Neurological Emergencies Flashcards
Define status epilepticus?
A tonic clonic seizure lasting greater than 30 minutes
Or
More than one tonic clonic seizures without the person returning to normal in between.
BUT Treat any seizure that lasts > 5 minutes as SE
Describe the treatment algorithm for status epilepticus?
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 midazolam (10mg) OR IV lorazepam (4mg) PR diazepam (10mg)
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 anaesthetist.
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.
Describe the clinical presentation of acute compression of the cauda equina?
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.
Describe the treatment of acute cauda equina syndrome?
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
Describe the symptoms of a cord transection?
Loss of motor and sensory function below the point of transection.
What is transverse myelitis?
It is inflammation transversely across a section of the spinal cord. It is often immune mediated following a viral infection.
What are the symptoms of transverse myelitis and how is it treated?
(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.
Can occur secondary to Syphillis, Measels, Lyme disease
Describe the symptoms of L5/S1 root impingement due to a prolapsed disk?
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.
Describe the clinical signs which point to neuromuscular ventilatory compromise?
Dyspnoea with a background of weakness elsewhere.
May be using accessory muscles.
May be signs of CO2 retention, CO2 flap, headaches etc.
Which tests are important in assessing neuromuscular ventilation?
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.
Which are the conditions which can lead to neuromuscular ventilatory compromise?
Acute: Guillian Barre Syndrome
Chronic and remitting: MS and myasthenia gravis
Progressive: ALS, DMD other muscular dystrophies
In a patient with a head injury describe the appropriate management?
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.
Which features reflect a serious head injury?
Reduced GCS is the most sensitive measure.
Focal neurology.
New onset confusion.
Vomiting.
What are the clinical signs of a base of the skull fracture?
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
What are the complications of base of skull fracture?
Infection (basal meningitis)
CN palsies (VII and VIII)
Carotid artery damage: dissection, pseudoaneurysm, thrombosis
Pneumocephalus (not usually a problem)
