Neurological Emergencies

Question 1

Type of brainstem herniation that occurs when the cingulate gyrus herniates to area directly below the falx cerebri in the frontal lobe. results in gait problems and possibly coma due to disruption of anterior cerebral artery.

Answer 1

subfalcial herniation (cingulate hernation)

Question 2

Type of brainstem herniation that occurs when the temporal lobe passes through tentoriium cerebrii. Damage to occulomotor nerve results in eye that is fixated down and outwards and post ganglionic parasympathetic fibers results in a dilated pupil.

Answer 2

uncal herniation

Question 3

Type of brainstem herniation that occurs when the cerebellar tonsus hernatiates through the foramen magnum. Affect cardiorespiratory centers of the medulla that is life threatening or results in death

Answer 3

tonsillar herniation

Question 4

What immobilization device should all patients with a head trauma be in as a precaution?

Answer 4

cervical spine collar

Question 5

Difference in shape of bleeds between subdural and epidural bleeds on CT scans

Answer 5

subdural is cresent shaped whereas epidural has a biconcave shape

Question 6

What is the glasgow coma scale of a patient who opens eyes spontaneously, is verbally oriented, and obeys motor commands?

Answer 6

15 (best score). 4 pts for spontaneous eye opening, 5 points for orientation, and 6 points for obeying motor commands

Question 7

What is the glasgow coma scale of a patient who is unable to open eyes, provides no verbal response, and has no motor response?

Answer 7

3 (worse score). 1 pt for each

Question 8

What are the ranges for mild, moderate, and severe traumatic brain injury using the Glasgow Coma Scale?

Answer 8

mild 13-15, moderate 9-12, and severe < 8

Question 9

Type of head injury that may be associated with brief LOC followed by vacant stare, inability to focus, memory deficits, incoherent speech, emotionality out of proportion to events. Neuroimaging is normal

Answer 9

concussion

Question 10

Indirect trauma that greatly stretches and damages nerve cells causing significant damage and even death and in adults may cause permanent brain damage

Answer 10

shaken baby or severe whiplash

Question 11

Seen in closed head injuries that are the result of result of shearing forces (deceleration). LOC at time of accident. characterized by multiple focal lesions typically located at the grey-white matter junction

Answer 11

diffuse axonal injury

Question 12

What criteria must a patient with head injury meet in order to be observed as an outpatient?

Answer 12

GCS = 15 and normal CT scan

Question 13

What should you always do when repairing a scalp laceration besides anesthetizing the wound, removing hair, and irrigation?

Answer 13

palpate the skull to be sure you don’t feel a fracture

Question 14

What are the layers of the skull from outside to inside?

Answer 14

skin–>periosteum–>bone–>dura mater–>arachnoid –> pia mater

Question 15

What locations of skull fractures that are particularly significant/concerning?

Answer 15

those that pass through a sinue or ovelie a major dural venous sinus or the middle meningeal artery

Question 16

Difficult to view on radiographs but can be felt on palpation under scalp laceration. predispose to significant underlying brain injury and to complications of head trauma

Answer 16

depressed skull fractures

Question 17

Linear fractures at the base of the skull. Usually occurs through the temporal bone. Can cause dural tear predisposing to infection of cranial cavity or CSF leak through the nose

Answer 17

basilar skull fractures

Question 18

What are the classic signs of a basilar skull fracture?

Answer 18

intraorbital bruising, retroauricular bruising, and hemotympanum

Question 19

What are the pharmacological treatment options for a migraine?

Answer 19

1st tryptans. 2nd ketorolac + antiemetic (metoclopramide or prochlorperazine)

Question 20

What are the treatment options for a cluster headache?

Answer 20

1st 100% O2. 2nd line sumatryptan

Question 21

What is the main difference between decorticate and decerebrate posture?

Answer 21

in decorticate there is flexion of the lower arms whereas with decerebrate there is extension and pronation of the lower arms (worse prognosis)

Question 22

What needs to be given before dextrose in a seizure patient since they often occur in alcoholics?

Answer 22

thaimine

Question 23

What is the first line pharmacological treatment of seizures due to their ability to terminate ictal activity?

Answer 23

benzos

Question 24

2nd line medication for seizure that does not suppress the electrical activity of ictogenic focus and takes 20 min to onset of action

Answer 24

phenytoin

Question 25

2nd line medication for seizure that causes sedation, depression of respiratory drive and BP so pt must be monitored closely

Answer 25

phenobarbital

Question 26

How can peripheral causes of vertigo be distinguished from central causes based on symptoms?

Answer 26

N & V more severe w/ peripheral causes. Gait disturbances are more pronounced w/ central etiologies

Question 27

What is the difference of duration between central and peripheral vertigo etiologies?

Answer 27

central etiologies last for hours to days, while peripheral are recurrent and last for a few minutes to 2-3 hours

Question 28

Characterization of CVA symptoms that indicate active discharge from CNS neurons (e.g. visual, auditory, somato-sensory, motor)‏

Answer 28

positive

Question 29

Characterization of CVA symptoms that indicate absence or loss of function (e.g. loss of vision, feeling or ability to move a part of the body)‏

Answer 29

negative

Question 30

What should be ordered immediately to evaluate a potential stroke patient?

Answer 30

noncontrast CT or MRI of brain

Question 31

In a patient who is suffering from an ischemic stroke and BP is elevated, at what level should you treat?

Answer 31

SBP > 220 or DBP > 120

Question 32

In a patient who is suffering from a hemorrhagic stroke is also on warfarin, what can be used to reverse its effects?

Answer 32

IV vitamin K and FFP

Question 33

What should be initiated within 48 hrs of stroke onset?

Answer 33

antiplatelet agent

Question 34

occurs when there is severe enough muscle weakness to necessitate intubation in order to prevent respiratory failure

Answer 34

myasthenic crisis

Question 35

When should elective intubation be considered in a patient who is having a myasthenic crisis?

Answer 35

if serial measurements of the FVC or inability to handle oropharyngeal secretions

Question 36

What is the treatment for a myasthenic crisis besides intubation?

Answer 36

Plasmapharesis or IVIG

Question 37

What is the treatment for acute exacerbations of multiple sclerosis?

Answer 37

methylprednisolone 1000 mg IV a day for 5 days

Question 38

What are treatment options for an exacerbation of chronic pain?

Answer 38

1 time IM dose of Demerol or 1 time dose of PO opioid

Question 39

Presents with Symmetric ascending muscle weakness that begins as paresthesias in hands/feet. May have severe back pain and dysautonia

Answer 39

Guillan-Barre

Question 40

How is Guillan-Barre diagnosed?

Answer 40

Marked elevation of CSF protein w/ normal WBC count