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Neuro and geriatrics > Neurological emergencies > Flashcards

Neurological emergencies Flashcards

1
Q

What do you need to check in a ABDEG examination?

A 
Airways
Breathing
Circulation
Deficit
Environment - no hyper/hypothermia
Glucose
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2
Q

Name 3 examples of neurological emergencies

A 
Coma - sudden state of unconsciousness
Sudden or subacute new headache
Weakness
- Generalised +/- resp failure
- Acute/subacute paraplegia/quadriplegia
- Acute hemi or monoplegia
Visual loss
Status epilepticus
Other (acute loss of bladder function, hemiballismus, status dystonicus, severe chorea, severe dysphasia, acute dysphagia)
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3
Q

What does unconscious mean?

A

Unarousable

Not aware

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4
Q

How is coma measured?

A

GCS

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5
Q

What does GCS measure?

A

Response of eyes, motor, and verbal to stimuli

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6
Q

What is eye opening assessed as?

A

None
To pain
To voice
Spontaneously

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7
Q

What is motor response assessed as?

A 
None
Extension to pain
Flexion to pain
Withdrawal from painful stimuli
Localises to pain
Obeys commands
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8
Q

What is verbal response assessed as?

A 
None
Groans
Inappropriate words
Confused speech
Orientated
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9
Q

What are the common causes of coma?

A 
Drugs/toxins (opiates, alcohol)
Anoxia post arrest
Mass lesions (bleeds)
Head injury
Infections (HSE, bacterial meningitis)
Infarcts (brainstem)
Metabolic (hypoglycaemia, DKA, hepatic encephalopathy, uraemia, Wernicke's)
SAH
Epilepsy
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10
Q

What are the uncommon causes of coma?

A 
Mass lesions (tumours)
Venous sinus occlusions
Hypothermia
Psychiatric (catatonia)
Toxins (CO)
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11
Q

What are the rare causes of coma?

A

Pituitary apoplexy

Fat embolism

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12
Q

What questions should you ask in the history of an unconscious patient?

A

Circumstances of event from witnesses
Previous events, suicide notes, travel Hx
PMH - general, psychiatric, head injury, alcohol
Drug - insulin, antiepileptics, antidepressants, benzos, recreational

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13
Q

What should you do in the examination of an unconscious patient?

A

Trauma, skull, fever, hypothermia, breath odour, needle marks, stigmata liver disease, evidence of convulsion, alert bracelet, skin colour
Assessment of GCS
Brainstem signs - pupil size, pupil reactions, eye movements, corneal reflexes
Focal deficits - asymmetry of motor function, tendon reflexes, plantars, meningism

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14
Q

What investigations should you do on an unconscious patient?

A 
Bloods - glucose, U&E, Ca, phosphate, LFT, toxicology, alcohol level, arterial gases, anion gap, ECG
Imaging - CT/MRI
LP
EEG
Rarely cortisol, TFTs, ammonia
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15
Q

What is status epilepticus?

A 
30 mins or more
Continuous
Intermittent attacks without recovery of consciousness
Practically > 10 mins
5 mins generalised tonic-clonic
10 mins focal
10-15 absence
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16
Q

How common is status epilepticus?

A

20% cases fatal

Long-term mortality rate 22% in children, 57% adults

17
Q

What are the consequences of status epilepticus?

A 
Increased CNS metabolic consumption
Rhabdomyolysis
Renal failure
Metabolic acidosis
Hyperthermia
Heart and other organ effects
18
Q

How do you treat status epilepticus?

A

IV lorazepam/diazepam/clonaazepam
Inform neurointerventivist or experienced anaesthetist
Antiepileptics - phenytoin, levetiracetam, valproate, phenobarbital
General anaesthesia with intubation and ventilation

19
Q

What are the harmless causes of sudden onset severe headaches?

A

Migraine

Cluster headache

20
Q

What are the serious causes of sudden onset severe headaches?

A 
SAH
Cerebral venous sinus thrombosis
Dissection - carotid/vertebral
Infection - bacterial meningitis/encephalitis/cerebral abscess
Acute haemorrhage/acute infarcts
Pituitary apoplexy
21
Q

What causes a spontaneous SAH?

A

Rupture of berry aneurysm

22
Q

How does SAH present?

A

Acute severe localised headache
Meningism - N&V, stiff neck, photophobia
Double vision, droopy eyelid
Sometimes - seizure, low GCS, sudden death
Can take up to an hour from mild headache to worst ever headache

23
Q

What might the examination in a SAH look like?

A

Normal or reduced GCS
Subhyaloid haemorrhage
3rd CN palsy - with sudden onset headache SAH until proven otherwise
Bilateral extensor plantar response
Severe meningism - pain on eye movement, neck stiffness
Focal neurological deficit due to mass effect of secondary vasospasm and cerebral ischaemia

24
Q

What investigations should you do in SAH?

A

CT within 6 hrs
CT angiogram or MRI/MRI angiogram
LP 12 hrs post event
Catheter angiogram

25
Q

What is GBS?

A

Acute/subacute

Demyelinating immune mediated multifocal polyradioculo-neuritis

26
Q

What are the clinical features of GBS?

A 
Numbness starting distally
Progressive ascending weakness
Bifacial weakness + other cranial neuropathies
Flaccid tetra/paraparesis
Areflexia
27
Q

What can mimic GBS?

A

Spinal shock syndrome 2ndary to cord compression
Botulism
MG
Lyme disease
Toxins - thallium, lead, hexane
Metabolic - porphyria
Neoplasia - multifocal carcinomatous/lymphomatous meningitis

28
Q

How do you diagnosed GBS?

A

CSF - elevated protein, fewer < 3 or no cells

EMG - slower nerve conduction velocities

29
Q

What are the dangers with GBS?

A 
Failure to recognise
- Severe weakness
- Aspiration
- Resp failure
- Autonomic instability - severe sudden hypotension, cardiac arrhythmias
May cause death
30
Q

What is the management of GBS?

A 
Always admit
Let ITU know early if vital capacity <1L - ITU care or sniff pressures, counting in one breath
DVT prophylaxis
BP
ECG
Monitor swallowing
31
Q

How do you treat GBS?

A 
IVIG
- 2g/kg total dose
- Split over 5 days
Plasma exchange
- Equally effective compared to IVIG
- Less available
- More cumbersome
- Alternative days for 5-7 exchanges

Neuro and geriatrics (21 decks)

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