Neurological emergencies Flashcards
What do you need to check in a ABDEG examination?
Airways Breathing Circulation Deficit Environment - no hyper/hypothermia Glucose
Name 3 examples of neurological emergencies
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)
What does unconscious mean?
Unarousable
Not aware
How is coma measured?
GCS
What does GCS measure?
Response of eyes, motor, and verbal to stimuli
What is eye opening assessed as?
None
To pain
To voice
Spontaneously
What is motor response assessed as?
None Extension to pain Flexion to pain Withdrawal from painful stimuli Localises to pain Obeys commands
What is verbal response assessed as?
None Groans Inappropriate words Confused speech Orientated
What are the common causes of coma?
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
What are the uncommon causes of coma?
Mass lesions (tumours) Venous sinus occlusions Hypothermia Psychiatric (catatonia) Toxins (CO)
What are the rare causes of coma?
Pituitary apoplexy
Fat embolism
What questions should you ask in the history of an unconscious patient?
Circumstances of event from witnesses
Previous events, suicide notes, travel Hx
PMH - general, psychiatric, head injury, alcohol
Drug - insulin, antiepileptics, antidepressants, benzos, recreational
What should you do in the examination of an unconscious patient?
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
What investigations should you do on an unconscious patient?
Bloods - glucose, U&E, Ca, phosphate, LFT, toxicology, alcohol level, arterial gases, anion gap, ECG Imaging - CT/MRI LP EEG Rarely cortisol, TFTs, ammonia
What is status epilepticus?
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
How common is status epilepticus?
20% cases fatal
Long-term mortality rate 22% in children, 57% adults
What are the consequences of status epilepticus?
Increased CNS metabolic consumption Rhabdomyolysis Renal failure Metabolic acidosis Hyperthermia Heart and other organ effects
How do you treat status epilepticus?
IV lorazepam/diazepam/clonaazepam
Inform neurointerventivist or experienced anaesthetist
Antiepileptics - phenytoin, levetiracetam, valproate, phenobarbital
General anaesthesia with intubation and ventilation
What are the harmless causes of sudden onset severe headaches?
Migraine
Cluster headache
What are the serious causes of sudden onset severe headaches?
SAH Cerebral venous sinus thrombosis Dissection - carotid/vertebral Infection - bacterial meningitis/encephalitis/cerebral abscess Acute haemorrhage/acute infarcts Pituitary apoplexy
What causes a spontaneous SAH?
Rupture of berry aneurysm
How does SAH present?
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
What might the examination in a SAH look like?
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
What investigations should you do in SAH?
CT within 6 hrs
CT angiogram or MRI/MRI angiogram
LP 12 hrs post event
Catheter angiogram
What is GBS?
Acute/subacute
Demyelinating immune mediated multifocal polyradioculo-neuritis
What are the clinical features of GBS?
Numbness starting distally Progressive ascending weakness Bifacial weakness + other cranial neuropathies Flaccid tetra/paraparesis Areflexia
What can mimic GBS?
Spinal shock syndrome 2ndary to cord compression
Botulism
MG
Lyme disease
Toxins - thallium, lead, hexane
Metabolic - porphyria
Neoplasia - multifocal carcinomatous/lymphomatous meningitis
How do you diagnosed GBS?
CSF - elevated protein, fewer < 3 or no cells
EMG - slower nerve conduction velocities
What are the dangers with GBS?
Failure to recognise - Severe weakness - Aspiration - Resp failure - Autonomic instability - severe sudden hypotension, cardiac arrhythmias May cause death
What is the management of GBS?
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
How do you treat GBS?
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
