Neurology Flashcards
Discuss possible etiology for new onset seizure
- stroke
- intra-cranial hemorrhage
- head trauma
- alcohol withdrawal
- brain tumour
Discuss the definition of status epilepticus
Any of the following
- single epileptic seizure lasting >30 minutes in duration
- series of epileptic seizures during which function is not regained between ictal events in 30 minute period
Clinically any of the following
- >5 minutes of continuous seizure
- >=2 discrete seizures between which there is incomplete recovery of consciousness
Discuss the ABC and initial investigations for seizure
Stabilization - intubation if vomiting or failure to ventilate/oxygenate - supplemental oxygen - initially have hypertension which switch to hypotension post-ictal which may need ephedrine/phenylephrine Investigations - CBC, electrolytes - blood glucose - blood toxicology screen - LFT, creatinine BUN
Discuss the management of seziure
Initial Therapy
- Lorazepam 0.1mg/kg
- Diazepam 0.1mg/kg
- Midazolam 0.05mg/kg (10kg IM if no IV access and >40kg)
- Fosphenytoin 20mg/kg in second IV
- No benefit with benzodiazepine then try second benzodiazepine after 1 minute
Refractory
- require intubation, mechanical ventilation, continuous EEG monitoring
- Midazolam (does not lower BP) 0.2mg/kg IV
- Can infuse at 0.1mg/kg/hr and titrate upward until seizure done
- Propofol 1-2mg/kg loading dose over 5 minutes then titrate to 10-12mg/kg/hr until seizure stops
- Pentobarbital 5mg/kg over 10 minutes and repeat until stops
Discuss the presentation and management of seizure
Presentation
- trigger, prodrome, ictal movements, post-ictal period
Investigation
- ECG for all with loss of consciousness
- EEG for all that do not return to normal level of consciousness
- CT if focal deficit
- headache then lumbar puncture
Management
- should not drive home
- start long-acting anti-convulsant if discharged home
List the criteria for a CT head in those with headache
Red Flags
- Onset after age of 50
- Sudden onset headache
- Headache with change of increased frequency or severity
- New onset headache in high risk population
- Headache with systemic illness
- Focal neurological deficits, confusion, LOS
- papilledema
- head trauma
- headache during pregnancy
Worsening headache despite therapy
Onset with exertion, cough, sexual activity
Orbital bruit
Family Hx of structural lesion
Discuss the presentation and management of meningitis
Etiology
- strep pneumonia
- neisseria meningitidis
- hemophilus influenza
Presentation
- triad of headache, fever, stiff neck
- photophobia
- seizure
- petechial rash in meningitis
- cranial nerve abnormality if involve brainstem
- nuchal rigidity
- positive Kernig (thigh and knee at 90 and pain with resisted knee extension)
- positive Brudzinski (flexion of neck elicits flexion at hips)
Investigation
- Lumbar puncture demonstrating
- High WBC with neutrophils
- low glucose, high protein, high lactate
- Gram stain and culture
Management
- <50 IV ceftriaxone with vancomycin
- >50 and immunocompromised IV ceftriaxone, vancomycin, ampicillin
- Dexamethasone
- Intracranial pressure control
- Elevate head of bed
- control BP
- Glycerol/Mannitol if ICP >20Discuss the presentation and management of subarachnoid hemorrhage
Pathophysiology
- rupture of intracranial aneurysm bleeding into subarachnoid space
Presentation
- Sudden onset, no prodrome
- Thunderclap headache
- Loss of consciousness
- Nausea/Vomiting
- Irritation of meninges so can have meningitis signs
Investigation
- CT head showing diffuse blood in subarachnoid space
- Lumbar puncture if CT negative but high clinical suspicion
- high RBC count in first and last tube
- xanthochromia
Management
- Surgical clipping or endovascular coiling
- Lower blood pressure with IV labetalol
- monitor in hospital for 1-2 weeks for any complications
- rebleeding
- hydrocephalus
- vasospasm leading to ischemic stroke
Discuss the diagnostic criteria for migraine without aura
At least 5 attack fulfilling 2-4 criteria Headache attackes lasting 4-72hrs Headache has at least 2 of the following - unilateral - pulsating quality - moderate to severe pain intensity - aggravation by or causing avoidance of routine physical activity During headache have at least one of - nausea/vomiting - photophobia and phonophobia
Discuss the diagnostic criteria for migraine with aura
At least two attack fulfulling 2 and 3
One or more of the following fully reversible aura symptoms
- visual (scintillating scotoma)
- sensory (paresthesia, numbness)
- speech and/or language
- motor
- brainstem
- retinal
At least 3 of the following
- at least one aura symptom spreads gradually over >5 minutes
- two or more symptoms occur in succession
- each individual symptom lasts 5-60 minutes
- at least one aura is unilateral
- at least one aura symptom is positive
- aura is accompanied or followed within 60 minutes by headache
Discuss the treatment for migraines
Acute - Mid to Moderate - NSAID Ibuprofen 400mg Q4-6H - antiemetic Acute - Moderate to Severe - Triptans (sumatriptan 6mg SC) - Ergotamines - Prochlorperazine 5-10mg IM/IV - Antiemetics (metaclopramid 10mg IV - diphenhydramine 10-20mg as well to prevent acute dystonia) - Fluids
Discuss the differential for Delirium
I WATCH DEATH
- infection (UTI, pneumonia)
- Withdrawal (alcohol, benzodiazepines)
- Acute metabolic disorder (electrolyte imbalance, kidney or renal failure)
- Trauma
- CNS pathology (stroke, hemorrhage, tumour)
- Hypoxia
- Defieciences (thiamine, vitamin B12)
- Endocrinopathies (thyroid, glucose, adrenal)
- Acute vascular
- Toxins, substance use
- Heavy metals
Discuss the diagnostic criteria for delirium
Disturbance in attention or awareness
- change in baseline
- reduced ability to focus, sustain and shift attention
- in awareness with reduced orientation to environment
Disturbance is acute and fluctuates
Cognitive decline in any domain
No other condition or substance
Discuss the management of delirium
History - baseline function - time course of cognitive change - medical conditions - medications (gravol, benzodiazepines, and susbtances) - collateral Investigations - CBC - electrolytes - calcium - magnesium - phosphate - TSH - folate - vitamin B12 - glucose - creatinien, urea - liver enzymes - urinalysis and culture - ECG - CXR Reverse Cause - correct sensory deficits - monitor constipation and urinary retention - fluids and nutrition Control Symptoms - behavioural management - family to visit - mobilize - prefered language with clear and simple communication - haldol 0.5-1mg with max of 3-4mg/24hrs until sedation achieved and then maintenance for 24 hours - atypical antipsychotics (must do ECG where QTc >450 or >25% increase from baseline then discontinue) - Benzodiazepines used in elderly to prevent QTc prolongation
