q

What is the prognosis of cerebral contusion

A

Good prognosis, reabsosrb over time

55
Q

What is a countercoup injury?

A

2 injuries- Injury to the brain at area of impact as well as the opposite side of the skull

56
Q

What is a Diffuse Axonal Injury (DAI)

A

“Tearing/shearing” of axons diffusely in the brain. primary lesion of rotational, accelerating/descelerating durring trauma

57
Q

What is the prognosis of DAI?

A

Bad, low GSC, deeply comatose and death is likely

58
Q

What is the imaging modality used fo DAI and what does it show

A

CT- normal followed by areas of small hemorrhages

59
Q

If I am stabbed in the head should you remove the knife?

A

No! you can worsen the neuro outcome. Go to OR to do that

60
Q

Where is an Epidural

A

Between dura and skull

61
Q

Classic presentation of an Epidural

A

1) Brief post trauma LOC,
2) Lucid interval,
3) Obtunded , contalateral hemiparesis, ipsilateral pupillary dilation

62
Q

What is the main vessel affected in an EDH

A

Middle Menigeal artery

63
Q

What is Kernohans phenomenon

A

Shift of the brain stem away from the mass/bleed with compression of the opposite cerebral peducle- causes ipsilateral hemiparesis

64
Q

How do you diagnose an EDH

A

CT- non contrast

65
Q

On CT does an EDH cross the suture line?

A

NO

66
Q

What is the treatment of a small EDH

A

Follow clinically + repeat neuro checks and CT

67
Q

Treatment for larger EDH

A

Surgical evacuation/clot removal, emergent burr holes for increasing ICP, Control BP/PAin

68
Q

Where is a subdural hematoma

A

between dura and arachnoid

69
Q

What is in the space between the dura and arachnoid space?

A

CSF

70
Q

What vessel is affected in a subdural hematoma

A

venous- common in elderly

71
Q

Diagnosis of SDH

A

CT- appears hyperdense

72
Q

Classic presentation of SDH

A

No lucid period, focal signs later and less prominent than with EDH

73
Q

Treatment of SDH

A

Control BP/ICP, reverse anticoagulation drugs, frequent neuro checks, maybe surgical intervention

74
Q

Chronic SDH

A

Common in elderly

75
Q

Symptoms of chronic SDH

A

HA, confusion, vomiting, AMS, language difficulties

76
Q

Tx of chronic SDH

A

maybe burr hole drainage but usually liquifies in 1-2 weeks

77
Q

Where is a subarachnoid hemorrhage

A

bleeding in subarachnoid space

78
Q

Presnetation of SAH

A

Thunderclap HA

79
Q

DX of SAH

A

CT

80
Q

Tx of SAH

A

Usually only need observation, no surgical intervention, serial examps and repat CT, consider ventriculostomy/EVD to drain if hydrocephalus presents

81
Q

TBI evaluation essentials

A

Meticulous Hx, Curent meds (anticoag), VS, head to tow PE, neuro exam

82
Q

What does a positive babinski indicate

A

Upper motor neuron lesion

ED (7 decks)

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