Neurological Emergencies

Question 1

Define status epilepticus?

Answer 1

A tonic clonic seizure lasting greater than 5 minutes

Or

More than one tonic clonic seizures within 5 minutes without the person returning to normal in between.

Question 2

Describe the treatment algorithm for status epilepticus?

Answer 2

0-5 mins: time the seizure. Remove any objects which may be a danger to the patient. Attempt to take BM and correct it if abnormal.

5-10 mins: benzodiazepine: buccal/IM midazolam OR IV lorazepam/diazepam

10-15 mins: second dose of a benzodiazepine: IV lorazepam or diazepam. Prepare for phenytoin infusion.

20 mins: Give phenytoin infusion over 20 mins. If phenytoin is not available give valporic acid or levetiracetam also 1st line. Contact and anaethetist.

40 mins: Intubate patient giving anaesthetic medication (propofol/thiopental/midazolam/pentobarbitol) + continuous EEG monitoring.

After a period of status epilepticus it is important to monitor myoglobin levels and CK as can cause myoglobin induced renal failure.

Question 3

Describe the clinical presentation of acute compression of the cauda equina?

Answer 3

Acute cauda equina syndrome:

• Severe lower back pain
• Loss of bladder and bowel function
• May have saddle anaesthesia.
• Sensory and motor deficits may develop in the lower limb within 24hrs.

Question 4

Describe the treatment of acute cauda equina syndrome?

Answer 4

Urgent neurosurgical/spinal intervention is needed to perform an emergency spinal decompression to prevent complications such as:

• lower limb paralysis
• saddle anaesthesia
• bowel, bladder and sexual dysfunction

Question 5

Describe the symptoms of a cord transection?

Answer 5

Loss of motor and sensory function below the point of transection.

Question 6

What is transverse myelitis?

Answer 6

It is inflammation transversely across a section of the spinal cord. It is often immune mediated following a viral infection.

Question 7

What are the symptoms of transverse myelitis and how is it treated?

Answer 7

(1) weakness (legs +/- arms depending on level affected)
(2) pain
(3) sensory alteration
4) bowel and bladder dysfunction

Treatment is with anti-inflammatory drugs and corticosteroids.

Question 8

Describe the symptoms of L5/S1 root impingement due to a prolapsed disk?

Answer 8

Sciatica

Lower back pain with shooting pain down the buttock and the leg. May also have numbness, parasthesiae and weakness.

Usually pain improves on it own or with physiotherapy occasionally surgery is needed to repair the herniated disk.

Note the nn exiting L5/S1 is the L4 nn root. But the L5 nn root transverses S1. In disk prolapse the disk prolapses inferiorly therefore in a L5/S1 prolapsed disk it is likely the L5 nn root will be compressed.

Question 9

Describe the clinical signs which point to neuromuscular ventilatory compromise?

Answer 9

Dyspnoea with a background of weakness elsewhere.
May be using accessory muscles.
May be signs of CO2 retention, CO2 flap, headaches etc.

Question 10

Which tests are important in assessing neuromuscular ventilation?

Answer 10

ABG’s to look for CO2 retention

Poor tidal volume (amount of air inhaled/exhaled in a normal breath) is an indicator of poor respiratory muscle function.

Question 11

Which are the conditions which can lead to neuromuscular ventilatory compromise?

Answer 11

Acute: Guillian Barre Syndrome

Chronic and remitting: MS and myasthenia gravis

Progressive: ALS, DMD other muscular dystrophies

Question 12

In a patient with a head injury describe the appropriate management?

Answer 12

ABC

D: assessment of conscious level AVPU/GCS
If GCS less than 8 involvement of anaesthetics as airway may not be safe.

Consider CT head if any focal neurology, confusion, reduced GCS, high risk group for example on anticoagulants.

Question 13

Which features reflect a serious head injury?

Answer 13

Reduced GCS is the most sensitive measure.

Focal neurology.
New onset confusion.
Vomiting.

Question 14

What are the clinical signs of a base of the skull fracture?

Answer 14

Raccoon eyes: bilateral black eyes (periorbital ecchymosis)

Battle’s sign: bruising behind the mastoid process (mastoid ecchymosis)

CSF rhinorrhoeaa/ottorhoea

Haematotympanum

CN VII/VIII dysfunction

Question 15

What are the complications of base of skull fracture?

Answer 15

Infection (basal meningitis)

CN palsies (VII and VIII)

Carotid artery damage: dissection, pseudoaneurysm, thrombosis

Pneumocephalus (not usually a problem)

Question 16

Describe the clinical presentation of acute hydrocephalus?

Answer 16

Headache and vomiting.

Signs of raised ICP:

• deterioration in GCS
• Cushing’s reflex: hypertension with bradycardia
• pupil dilation or sloww pupillary reflexes

Question 17

Which patient groups are at risk of acute hydrocephalus?

Answer 17

Those who have had a intercranial bleed.

Tuberculoid meningitis.

Infants with congenital abnormalities.

Question 18

Describe the immediate investigation of suspected acute hydrocephalus?

Answer 18

CT scanning with or without contrast is considered to be adequate for the diagnosis of hydrocephalus.

Question 19

Describe the immediate management of a patient with acute hydrocephalus?

Answer 19

A-E

Management is dictated by severity.

Pharmacological management can be used as a temporary measure to defer surgery: Furosemide and acetazolamide work by inhibiting CSF production in the choroid plexus. Isosorbide promotes reabsorption.

Mannitol can be given to help reduce pressure in severe cases.

Surgical procedures can be used:
Ventriculo-peritoneal shunt insertion.

Question 20

Provide a differential diagnosis for a semi/unconscious patient?

Answer 20

Traumatic
-SAH, subdural/extradural haemorrhage.

Ingestion:
-overdose of sedating drugs (e.g. opioid overdose)

Non traumatic

• Post anoxic (aka after cardiac arrest)
• Post ischaemic
• Systemic infection
• Metabolic disturbance (hypoglycaemia)

Question 21

Describe the scoring system for the glasgow coma scale?

Answer 21

Eyes: out of 4

4: Open spontaneously
3: Open to voice
2: Open to pain stimuli
1: Don’t open

Verbal: out of 5

5: Orientated to time place and person
4: Confused
3: Inappropriate words
2: Incomprehensible sounds (grunts/moans)
1: No response

Motor: out of 6

6: Obeys commands
5: Moves to localised pain
4: Flexion withdrawal from pain
3: Abnormal flexion
2: Abnormal extension
1: No response

Question 22

Describe how you would assess a semi conscious patient?

Answer 22

A: Is the airway patent, do they need an adjunct?

B: Are they breathing, rate, o2 sats, do they need a bag valve mask?

C: Peripheries, pulse, BP, heart sounds, ECG has there been an MI.

D: AVPU/GCS, Pupils, BM, do they need a CT?

E: Expose + quick abdo exam.

Question 23

How should you investigate a semi/unconscious patient once you have performed an A-E assessment?

Answer 23

Most important try and get a collateral history from a witness.

Bloods: FBC, UE, LFTs, CRP, Troponin

Any signs of head trauma + reduced consciousness = head CT.

Meningisms + reduced consciousness = LP

No other signs except reduced consciousness consider a toxin screen.