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Emergency Medicine > non-traumatic neurological complaints in the ED > Flashcards

non-traumatic neurological complaints in the ED Flashcards

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1
Q

big question if you suspect a seizure

A

primary: without provocation-epliepsy
secondary: response to something

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2
Q

what does a post ictal state look like both in presentation and specifically with regards to chemistry panel

A

Disorientation, sleepy, amnesia, HA,

lactic acidosis (from the clonic muscle movements)

high PC02 metabolic acidosis

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3
Q

how long does a post ictal state last

A

Commonly lasts 30min-1hr – LOC gradually improves

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4
Q

grand mal seizures have been replaced by

A

generalized seizures

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5
Q

tell the store of a generalized convulsive seizure

A

the person experiences LOC

tonic movement followed by clonic

resolves spontaneously with post ictal state

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6
Q

rhythmic jerking of seizure pt

A

clonic phase

if they bit down they can
swallow it and swallow

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7
Q

what can you see that would point to a generalized seizure in a pt that has loc

A

stigmata of a seizure

urinary incontinence and tongue biting

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8
Q

generalized non-convulsant seizures

A

aka absense

like daydreaming

lasts seconds

formerly petit mal

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9
Q

simple partial seizure is now known as

A

focal aware seizure

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10
Q

three things key in focal aware seizure

A

awareness consciouness and memory preserved

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11
Q

sxs of focal aware seizures

A

Awareness, memory, consciousness is preserved

Uncontrolled movement, visual, auditory sx, autonomic sx’s

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12
Q

focal impaired awareness seizures aka

A

used to be a complex partial

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13
Q

focal impaired awareness

A

déjà vu,
jamais vu (You are in your house but you don’t know where you are; the familiar becomes the unfamiliar), sounds,
smell (“who is smoking a cigar right now? Nobody, we are in church”),
taste,
numbness,
automatisms,
fear/panic

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14
Q

Partial what is this and what are the 2 types

A

Limited area of brain

Sx’s match area affected

simple and complex or focal imparied and focal aware

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15
Q

Status Epilepticus

A

Seizure activity lasting > 5min

or repetitive seizures without CLEARING of mental state in between

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16
Q

what is the probelm with seizing for more than 5 minutes

A

Seizures >5min are unlikely to spontaneously resolve

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17
Q

Often result of secondary cause, so start looking… with status epilepticus

A

Electrolytes (especially: glucose (hypoglycemic), sodium, magnesium (hypomagnesemic))

Intracranial bleed, trauma

Tox, OD-until it is eliminated will not stop

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18
Q

status epilepticus tx

A

ABORT seizure before neuronal injury occurs

Benzodiazepines FIRST

THEN 2nd or 3rd line drugs (Dilantin, Phenobarb, etc)

these people are often intubated because they are not breathing

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19
Q

concerns with paralyzing someone

A

need to for intubation but can’t tell if your pt is still seizing

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20
Q

Most common cause of seizures in EDMost common cause of seizures in ED

A

Out of meds? Most common cause of seizures in ED

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21
Q

Hx of a seizure

A

have you ever had this before
if you have epilepsy is the pattern changing?

Trauma Hx?
people that see fall with abandon

Substances used?

recent illness?

LMP?

Country of origin

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22
Q

seizure after trauma

A

concern for internal bleeding in the brian

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23
Q

why are we worried about substance abuse with seizing

A

lack of alcohol can cause seizing

if you are too sick to get alcohol you need to know

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24
Q

why are we asking lmp in a female pt

A

do not want to miss pre eclampsia

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25
Q

PE with seizure

A

Post-ictal or still seizing?

ABCDE’s first

VS should improve with recovery

Tongue trauma, urinary incontinence

AND head to toe exam

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26
Q

what is the head to toe exam in a pt with a seizure

A
  • Trauma
  • Neuro deficit
  • Infection
  • Evidence other Dz
  • Stigmata of EtOH
  • Toxidrome
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27
Q

Red flags in a seizure

A

First seizure: Why??

Head trauma: Bleed, ICP

VS not resolving: Why??

Alcohol withdrawal (these folks are SICK – ICU admit)

Fever, infection: Need LP? Shock?

Rash: Meningitis?

Vomiting: Airway disaster, aspiration risk

Electrolytes: Which ones? Mg,

Stimulants: Bleed? CVA?

Prolonged post-ictal state: Why?

Focal neuro deficit: CVA, bleed?

Travel/Endemic area?

Neurocystercercosis

Malignancy: Mets to brain? – Often present with a first time seizure

Renal/liver Dz: Uremic or encephalopathic??

HIV: Toxo-, histo-, infection

Coumadin/Plavix: Bleed?

Pregnancy: Eclampsia

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28
Q

Head trauma with seizure concerns

A

: Bleed, ICP

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29
Q

Fever, infection:

A

LP

meningitis

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30
Q

if vomiting we are worried about

A

airway

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31
Q

Travel/Endemic area couplex with first seizure worry about

A

• Neurocystercercosis

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32
Q
  1. If history of seizures workup labs
A

a. D-stick on all, upreg
b. Observe, reassess
c. Safety: bedrails, etc
d. Measure drug levels
e. Alcohol, tox screen
f. Chem for electrolytes
ii. Sz causes lactic acidosis

Creatinine Kinase (CK) if prolonged down-time –> looking for rhabdomyolysis

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33
Q

Chem for electrolytes in a seizure where the pt has a history of seizure

A

If cause not obvious

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34
Q
  1. If first seizure
A

D-stick on all, upreg

If sz stops, pt now normal, and there is no obvious cause:

Chem panel

Magnesium, phosphorus if EtOH

EtOH, U tox

Coumadin? PT/INR

HIV test

Consider Head CT non-con

Add lumbar puncture only if fever, suspect SAH, encephalitis, etc

EEG: on admission or as outpt

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35
Q

what drug levels would we measure in a pt with a hx of a seizures

A

Dilantin, Carbamazepine, Valproic acid, Phenobarb

ii. Not: Keppra, Lamictal, etc

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36
Q

when would you be worried about rhabdomyolosis

why?

what would you order?

A

Creatinine Kinase (CK) if prolonged down-time

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37
Q

what would you do for a actively seizing pt

A

Protect pt, abort the seizure with meds

order lorazepam diazepam

When stop: suction oral blood/secretions, O2, time the event

Recheck d-stick, re-examine, cardiac monitor

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38
Q

what is the abortive treatment

A

Abortive Tx 1st line: Benzodiazepines – know 3

Lorazepam (2mg IM/IV)

Midazolam (2-5mg IM/IV),
Diazepam (5mg IV)

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39
Q

New Sz, now well and no Red Flags?

A

New Sz, now well and no Red Flags? Neurology consult to initiate EEG, tx and follow up.

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40
Q

etiology of febrile seizures

A

Rapid rise in temperature, not the number itself

Risks: hx same, family hx

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41
Q

want this on all children with a febrile seizure

A

D stick

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42
Q

• Search for source of fever or occult infection in children would involve getting a

A

CBC, Chem, UA, CXR

Blood and +/- stool culture

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43
Q

when would you get a CT or a LP in a kid with a seizure

A

No CT.

No LP if dx clear and kid looks great

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44
Q

When would you get a LP on a kid with seizures

when would you get a LP on a adult with seizures

A

recent anbx use –>LP
you’re missing whatever bug it is

kid look sick

Add lumbar puncture only if fever, suspect SAH, encephalitis, etc

if RBC are in CSF–> SAH

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45
Q

febrile seizure tx

for the most part febrile seizure are partial or generalized?

A

NOT MEDS

**
they are generalized

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46
Q

5 essential questions for syncope

A
  1. Ever had this before? What was the Dx?
  2. Really lose consciousness? Fall? Hurt yourself?
  3. What were you doing? Last thing you remember?
  4. Sick lately? Upset? EtOH, drugs?
  5. PMHx, Meds, Fam Hx, Soc Hx
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47
Q

Pseudoseizure

A 
Psych, emotional distress
•	Atypical movements
•	Brief post-ictal period
this is where you can tell 
•	Good Soc Hx
•	Refer to psych, EEG outpt

say “it’s a little inconsistent with a generalized seizure post ictal”

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48
Q

over the age of __ we are worried about syncope

A

> 50yrs

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49
Q

how does syncope look like seizure

A

brief clonic activity is a thing

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50
Q

syncope and cardiac issues might be suspected if

A

Syncope w/ exertion (critical aortic stenosis) or when supine – think cardiac

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51
Q

Red flag hx with syncope (7)

A

before/after event

a. Chest pain
b. Palpitations
c. Headache
d. SOB
e. Abd pain
f. Back pain (aortic dissection)
g. Bleeding (coumadin)

have you been recently hospitalized

melena

pace maker?

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52
Q

important recent social/family hx as it pertains to syncope

A

Recent hospitalization, surgery, procedure

Fam Hx of sudden death (Thoracic aortic Dissection, PE, cardiac arrhythmias)

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53
Q

abnormal sxs after syncope that are of concern

A

Abnormal VS
• Hypotension
• Tachy-, bradycardia
• Fever

	Diaphoresis
•	Confusion, focal deficit
•	Cardiac murmur
•	Rales, wheeze, edema
•	Melena (GI bleed)
•	Head trauma
•	Pregnancy
•	Pacemaker (issue with it itself)
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54
Q

main categories for the syncope ddx

A 
cardiac
intracerberal 
aorta
GIB/anemia
ectopic pregnancy 
pulm embolism
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55
Q

cardiac -three big causes of syncope

A

i. Arrhythmia
ii. Aortic stenosis
iii. Hypertrophic, other cardiomyopathies

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56
Q

intracerberal

A

i. Hemorrhage, SAH

ii. Ischemic stroke: rarely

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57
Q

common reasons people faint

A

a. Volume depletion – dehydration or are you bleeding from somewhere?
i. Dehydration, n/v/d
b. Medication effect
c. Drug/EtOH effect
d. Vasomotor (vasovagal)
e. Emotional event/reaction
f. Mimic – unwitnessed seizure
g. Hypoglycemia**

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58
Q

what are you worried about with the aorta that can cause syncope

A

Dissection, aneurysm, aortic stenosis

59
Q

Syncope in young, healthy, completely recovered person

A

All get:

EKG

consider D-stick (although you really wouldn’t come back if you were hypoglycemic)

Hct +/- depending on history

60
Q

Syncope in young, healthy, completely recovered person- female

A

All females (12-55yrs) get Upreg

61
Q

what is not routine for syncope in young healthy person

A

CT, CBC, Chem, troponin, etc; not routine part of w/u

unless you have red flags

62
Q

Other diagnostics driven by age, Hx, PE

A

IV hydration, O2, monitor, labs, troponin

CXR, +/-CT. Echocardiogram, Holter Monitor

c. >50yo – higher risk, more extensive work up

63
Q

Young, healthy, completely recovered, stable?-syncope

A

Young, healthy, completely recovered, stable?

Likely benign cause. Home if stable w/ return precautions

EKG and UPT

Close follow-up, PO hydration, avoid risks
>50yo – bigger work up, home if w/u all neg, no risks

64
Q

Vertigo

A

Sensation of motion, room spinning

is the room spinning or are you spinning inside the room

65
Q

what are the two types of vertigo

A

Major question for us = Central or Peripheral?

  1. Peripheral is usually benign
  2. Central causes usually serious – red flag!
66
Q

Hx of vertigo

A
  1. Describe what you feel
  2. OPQRST the sx to death
  3. Trauma, recent illness?
  4. Hearing changes, tinnitus?
  5. Headache, weakness?
  6. Associated sx’s – fever, bleeding, etc…
67
Q

can you describe peripheral vertigo

onset

nystagmus is

worse with

associated sxs?

neuro deficits ?

A

sudden onset, intense, paroxysmal, w/ movement;
nystagmus is horizontal/torsional, fatigable; tinnitus, n/v,
+/- normal TM,

NO FOCAL NEURO deficit

68
Q

BPPV -what is the cause

A

MOST common cause

Otolyth in the semicircular canal

Vertigo lasts seconds, positional

69
Q

inflammation, after viral infection can cause this type of vertgio-ear sxs

A

labrynthitis

70
Q

labrynthitis story

A

• Vertigo for days, ear/hearing sx’s

Movement exacerbates, post viral

71
Q

Vestibular Neuritis:

A

inflammation
• Vertigo for days, no ear sx’s
• Movement worse, post viral

72
Q

Story behind Meniere’s, what does it look like and what age do we see it most commonly present

A

40-70s

Episodic, chronic, incurable

SN hearing loss, tinnitus

73
Q

central causes of vertigo

A

Cerebellar CVA, hemorrhage

Vertebrobasilar vascular insufficiency/CVA

Basilar artery migraine

Multiple sclerosis

Temporal lobe seizure

74
Q

vertigo caused by drugs will be seen with

A

Drugs cause peripheral sx’s – ear sx’s predominate

75
Q

nystagmus in central vertigo

A

Nystagmus present in all: type, direction, duration matter

76
Q

peripheral vertigo presents with this type of nystagmus

A

horizontal and fatiguable

(bppv can be nonfatiguable_

77
Q

Ptosis? w/ vertigo what are you worried about (4)

A

Botulism, MG, CVA, CN

78
Q

what are you looking for in the ears with vertigo

A

Vesicles, cholesteatoma -tumor behind the eardrum, perforated TM?

79
Q

Head impulse with peripheral vertigo

A

Abnormal (saccade) suggests peripheral

80
Q

Head impulse w/ central vertigo

A

Normal in central causes

81
Q

peripheral vertigo nystagmus

A

one direction: horizontal/torsional – never vertical, fast phase away from affected ear, intensity decreases w/ fixation, fatigues on repeat

82
Q

what type of peripheral vertigo would NOT fatigue

A

BPPV may not fatigue

83
Q

nystagmus beats towards or away from affected ear with peripheral vertigo

A

away

beats towards opposite eye

84
Q

nystagmus with central vertigo

A

any direction (vertical, rotary), fast toward lesion, little effect with fixation/gaze direction change, does not fatigue

85
Q

Test of Skew

A

Cover one eye, uncover, repeat. Eye position deviation when uncover, corrects.

86
Q

positive test of skew indicated

A

b. Positive suggests central cause

87
Q

Peripheral Motor Weakness differs from central how?

A

i. Not central nervous system
1. CVA/TIA is sudden onset, unilateral
1. Slower onset, progressive, bilateral
2. Neuromuscular junction vs. muscles
3. Respiratory compromise concerns

88
Q

PE of peripheral motor weakness

A
  1. Strength testing
  2. DTR’s: +2 is normal
  3. Cranial nerves
  4. Sensation testing
  5. Cerebellar testing
89
Q

Most common cause of
acute
bilateral
flaccid paralysis

A

v. Guillain-Barre

90
Q

story of Guillain-Barre

A

Autoimmune, demyelinating, progressive, symmetrical

91
Q

paralysis with guillain barre starts with

A

Ascending pattern – legs first

loss of DTR

92
Q

grade 1 strength

A

a trace of contraction is noted in the muscle by palpating the muscle while attempting to contract

93
Q

the pt may move muscles against gravity but not resistance form the examinar with the grade of strength

A

grade 3

94
Q

the patient is able to actively move the muscle when gravity is eliminated

A

grade 2

95
Q

the patient may move the muscle agains some resistance

A

grade 4

96
Q

tx of guillaine barre

A

immunoglobulins, plasmapheresis

97
Q

who gets guillane barre

A
  1. 2/3 have preceding viral illness (also Zika, etc)

a. 1/6 GB cases after Flu shot

98
Q

what sxs do you see with GB

A

Hand paresthesia, muscle pain, may involve CN’s

99
Q

what are we concerned about with GB

A

Dx is clinical; worry about respiratory issues, dysautonomia

Neurology consult. Admit.

100
Q

Most common disorder of neuromuscular transmission

A

MG

101
Q

MG is seen most commonly in the population

A

Bimodal peak: 30’s (female predominant), 80’s (male)

102
Q

SXS of MG

A

Eye, facial, swallowing, speech muscle sx’s predominate

Bilateral or unilateral ptosis, diplopia, vision changes

Peek sign: close eyes –> can’t maintain, can see sclera

Flat expression, “lost their smile”

Gets “tired” talking, chewing fatigue, difficulty swallowing

Generalized weakness, fatigue, can’t climb stairs

103
Q

DTR w/ MG

A

intact

104
Q

botulism pt looks like

A

IVDU with eye sxs, facial sxs, weakness

105
Q

what is the key to MG

A

Key: sx’s get worse with use, better with rest

Descending, DTR’s intact

ED Dx:
Tensilon (Enlon)/ edrophonium test, ice pack test (their strength comes back but when their eyes warm up their deficit comes back).
Neuro consult, Admit.

106
Q

sx of botulism

A

Sudden, severe, symmetric, bilateral weakness – eyes, face, neck first; extremities last

Mental status, sensory intact

Infants: floppy, lethargic

107
Q

tx of botulism

A

These pt’s are sick: recognition is key, respiratory concerns

Tx: Antitoxin, supportive care. Neuro consult. Admit

108
Q

Young, female > male, autoimmune?

A

MS

look for monocular vision changes

need labs LP and mRI

Episodic weakness, paresthesias, disequilibrium – atypical pattern
109
Q

Abrupt, progressive, bilat, proximal muscle weakness – legs usually before arms

  1. Can’t rise from chair, brush hair, lift, etc

May have dysphagia

A

Polymyositis

110
Q

Must consider this Dx in anyone w/ low back pain!

A

Cauda Equina Syndrome
Transverse Myelitis
Spinal epidural abscess

111
Q

Cauda Equina Syndrome sxs

A

Symptoms: Unilateral or bilateral radicular back pain with:

True leg weakness, bilat or unilateral

Bladder incontinence or retention, hesitancy

Stool incontinence, loss of anal tone

Numbness in the “saddle” and perineal distribution; genitals

Loss of or reduced lower extremity DTR’s

. Charting should reflect all of above in low back pain pt’s

“SENSORY IS INTACT in the b/l lower extremities INCLUDING the saddle region”

112
Q

cause of Cauda Equina Syndrome

A
  1. Cause: mechanical compression on “horse’s tail”

a. Disc, fracture, infection, tumor

113
Q

IVDU with fever + back pain, radicular sx’s

need to think about

A

Spinal epidural abscess

114
Q

picture of transverse myelitis

A

Bilateral motor and sensory loss w/ radicular back pain, B/B dysfunction/incontinence, sensory changes

rapidly progressively

115
Q

Low K+, Fam Hx, meds (diuretics)

Weakness local or generalized

Descending, DTR’s diminished

A

Hypokalemic Periodic Paralysis

116
Q

Hypokalemic Periodic Paralysis triggers

A

Triggers: carbs, cold, exercise

117
Q

Tick Paralysis looks like

A
  1. Suggestive Hx
  2. Ascending, DTR’s diminished
  3. Remove tick – resolves 24-48hrs
118
Q

“Saturday Night Palsy” can’t do what

A

stop in the name of love

119
Q

tx of “Saturday Night Palsy”

A

vi. Splint with wrist in extension
1. Resolves weeks to months
vii. Consider occult Fx
viii. Referral to PMD, neurologist

120
Q

CN VII mononeuropathy

A

b. Bell’s Palsy

121
Q

how do you know bells from stokre

A

persons forehead is involved in bells

in CVA the forehead is spared

122
Q

Bell’s Palsy need a

A

ear exam

123
Q

Diplopia can be caused by

A

cranial nerve palsy III, IV, VI

124
Q

who gets diplopia

A

Idiopathic, traumatic; central: tumor, etc vs. peripheral: vascular (DM, vascullitis), cavernous sinus thrombosis

125
Q

what do you need to do with pt w suspected palsy

A

need to isolate what is wrong (look at the chart)

3 and 6 is the most common

  1. Monocular or binocular? Evoke the diplopia
  2. Do the eyes line up on EOM’s/cover test?
  3. Ptosis? Pupils?
126
Q
  1. Ptosis, “down and out” gaze, non-reactive, dilated pupil
A

iv. CN III – occulomotor – DM, temporal arteritis

127
Q
  1. “head-tilt” to opposite shoulder to avoid diplopia, eye “down and away”
A

v. CN IV – trochlear – rare, idopathic, kids

128
Q
  1. Lose lateral gaze, horizontal diplopia, cover affected eye – diplopia resolves
A

vi. CN VI – abducens – DM, increased ICP

129
Q

what should you consider with palsy

A

: Lupus, Lyme’s, Botulism, Wenicke’s, Syphilis, Thyroid, Vit B Deficiency too
ix. Labs, CT head/face

130
Q

most common location of a focal impaired awareness seizure

A

temporal lobe

131
Q

Drug induced causes of vertigo will most likely present with

A

ear sxs predominate

132
Q

very rare tumor that can be the cause of vertigo

A

cerebellar pontine angle tumor

133
Q

vertigo tx

A

labs no necessary for peripheral

antiemetics
antihistamines
benzodiazepine

safety return precautions

epley in ED
semont at home
ENT refereal if reoccurent or hearing loss findings

134
Q

central vertigo tx

A

w/u is necessary

MRI

135
Q

UMN findings

A

hyper-reflexia
muscle tone: increased spastic
no fasiculations
no atrophu

babinski present

136
Q

LMN findings

A

hyporeflexive

decreased or flaccid muscle tone
fasiculations
severe atrophy
and absent babinski

137
Q

RF for transverse myelitis

A 
Risks: 
Herpes
MS
vasculitis
Lyme dz 
TB
IVDU
IMZ
138
Q

polymyositis

A

abrupt
progressive
bilat
proximal muscle weakness

USUALLY legs before arms

139
Q

polymyositis common lab finding

A

increase CK
increase aldalase
Anti-JO1 antibody

DYSPHAGIA
HYSPHONIA
Proximal abrupt and progressive b/l weakness

legs usually before arms
cna’t prush hair

140
Q

dermatomyositis sxs

A

similar to polymyositis but with race to face chest and upper back in a shawl pattern

141
Q

Tx for guillane Barre

A

immunoglobulins and plasmapharesis

142
Q

age of MG pts

A

bimoda;

30s and 80s

143
Q

what motor weakness syndromes would lead to a loss of DTRs

A

guillan barre- ascending
tick paralysis ascending (diminished)
hypo kalmeic paralysis (diminished) -descending
cauda equina (diminished

144
Q

what would be an essential hx question to ask in a pt suspected of hypokalemic periodic paralysis

A

usually on diuretics

triggered by cold or carbs or exercise

Emergency Medicine (28 decks)

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