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Medical Conditions > Week 3 - Neurological Emergencies > Flashcards

Week 3 - Neurological Emergencies Flashcards

1
Q

What Medical Conditions are Neurological Emergencies?

A
  • Stroke
  • TIA (Transient Ischemic Attack)
  • SAH (Subarachnoid Haemorrhage)
  • Seizures
  • Syncope (loss of consciousness)
  • Cauda Equina Syndrome:

(a rare spinal condition that occurs when the nerves at the end of the spinal cord are compressed)

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2
Q

how many deaths in UK attributed to stroke?

A

11%

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3
Q

How many people in the UK currently living with the effect of a stroke?

A

900,000

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4
Q

Risk factors for stroke?

A
  • previous DVT
  • smoking
  • obesity
  • hypertension
  • diabetes
  • chronic cardiovascular conditions
  • atherosclerosis (thinning if arteries and veins)
  • Atrial Fibrillation (AF)
    -Age
  • gender (men more likely to have stroke at younger age. Women at increased risk due to medicines such as contraception.
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5
Q

Why can Atrial Fibrillation be a risk factor for a stroke?

A

atria does not contract and push blood to ventricles.

Atria quivers -> this causes stasis and means blood starts pool, which leads to:

blood congealing and clotting. It then shoots out of the heart, through the aorta and can end up in the brain, resulting in a stroke.

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6
Q

Define stroke?

A

‘Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global
neurological disturbance which lasts more than 24 hours or leads to death.’ NICE, 2020

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7
Q

What is Focal neurological deficit?

A

A symptom of a stroke that affects a specific part of the body, such as the face, arm, or tongue.

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8
Q

Approximately how many strokes are Ischaemic and how many are Haemorrhagic?

A

Ischaemic = 8.5% of strokes

  • Haemorrhagic = 15% strokes

(NICE, 2020)

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9
Q

Clinical Signs/Symptoms of a Stroke?

A
  • Confusion, TLoC, altered level of consciousness, coma.
  • Headache; usually appears suddenly and may be associated with neck stiffness. SENTINAL HEADACHES may occur in the weeks preceding (known as minor leaks/aneurysm)
  • Sensory loss; paraesthesia or numbness
  • Visual problems; DIPLOPIA
  • Speech problems; Dysarthria or Dysphasia
  • Dizziness, Vertigo, loss of balance.
  • Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
  • Difficulty with fine motor coordination.
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10
Q

What is Hemiplegia?

A
  • characterized by Paralysis on one side of the body
  • caused by nervous system injuries.
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11
Q

What is Hemiparesis?

A
  • Characterized by weakness on one side of the body.
  • Caused by nervous system injuries.
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12
Q

FAST test for stroke?

A

F = Face ; is it weak/ drooping on one side of the face? Can patient use facial muscles to pull different facial expressions upon request?

A = Arms; can patient lift both arms forward, reaching a position where both of the patients hands are raised to the height of their shoulders.

S = Speech; is their speech slurred? Can they formulate proper sentences?

if these test showing signs of a Stoke:

T = Time to call 999

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13
Q

What are flaws in the FAST assessment?

A
  • Not all patients will present with typical symptoms of stroke - 14.1% in the following study did not present with any FAST symptoms. EG; in a 2017 study; Aroor et al (2017) - University of Kentucky Stroke Centre.
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14
Q

What is the BEFAST assessment?

A

B = Balance; Loss of balance? Headache or dizziness?

E= Eyes; Blurred vision?

F = Face

A= Arms

S = Speech

T = Time to call 999

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15
Q

What is a MEND assessment?

A

Miami Emergency Neurological Deficit.

-MENTAL STATUS: AVPU? Speech normal? Age? Command - can patient open/close eyes etc.

CRANIAL NERVES: Facial droop? , Visual Fields? Horizontal Gaze?

LIMBS: Close eyes and hold out both arms, do arms drift? Can patient move arm up? sensory arm and leg (close eyes and touch something upon request? can they pinch things <- this tests motor coordination.) Coordination -> finger to nose? Heel to shin?

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16
Q

Stroke Management in Pre-Hospital Care? ordered in terms of priority.

A

1) Manage ABCD

2) O2 if SpO2 below 95%, with COPD below 88%

3) NIL by mouth = patient is not allowed to eat or drink.

4) reassurance and explanation

5) Guard against secondary injuries: hypoxia, dehydration, hemiparesis

6) Access CBG and correct if Hypoglycaemic (low blood sugar)

7) 12 lead ECG

8) IV access; fluids/medications etc.

9) how much time has passed since onset of the incident? Is it under 3 hours?

10) note patients anticoagulant status (is patient on Warafin/NOAC’s (Novel Oral AntiCoagulants))?

11) Pre-alert and convey under emergency conditions to nearest ED -> REFER TO SWAST GUIDANCE

12) Note an report onset time during pre-alert

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17
Q

Stroke treatment and management in Hospital?

A

1) Straight to CT scan.

2) Scan of head using positive/negative contrasting agents.

3) Bleed or Thombo-embolic?

4) Thrombolysis/Surgery?

5) Admitted

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18
Q

What conditions can mimic a stroke? approximately how many suspected strokes do these mimics account for?

A
  • hypoglycaemia
  • Sepsis
  • Hyperglycaemia
  • Vertigo/Dizziness
  • Migraine
  • Neurological Abnormalities
  • Functional Neurology
  • Physiological disorders including anxiety
  • mass lesions such as subdural haemotoma or tumors.
  • seizures
  • physical trauma

ACCOUNT FOR APPROXIMATLEY 25% OF ALL SUSPECTED STROKES?

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19
Q

What is a TIA?

A

Transient Ischaemic Attack

“The incidence of first-ever TIA in the UK is approximately 50/100,000 people
per year.”

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20
Q

How do you tell if it is a TIA?

A

“Transient episode of neurologic dysfunction due to focal brain, spinal cord or
retinal ischaemia, without acute infarction or tissue injury”

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21
Q

Psychophysiology of a TIA?

A
  • Typically lasts less than an hour
  • usually only lasts a couple of minutes
  • definition of a TIA has moved from Time based - > Tissue Based

SWAST definition of a TIA:

“Where the focal and subtle neurological signs and symptoms have completely resolved
when they are assessed by the clinician”

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22
Q

What assessment are used to initially diagnose (provisional diagnosis) a TIA?

A
  • FAST
  • MEND
  • Full neurological examination including cranial nerves.
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23
Q

ABCD2 Score assessment?

A

A= age
B= Blood pressure
C= Clinical Features
D= duration of symptoms/ diabetes mellitus?

Score of 0-3 = low risk
moderate risk = 4-5
high risk = 6-7

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24
Q

How to treat a TIA?

A

Patients with the following high risk factors must be conveyed to an ED:

  • Cresendo TIA (more than 1 suspected TIA occured in 7 days)
  • Prescribed/using Anticoagulants
  • Diagnosed clotting disorders
  • Diagnosis of AF or AF present on ECG readings.

-ABCD2 score of less than 4

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25
Q

If patient is not high risk TIA?

A

Patients not meeting the “high risk” criteria, may be able to be referred to a
TIA clinic for an appointment within 24 hours:

  • This will depend on local availability of TIA clinic and appointments
  • Local facilities can be seen in SWAST Stroke/TIA guidelines, Appendix 2
  • Administration and supply of aspirin can be considered
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26
Q

TIA treatment management - medication?

A
  • all patients with suspected TIA must be considered for administration of a start dose of 300mg aspirin.
  • patients can also be supplied a course of 300mg aspirin to take once daily until seen by a specialist or for a maximum of 7 days.
  • this is given under a patient group directive (PGD)
  • Strict inclusion and exclusion criteria for prescribing this medication.
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27
Q

What is a Sub-arachnoid Haemorrhage (SAH)?

A

SAH affects 6–12 people per 100,000 population per year in the UK. The source of
bleeding is an intracranial aneurysm in approximately 85% of people.

  • A non-aneurysmal per-mesencephalic haemorrhage: a rare type of bleeding in the brain that occurs when blood pools in the perimesencephalic cisterns without an aneurysm occurs in 10% of people

-other vascular abnormalities in 5% of people

  • more common in females than males.
  • can occur in young people (most common ages 40-65).
28
Q

Risk factors of SAH?

A
  • smoking
    -obesity
    -alcohol consumption
  • drug use
  • hypertension

etc

29
Q

SAH clinical signs/symptoms?

A
  • severe headache (thunderclap)
  • stiff neck
  • nausea/vomiting
  • photophobia; discomfort or pain in the eyes when exposed to bright lights.
  • Blurred/double vision
  • facial neurological deficit
  • Confusion
  • reduced level of consciousness
30
Q

What are prodromal (Happening at the beggining of a particular medical condition) clincal signs/symptoms of TIA?

A

These signs/symptoms occur approximately 10-20 days prior to rupture:

  • Headache
  • Dizziness
  • Orbital pain
  • Diplopia (double vision)
  • Visual loss
31
Q

Clinical signs/symptoms of SAH present in some patients eyes?

A

Pupillary Changes:

  • single pupil = fixed and dilated is BAD
  • Pupils bilaterally (both eyes) fixed and dilated = WORSE
32
Q

How do you assess for SAH?

A
  • ABCD assessment

Disability?

  • GCS
  • Pupil examination
  • PERRLA
33
Q

What is the PERRLA eye assessment?

A

P = Pupils - do they dialate/constrict normally

E = Equal? - pupils the same size?

R = Round - are pupils round?

R = Reactive too? (next steps apply)

L = Light - test patients response to light

A = accommodation - do eyes dilate and shrink as expected - looking at things close/ far away etc.

34
Q

What are seizures?

A

“Clinical manifestation of an abnormal, excessive, hypersynchronous discharge of
a population of cortical neurons” (Bromfield et al (2006)).

“A seizure is caused by a sudden burst of excess electrical activity in the brain,
causing a temporary disruption in the normal message passing between the brain
cells” (Strong (2021))

35
Q

Seizures Epidemiology?

A
  • Incidence of unprovoked seizures if 23-61/100,000 people/year.
  • Most common cause of Seizures is Epilepsy (600,000 people in UK have it)
  • Approx 3% of calls to the ambulance service are due to seizures.
36
Q

Risk factors - Seizures?

A
  • Born premature/ small baby
  • brain deformity
  • brain haemorrhage
  • brain injury/Hypoxia
  • brain tumor
  • infections of the brain
  • stroke
  • cerebral palsy
  • family Hx
  • Alzheimer’s disease
37
Q

Types of Seizure?

A

Tonic Clonic = Also called “grand mal” seizures, these seizures cause the body to jerk and shake

Atonic = These seizures cause the muscles to suddenly relax, which can lead to a fall

Absence = Also called “petit mal” seizures, these seizures cause a brief loss of awareness

38
Q

what commonly triggers seizures in people with epilepsy? (ordered)

A

1) non-compliance with medication
2) Stress
3) Lack of sleep
4) alcohol
5) Drug abuse
6) Fever
7) Photophobia

39
Q

Focal Seizures?

A

Aura= facial seizure -> seen as a warning of tonic-clonic seizure

symptoms will depend of location of Focal seizure within the brain.

Motor = muscle activity

non-motor = main symptoms that dont involve muscle activity. I.E; emotions, thinking and sensations.

40
Q

what is the Tonic phase of a seizure?

A

Tonic phase:
- Loss of consciousness
- Muscle stiffness (if standing will fall to floor at this point)
- Bite down on tongue

41
Q

What is the Clonic phase of a seizure?

A

Clonic phase:
- Limbs jerk quickly and rhythmically
- May lose bladder/bowel control
- Cyanosis (hypoxia)

42
Q

History taking during assessing for a seizure?

A
  • “Do they have a history of Epilepsy or PNES?
  • “When did the seizure start?”
  • “Was it witnessed?”
  • “Did they hit anything when they collapsed?”
  • “Did they report any symptoms before the seizure started?”
  • “Have they been feeling unwell recently? Has anything changed?”
  • “Have they been taking their medication?”
  • “Have you given anything for their seizure?”
43
Q

Seizure Assessment?

A

-AVPU
-SpO2/pulse
- GCS
-CBG
-temp
-Evidence of head injury

44
Q

Treatment of seizures?

A

1) manage airway (often complicated by trimus (muscle spasm near jaw - can affect airway)

2) administer O2 if hypoxic

3) consider/ treat any potential/known underlying causes

4) Remove/move items likely to cause harm (furniture, objects etc)

5) Cushion behind the head (support head)

6) loosen tight clothing

7) prevent people crowding

8) Talk quietly/ reassure

45
Q

Seizure Management/treatment - medication?

A

If seizure if LESS THAN 5 minutes:

  • position patient comfortably and prevent further harm.
  • Further treatment not usually indicated.

If seizure is LONGER THAN 5 minutes:

  • administer 1 dose of Benzodiazepines e.g; Midazolam
  • attempt IV/IO access
    -If still convulsing after 10 minutes after 1st dose of benzos -> administer 2nd dose of Benzos.
  • potentially administer a 3rd dose depending on risk/reward.
46
Q

what benzodiazapines are commonly used to treat seizures?

A
  • Diazepam:
    10mg initial dose, 10mg 2nd dose, 3rd dose prescribed under advice of senior clinician.
  • Midazolam:
    IV administration, 5mg/1ml (2ml ampules) so 10mg/dose

Diazepam can be administered rectally, same process but 20mg initial dose unless patient is over 70, in which case it is still a 10mg dose initially.

47
Q

what are PSYCHOGENIC NON-EPILEPTIC SEIZURES (PNES)?

A

ESSENTIALLY SEIZURES CAUSED BY STRESS:

a type of seizure that look like epileptic seizures but are caused by psychological or emotional stress, rather than abnormal electrical activity in the brain

48
Q

Psychogenic Non-Epileptic Seizures (PNES) Psychophysiology?

A
  • May appear to be epileptic seizures but they are caused by psychological factors.
  • physical manifestation of psychological distress
  • also known as dissociative seizures
  • used to be called psuedoseizures
  • dissociative seizures happen unconsciously - patient has no control over them.
  • Can lead to physical symptoms such as Tachycardia and palpitations.
49
Q

PNES assessment?

A

DO THIS WHEN I SEE THIS CARD

Please look at “Convulsions in Adults” JRCALC
See Table 3.33 “Features which help to distinguish between BTCS (Bilateral Tonic
Clonic Seizures) and PNES

50
Q

PNES treatment/manegment?

A
  • often last longer than epileptic seizures and drug treatment is often ineffective and dangerous due to side effects.
  • best thing to do is be kind, calm and reassure the patient.
51
Q

What is Syncope?

A

Syncope is a common medical problem, with a frequency
between 15% and 39%. In the general population, the annual
number episodes are 18.1–39.7 per 1000 patients, with
similar incidence between genders”

Silva (2014)

52
Q

Syncope Pathophysiology?

A
  • reduction in systemic blood pressure that causes a decrease in global cerebral blood flow, resulting in a loss of consciousness.
  • state of consciousness is maintained by adequate central blood flow. with age we become more susceptible to relatively small falls in systemic blood pressure:
  • THIS LEADS TO increased incidence in Syncope.
53
Q

Cardiac Syncope?

A

Caused by:

Arrythmias (e.g VT)
* Structural cardiac diseases
(e.g. aortic stenosis)

54
Q

Non-Cardiac Syncope?

A

Further classifications:

Reflex
* Vasovagal
* Situational

  • Orthostatic Hypotension
55
Q

Reflex Syncope?

A

Reflex Syncope:

  • Refers to a group of conditions in which cardiovascular reflexes that are normally useful in
    controlling circulation become intermittently inappropriate.
  • This is usually in response to a trigger, causing vasodilatation and/or bradycardia and thereby
    a fall in BP and global cerebral perfusion.
56
Q

Vasovagal or Neurocardiogenic syncope?

A
  • known as a SIMPLE/COMMON FAINT
  • potentially triggered by pain or emotional upset/distress. Specific trigger is often not identified.
  • usually preceded by prodromal symptoms of autonomic activation.
57
Q

Situational Syncope?

A

Triggered by a specific “situation”, including micturition, post-exercise, postprandial, gastrointestinal
stimulation, cough, phobia of needle of blood.

58
Q

Orthostatic Syncope?

A
  • Defined as a fall in systolic blood pressure of at least 20mmHg or diastolic blood pressure of at least
    10mmHg when a person assumes a standing position.
  • Dysfunction of the autonomic nervous system, leading to reduced peripheral venous resistance and
    therefore a decrease in pre-load and cardiac output.
  • Causes include various medications, dehydration, blood loss and anaemia.
  • Most of us would have experienced a mild version of this, with light-headedness upon standing
59
Q

causes of Cardiac Syncope?

A

structural cardiac disease, such
as cardiac valvular diseases, myocardial infarction
cardiac tamponade or cardiomyopathy

60
Q

Clinical signs/symptoms of Syncope?

A
  • Prodromal Syncope
  • with some forms of Syncope, you can expecty patients to report prodromal symptoms.

Symptoms include:

-light headed
-sweating
-nausea
-visual disturbance

HISTORY TAKING IS IMPORTANT TO DECIDE IF PATIENT HAS COMMON SYNCOPE OF NEEDS TO BE TRANSFERRED TO ED.

61
Q

Syncope assessment?

A

-Assess/manage CABCD
-ascertain what happened before, during and after the event.
-do an ECG
-full examination and all observations
-specifically assess for uncomplicated and situational Syncope

62
Q

Red Flags of a Syncope assessment?

A

-New ECG Abnormalities
* Physical signs of heart failure
* Transient loss of consciousness during exertion
* Family history of sudden cardiac death in people aged younger than 40 years old or with a history
of an inherited cardiac condition
* New or unexplained breathlessness
* Heart murmur
If ANY present, then patient has to be conveyed to ED.

63
Q

Treatment of Syncope?

A

-Manage CABCD
-Oxygen (rarely needed)
-consider if IV sodium chloride is necessary (rare)
-Raising legs?
-Allow patient to recover, which will take time.

Do History taking during this.

64
Q

What is Cauda Equina Syndrome (CES)?

A
  • collection of nerves at the end of the spinal cord.
  • Named due to its resemblance to a horses tale
  • Nerves are responsible for sending/receiving messages to the lower limbs and pelvic organs
65
Q

When does Cauda equina Syndrome (CES) occur?

A

Occurs when nerve roots of the Cauda Equina are compressed and disrupt motor and sensory function to the lower extremities and bladder.

66
Q
A

Medical Conditions (12 decks)

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