Neurological emergencies

Question 1

What do you need to check in a ABDEG examination?

Answer 1

Airways
Breathing
Circulation
Deficit
Environment - no hyper/hypothermia
Glucose

Question 2

Name 3 examples of neurological emergencies

Answer 2

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)

Question 3

What does unconscious mean?

Answer 3

Unarousable

Not aware

Question 4

How is coma measured?

Answer 4

GCS

Question 5

What does GCS measure?

Answer 5

Response of eyes, motor, and verbal to stimuli

Question 6

What is eye opening assessed as?

Answer 6

None
To pain
To voice
Spontaneously

Question 7

What is motor response assessed as?

Answer 7

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

Question 8

What is verbal response assessed as?

Answer 8

None
Groans
Inappropriate words
Confused speech
Orientated

Question 9

What are the common causes of coma?

Answer 9

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

Question 10

What are the uncommon causes of coma?

Answer 10

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

Question 11

What are the rare causes of coma?

Answer 11

Pituitary apoplexy

Fat embolism

Question 12

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

Answer 12

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

Question 13

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

Answer 13

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

Question 14

What investigations should you do on an unconscious patient?

Answer 14

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

Question 15

What is status epilepticus?

Answer 15

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

Question 16

How common is status epilepticus?

Answer 16

20% cases fatal

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

Question 17

What are the consequences of status epilepticus?

Answer 17

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

Question 18

How do you treat status epilepticus?

Answer 18

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

Question 19

What are the harmless causes of sudden onset severe headaches?

Answer 19

Migraine

Cluster headache

Question 20

What are the serious causes of sudden onset severe headaches?

Answer 20

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

Question 21

What causes a spontaneous SAH?

Answer 21

Rupture of berry aneurysm

Question 22

How does SAH present?

Answer 22

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

Question 23

What might the examination in a SAH look like?

Answer 23

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

Question 24

What investigations should you do in SAH?

Answer 24

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

Question 25

What is GBS?

Answer 25

Acute/subacute

Demyelinating immune mediated multifocal polyradioculo-neuritis

Question 26

What are the clinical features of GBS?

Answer 26

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

Question 27

What can mimic GBS?

Answer 27

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

Question 28

How do you diagnosed GBS?

Answer 28

CSF - elevated protein, fewer < 3 or no cells

EMG - slower nerve conduction velocities

Question 29

What are the dangers with GBS?

Answer 29

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

Question 30

What is the management of GBS?

Answer 30

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

Question 31

How do you treat GBS?

Answer 31

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