Non-trauma Neurology Flashcards
1
Q
Seizures
A
Really common – huge DDx
-The big question: Hx of same or first seizure?
Primary vs. Secondary seizure
- Primary: occurs w/o provocation/cause - epilepsy
- Secondary: response - toxic, metabolic, infectious, traumatic, vascular, neurologic, etoh withdrawal, eclampsia, fever, etc
Post-ictal state
- Disorientation, sleepy, amnesia, HA, sonorous breathing, diaphoresis, lactic acidosis (high TCO2 on chem panel)
- Commonly lasts 30min-1hr – gradually improves to normal
2
Q
Generalized seizure - convulsive
A
- Formerly “grand mal”
- Involves both hemispheres
- Loss of consciousness, amnesia
- Tonic then clonic movements
- Tonic: stiffen, arch back, cry out
- Clonic: rhythmic jerking bilat arms/legs, facial grimace, clench teeth
- Urinary incontinence, tongue biting
- Resolve spontaneously, post-ictal state
3
Q
Generalized seizure - non-convulsive
A
- Absence Sz – formerly “petit mal”
- More common in kids
- “Daydream”, +/- LOC, +/- clonic sx’s
- Lasts seconds – can go on as if nothing happened – no post-ictal state
Urinary incontinence and tongue biting are common if a generalized seizure occurred – helps determine if a seizure has occurred for someone who doesn’t remember and was alone
4
Q
partial - 2 types
A
- Limited area of brain
- Sx’s match area affected
5
Q
focal aware seizure (simple partial)
A
- Awareness, memory, consciousness is preserved
- Uncontrolled movement, visual, auditory sx, autonomic sx’s
6
Q
focal impaired awareness seizure (complex partial)
A
-Any of: awareness, memory, consciousness is not preserved
-Temporal lobe Sz most common
-Aura common – déjà vu, jamais vu, sounds, smell, taste, numbness, automatisms, fear/panic
-Deja vu – unfamiliar is familiar
-Jamais vu – the familiar is unfamiliar (“who’s house is this?” this is your house!)
-Focal aware: THEY ARE AWAKE and watching their strange movements
Don’t need to know ECG pattern
-Why do we need to know which type of seizure? You need to be able to recognize the family’s description of what happened
7
Q
Status epilepticus
A
- Seizure activity lasting > 5min or repetitive seizures without clearing of mental state in between
- Life-threatening – airway compromise
- Seizures >5min OR seizures that don’t have a clearing of mental state inbetween!! are unlikely to spontaneously resolve
- Often (almost always) result of secondary cause, so start looking…
- Get D-stick right away – hypoglycemia is often the cause of status
- Electrolytes (especially: glucose, sodium, magnesium)
- Intracranial bleed, trauma
- Tox, OD
- Goal after ABC’s: abort seizure before neuronal injury occurs
- Benzodiazepines 1st. Then 2nd or 3rd line drugs (Keppra, Valproic Acid, Fosphenytoin, Phenobarb, etc)
- Intubation common because they are not ventilating during the seizure but remember – can’t see seizure if paralyzed – you have to be very careful!
8
Q
Seizures: Hx and PE
A
History
- Ever seized before?
- Yes? Changing pattern?
- Out of meds? Most common cause of seizures in ED
- Witnesses: how long, how many?
- Trauma – before, after
- Head, tongue, extremities
- EtOH? Drugs?
- Stop? Why??
- Recent illness? LMP?
- Country of origin, travel
PE
- Post-ictal or still seizing?
- ABCDE’s first
- IV, O2, monitor
- VS improve with recovery
- Tongue trauma, urinary incontinence
- Head to toe exam
- Trauma
- Neuro deficit
- Infection
- Evidence other Dz
- Stigmata of EtOH
- Toxidrome
- When the pattern in true epilepsy changes, that means your meds need to be changed
- Seizure after trauma is concerning for brain bleed
- LMP? Don’t want to miss eclampsia
9
Q
Seizure red flags
A
- First seizure: Why??
- Head trauma: Bleed, ICP
- VS not resolving: Why??
- Alcohol withdrawal
- Fever, infection: Need LP? Shock?
- Rash: Meningitis?
- Vomiting: Airway, aspiration risk
- Electrolytes: Which ones?
- Stimulants: Bleed? CVA?
- Prolonged post-ictal state: Why?
- Focal neuro deficit: CVA, bleed?
- Travel/Endemic area?
- Neurocystercercosis
- Malignancy: Mets to brain?
- Renal/liver Dz: Uremic or encephalopathic??
- HIV: Toxo-, histo-, infection
- Coumadin/Plavix: Bleed?
- Pregnancy: Eclampsia
10
Q
seizure work-up if pt has history of seizures
A
- D-stick on all, upreg
- Observe, reassess
- Safety: bedrails, etc
- Measure drug levels
- Dilantin, Carbamazepine, Valproic acid, Phenobarb
- ?Keppra, not Lamictal, etc
- Alcohol, urine tox screen
- Chem for electrolytes
- If cause not obvious
- Sz causes lactic acidosis
- Creatinine Kinase (CK) if prolonged down-time
11
Q
seizure work-up if this is the first seizure
A
- D-stick on all, upreg
- If sz stops, pt now normal, no obvious cause:
- Chem panel
- Magnesium, phosphorus if EtOH
- EtOH, U tox
- Coumadin? PT/INR
- HIV test
- Head CT non-con
- Add lumbar puncture only if fever, suspect SAH, encephalitis, etc
- EEG: on admission or as outpt
12
Q
seizure tx
A
- Active tonic/clonic seizure in ED
- Protect pt, abort the seizure with meds
- When stop: suction oral blood/secretions, O2, time the event
- Recheck d-stick, re-examine, cardiac monitor
- Abortive Tx 1st line: Benzodiazepines – know 3
- Lorazepam (2mg IM/IV)
- Midazolam (2-5mg IM/IV), Diazepam (5mg IV)
- Hx seizure? Give regular med in ED – refill meds, f/u
- New Sz, now well and no Red Flags? Neurology consult to initiate EEG, tx and follow up.
- Alcohol related sz’s are not prevented with meds
- Alcohol related seizures are NOT prevented with meds. Phenobarbital is the longest lasting and has the best chance of preventing alcohol related seizures but its not reliable!
13
Q
febrile seizure in kids
A
- Rapid rise in temperature, not the number itself
- Risks: hx same, family hx
- Get a d-stick on all
- Search for source of fever or occult infection
- CBC, Chem, UA, CXR
- Blood and +/- stool culture depending on whether or not they have diarrhea
- No CT. No LP if dx clear and kid looks great
- Yes LP if recent abx use
- LP, +/-CT if kid looks sick
- Clear Dx = no anti-sz meds
14
Q
eclampsia seizures
A
- Usually >20wks
- Get a Upreg!
15
Q
alcohol withdrawal siezure
A
- Common but dangerous
- Tx w/d agressively
- Admit
16
Q
pseudoseizure
A
- Psych, emotional distress
- Atypical movements
- Brief post-ictal period
- Good Soc Hx
- Refer to psych, EEG output
17
Q
syncope
A
- Transient LOC, loss of postural tone with spontaneous recovery
- Brief clonic activity common – mimics seizure
- Loss of cerebral perfusion leads to loss of O2 and glucose needed by the brain and RAS to function
- DDx is large; most benign, some life threatening
- Hx is key – drives work up (like everything else…)
- Ever had this before? What was the Dx?
- Really lose consciousness? Fall? Hurt yourself?
- What were you doing? Last thing you remember?
- Sick lately? Upset? EtOH, drugs?
- PMHx, Meds, Fam Hx, Soc Hx
- Near-syncope, “pre-syncope” – treated like true syncope
- RAS: Reticular Activating System – neuro network in the brainstem that controls level of consciousness
- There may be brief clonic activity in syncope – this does NOT mean they are seizing!! Don’t be fooled!
18
Q
syncope red flags
A
- Syncope in person >50yrs
- Syncope w/ exertion or when supine – think cardiac
- Hx – before/after event
- Chest pain
- Palpitations
- Headache
- SOB
- Abd pain
- Back pain – thoracic aorta dissection
- Bleeding (coumadin)
- Recent hospitalization, surgery, procedure
- Fam Hx of sudden death
- Syncope PE findings:
- Abnormal VS (Hypotension, Tachy-, bradycardia, Fever)
- Diaphoresis
- Confusion, focal deficit
- Cardiac murmur
- Rales, wheeze, edema
- Melena
- Head trauma
- Pregnancy
- Pacemaker
