Ross - common Neuro complaints Flashcards
What is a “FAST” exam?
FAST or Cincinnati scale is a prehospital stroke scale F - Facial droop A - Arm Drift S- Speech T - Time of onset (must get exact time)
If a patient has focal weakness what should be your first consideration
It is from a neurological origin
i.e. CVA, MS, CN palsy, Guillain Barre, ETC
What is Guillain Barre…
A post-infectious polyneuritis causing autoimmune demyelination
Condition that causes ascending Paralysis, loss of deep tendon reflexes but sensation is preserved
Guillain Barre syndrome
acute flaccid paralysis that ascends quickly
24hrs
Condition that occurs 3-4 weeks after a viral infection. What is the most common cause of that infection?
Guillain Barre Syndrom
Camphylobacter jejuni
But can also occur after previous GI illness, mycoplasma infection, post vaccination
Treatments for Guillain Barre syndrome?
Consider CT - rule out intracranial event (can be done with history)
Lumbar Puncture - elevated protein, no WBC in CSF
Admit - monitor respiratory status (NIP test)
Plasmapheresis - filters out antibodies
IVIg
True or False: Bell’s palsy only causes weakness in the lower half of the face.
False: causes weakness of entire face (including forehead)
True or False: Bell’s palsy never have taste difficulties or ear pain.
False: BP may have taste difficulties and/or ear pain
What other neurological deficits will present in a patient with Bell’s palsy?
none. No other neurological deficits are present with isolated BP
True or False: Bells palsy has an acute onset, usually develop over 24-48 hours.
True
Name one way to differentiate Bell’s palsy from a CVA.
Forehead sparing. A CVA will spare the forehead because each 7th nerve nuclei innervate both sides of the forehead
Should a 68 yo person with suspected Bell’s palsy get a CT scan?
Yes. People over the age of 50 should get a CT to assess for CVA. MRI is also an option
Treatments for Bell’s palsy
Protect the eye (they are unable to close it)
Consider steroids and acyclovir if 1-4 days within start of symptoms
If persistent 6-8 weeks consider MRI
Which organism produces Botulism Toxin?
C. botulinum
What TOXIN inhibits acetylcholine release from pre-synapse at neuromuscular junction?
Botulism toxin
What are the 4 D’s of botulism?
1) diplopia
2) dilated eyes
3) dysphagia
4) descending flaccid paralysis
What are the 3 types of Botulism?
Food born - mainly from home canned goods
Wound form - IV drug users, incubation of 10 days
Infant form - constipation, feeding difficulties, weak cry
Treatment for Botulism
Antitoxin - binds to neurotoxins and prevents binding to NMJ
Admit to hospital for monitoring - especially respiratory status
Peds may use Botulinum immune globulin BIG-IV
Causes Descending paralysis
Botulism
Bacteria that causes Tetanus
Clostridium tetani
Found in soil infected wounds
This pathology starts by causing lockjaw and them moves down
Tetanus
How does clostridium tetani cause lockjaw?
Bacteria produces toxin tetanospasm by inhibiting the inhibitory neurotransmitter Glycine at the motor nerve endings
You have a person with a very dirty wound at high risk for tetanus. Within how many years should they have had a tetanus shot?
5 years
Immunization lasts 10 years but for high risk it is within 5.
Farmer cuts his hand and then falls into the cow pile next to the fence. He has never been immunized for tetanus what should the treatment be?
Needs tetanus immunoglobulin AND tetanus immunization.
True or False: Die Hard is a Christmas movie?
Yes no other answer is acceptable
Large Vessel CVA’s have a mortality of…
40%
Ischemic stokes account for what % of CVA’s
80%
Hemorrhagic strokes account for what % of CVA’s
20%
CVA’s are caused by
Atherosclerosis Either Thrombosis (plaques in the arteries) or emboli
The minimum cerebral blood flow the brain needs is ..
750ml/min
What cerebral blood flow amount indicates brain death?
Below 60 ml/min
These types of strokes usually present with pure motor or sensory deficits; usually associated with chronic HTN.
Lacunar strokes
What are the 4 large vessels of the brain?
Anterior cerebral artery
Middle cerebral artery
Basalar artery
posterior cerebral artery
True or false: tPA is very helpful in treating lacunar strokes?
False. tPA not really helpful
Areas most commonly impacted by lacunar strokes.
small penetrating vessels of
basal ganglia
internal capsule
upper brain stem (lenticulostriate arteries)
Examples of Stoke mimics
diabetic - low blood sugar seizure - postictal, Todds paralysis Complex Migraines Bell's palsy Brain tumor infection MS Conversion disorder
4 main risk factors for CVA
HTN
Smoking
DM
known atherosclerosis
Exam used to assess CVA’s (not the FAST)
NIHSS
National institutes of health stroke scale
True or false: tPA can be given up to 5 hours after onset of symptoms.
False. tPA can be given within 3 hours and 4 if at stroke center
What at the 6 must haves before admin of tPA?
non-contrast head CT - read by radiologist NIHSS score Make sure no stroke mimics Blood pressure under control Go though exclusion criteria Get consent from patient / family
What is the mechanism of action of tPA
Breaks up fibrin clots by plasmin activation
Controversy of tPA
2% mortality rates in those receiving the drug due to ICB
Which large vessel would you suspect if a patient could not move their leg?
Anterior cerebral
Which large vessel would you suspect if a patient presented with face / arm paralysis, gaze towards defect, and homonymous hemianopsia?
Middle cerebral
In CVA’s localized to the areas of posterior circulation what signs / symptoms would you expect?
Impaired vision, visual agnosia and 3rd nerve palsy
can have LOC
impairment of thought process
Contralateral motor/sensory loss in limbs and facial sensory findings (pain/temp) are indicative of what area of infarct?
Cortical infarcts
In brain stem infarcts what location would you get deficits?
Crossed findings - Left limbs and Right arm (visa versa)
A lesion in this area would cause coma, miosis, and gaze paralysis
Pontine lesion
This type of brain lesion would result in dizziness, nausea, and difficulty standing.
Cerebellar lesion
While waiting to get your patient to CT for a suspected CVA what general treatments would you provide?
Oxygen / airwary management - prevent hypoxia
address any hypoglycemia - give glucose if needed
HTN management - Labetalol
Head of bed - 30 degrees
No PO fluids
Transient episodes of neurologic dysfunction caused by ischemia of spinal cord, retina or CNS with infarction are called.
Transient ischemic attacks
10% of TIA patients develop _____ _______ ______ within 3 months, half of them within the first 48 hours
Acute ischemic stroke
ABCD2 scale for hospitalization
Age > 60 Blood pressure >140/90 Clinical feature unilateral motor Duration: greater than 60 min Diabetic
Which medciation should a patient be on “for life” after suffering a TIA?
Asprin. Reduces mortality and morbidity
The #1 risk factor for hemorrhagic bleeds?
Anticoagulation (Warfarin)
Are from which more subarachnoid bleeds originate?
5 ARM STAR OF DEATH!!!! or circle of willis
What is the gold stardard diagnostic test for Subarachnoid hemorrhages?
Lumbar puncture
Pt reports sudden onset of “worst headache of my life” and possibly began during exertion or valsalva is experiencing what time of event?
Subarachnoid hemorrhage
Meningitis / brain abscess have which classic symptoms?
Photophobia, neck stiffness, fever
Limitation or pain with eye movments can be caused by?
Cavernous sinus thrombosis
Red flags of new onset HA after age 50 could indicate?
glaucoma
temporal arteritis
Intracranial lesion
Work up for first time headache or red flag headache?
Electrolytes, CBC
CT head with and without contrast - masses or blood
Subarachnoid bleeds need LP
CT angiogram
MRI - bad for acute blood but good for tumor, masses, small strokes
Pt with fever, HA, and RAPID DECLINE you should consider _______ _______
Herpes enchephalitis
Cluster Headaches
Age 2-50 M>F Periorbital pain and unilateral tearing, nasal discharge and conjunctival irritation can have ptosis Treatment is with 100% O2
ICH pseudo tumor
Typically female Overweight HA for months Papilledema CT / MRI normal Need LP to measure opening pressure
A clear definition of migraine is..
3 attacks in 6 months
A sphenopalatine ganglion block is used to treat?
Migraines
Dopamine agonist treatments for migraine
Prochloperazine (Compazine)
Metoclopramide (Reglan)
5-HT agonist for migraine
Erogtamine, sumatrytphan DHE 45
Steroids for migraine
Dexamethasone (Decadron)
Anti-inflammatory for migraine
Ketoralac (Torodol)
Treatment for Temporal arteritis
biopsy and steroids immediately
Which type of seizure is the most concerning and causes changes in mental status?
Tonic-clonic
Which type of seizure is this: Brief eposodes of unresponsiveness usually no motor activity. Pt does not remember the event
Absence seizure
True or false: partial seizures have bilateral tremors and loss of consciousness.
False. Usually does not cross midline. There is no change in mental status
What is the most common mimic of a seizure?
Syncope
SICK DRIFTER for DDx of seizures
Substrate infection cation's (Na, Ca, mag) Kids (eclampsia) drugs rum (alcohol) Illness (chronic seizure disorder) Fever Trauma Extra toxins Rat poison
True or false: Todds paralysis causes bilateral deficits
false. Unilateral. Todds paralysis is a residual neuro deficit occurs after a seizure
True or false: First time seizures need an urgent full work up.
True
ED seizure workup for first time or atypical seizures
Head CT, CMP, LFT’s
Lactate, prolactin (both will be increased after a seizure)
Consider tox screen, ETOH
Acute Seizure medications
Potentiate Gaba –Benzodiazapines
- -Lorazapam 0.1 mg/kg
- -diazepam 5-10mg q4min up to 30
Inhibition of Na dependent action potentials
- -phenytoin: 20mg/kg
- -phosphenytoin 20mg/kg
Inhibition of Ca channels
- -valproic acid
- -gabapentin
When a patient does not return to baseline mental status before another seizure starts or if a seizure lasts more than 5 min
Status Epilepticcus
Treatment for status epilepticcus
Oxygen, ECG monitor, keep safe
Glucose
Lorezapam (ativan) 0.1mg/kg IVP
True or false: You should treat eclampsia seizures with Magnesium and Benzodiazapines
True. Eclampsia presents with seizures, proteinuria, and edema.
May occur up to 8 weeks post partum
PRES syndrome
Posterior reversible encephalopathy syndrome
- -seizures
- -AMS
True or false: Simple febrile seizures longer than 15min
False. Simple febrile seizures <15min duration age 6months - 5 years Otherwise healthy Key - child had fever and the mental status is normal a few min after the seizure
Complex febrile seizures features
Duration >15 min
Any focal neurological features after or during seizure
outside age range (6month -5year)
Work up for peds 1st time seizure
Check glucose!
CBC, blood culture, metabolic panel, LP
Exam preformed to assess for CVA (not the FAST)
NIHSS
national institutes of health stroke scale
True or false: tPA can be given within 5 hours of symptom onset?
False. tPA must be given within 3 hours, 4hours at stoke centers
The 6 must haves before giving tPA?
Non-contrast head CT NIHSS score Make sure no stroke mimics Blood pressure under control Go though exclusion criteria get consent from patient / family
