Neurological Emergen..


Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Although a number of primary headache syndromes exist that can present with sudden, severe headache, many underlying diseases that can be clinically indistinguishable from benign thunderclap headache (TCH) to SAH also occur. These include: Venous sinus thrombosis Pituitary apoplexy Arterial dissection Meningoencephalitis Acute hydrocephalus Acute hypertension Some of these conditions may be very difficult to detect on CT scan, which underscores the need for MRI in patients with bloodless CT and CSF who present with a sudden-onset severe headache. de Bruijn SF, Stam J, Kappelle LJ. For the Cerebral Venous Sinus Thrombosis Study Group. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. Lancet. 1996;348(9042):1623-1625. de Bruijn SF, Stam J, Vandenbroucke JP. For the Cerebral Venous Sinus Thrombosis Study Group. Increased risk of cerebral venous sinus thrombosis with third-generation oral contraceptives. Lancet. 1998;351(9113):1404.
  • Although CT scans are very sensitive, with 92% to 95% probability in detecting acute SAH if performed within 24 hours after ictus, blood rapidly clears from the subarachnoid space. The sensitivity of CT scanning decreases to 80% at 3 days, 58% to 85% at 5 days, 50% at 1 week and 30% at 2 weeks. At 3 weeks after the hemorrhage, the CT scan will be negative. Kassell NF, Torner JC, Haley EC Jr, et al. The International Cooperative Study on the timing of aneurysm surgery. Part 1: Overall management results. J Neurosurg. 1990;73(1):18-36. van Gijn J, van Dongen KJ. The time course of aneurysmal haemorrhage on computed tomograms. Neuroradiology. 1982;23(3):153-156.
  • Neurological Emergen..

    1. 1. Neurological Emergencies
    2. 2. Status Epilepicus <ul><li>Two or more Seizures </li></ul><ul><li>Failure to regain consciousness Between Seizures </li></ul><ul><li>Some define it as 30 minutes of continuous seizure without regaining consciousness </li></ul><ul><li>GTC status epilepticus </li></ul><ul><li>“ petit mal” status </li></ul>
    3. 3. Status Epilepicus <ul><li>Alcohol or Drug Withdrawal, illicit drug ingestion </li></ul><ul><li>Failure to take anti-Convulsants </li></ul><ul><li>Diabetic non-ketotic Hyperglycemia </li></ul><ul><li>Irritative structural lesion </li></ul><ul><ul><li>Abscess </li></ul></ul><ul><ul><li>Tumor </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Threatened infarct </li></ul></ul><ul><li>Meningoencephalitis especially Herpes </li></ul><ul><li>Cerebral anoxia </li></ul><ul><li>Metabolic derangements eg Hypoglycemia, hyponatremia </li></ul>
    4. 5. Status epilepticus dangers <ul><li>Increased CNS metabolic consumption </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Muscle breakdown </li></ul></ul><ul><li>Metabolic acidosis and other derangements </li></ul><ul><li>Hyperthermia </li></ul><ul><li>Heart and other organ effects </li></ul><ul><li>Mortality is around 20% </li></ul>
    5. 6. Status Epilepticus <ul><li>Pay attention to the Basics </li></ul><ul><ul><li>Airway, breathing, heart, bp, vitals </li></ul></ul><ul><li>Rapid assessment </li></ul><ul><li>History during management </li></ul><ul><li>Basic Labs, lytes CBC, Glucose as i.v. goes in </li></ul><ul><li>Drug Screen </li></ul><ul><li>CT scan </li></ul><ul><li>Stop the Seizure!! </li></ul>
    6. 7. Goals with Status Epilepticus <ul><li>Stop the Seizure </li></ul><ul><li>Find our what is wrong and correct it </li></ul>
    7. 8. AntiConvulsants <ul><li>Ativan (Lorazepam)is benzodiazepine of choice 4 mg iv up to 8 mg in 12 hours </li></ul><ul><li>Simultaneously load with fosphenytoin 18 mg/kg phenytoin equivalents foll’d by maintenance dose and levels </li></ul><ul><li>If Seizure is not stopped in 30 mins add phenobarbital 15-20 mg/kg and/or Depacon iv. Depacon 1500 mg for nl adult foll’d by levels and maintenance dose. </li></ul><ul><li>If not successful in 1-2 hours, general anesthesia eg propofol 20-50 mg intermittent bolus </li></ul><ul><li>Norcuron may be used to stop movement to obtain CT, MRI, helpful to control acidosis, rhabdomyolysis but obviously does not stop seizure up to .1 mg/kg iv </li></ul>
    8. 9. Vignette 1 <ul><li>55 year old lady </li></ul><ul><li>Onset 3 days ago of tingling in hands and feet and ankle instability, falling </li></ul><ul><li>Now weaker, unable to stand on own or hold utensils reliably </li></ul><ul><li>Toes go down. Lacks all but knee reflexes </li></ul>
    9. 10. Guillian- Barre <ul><li>Acute, subacute demyelinating multifocal immune mediated radiculoneuropathy </li></ul><ul><li>Numbness typically starts distally or multifocally, significant weakness </li></ul><ul><li>Bifacial weakness and other cranial nerve findings </li></ul><ul><li>Arreflexia </li></ul>
    10. 11. Guillian Barre Diagnosis <ul><li>Spinal Fluid </li></ul><ul><ul><li>Elevated Protein </li></ul></ul><ul><ul><li>Few Cells (cyto-albuminologic dissociation) </li></ul></ul><ul><li>Slow Nerve Conduction Velocities </li></ul>
    11. 12. Guillian Barre dangers <ul><li>Failure to recognize may cause death </li></ul><ul><ul><li>Severe weakness </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><ul><li>Autonomic instability </li></ul></ul><ul><ul><ul><li>Major cause of death </li></ul></ul></ul><ul><ul><ul><li>Severe sudden hypotension </li></ul></ul></ul><ul><ul><ul><li>Cardiac arrhythmia </li></ul></ul></ul>
    12. 13. Guillian Barre management <ul><li>Always admit to hospital </li></ul><ul><li>Neurological consultation </li></ul><ul><li>CBC, sed rate, lyme antibody titre, tox screen if indicated </li></ul><ul><li>Monitor vital capacity and respiratory parameters </li></ul><ul><li>DVT prophylaxis </li></ul><ul><li>IVIg or pheresis </li></ul>
    13. 15. Vignette 2 <ul><li>36 year old woman with history of some headaches has very severe head pain, vomiting </li></ul><ul><li>? Lid droop in right with slightly larger pupil noticed by nurse </li></ul><ul><li>Altered sensorium </li></ul><ul><li>Mildly stiff neck </li></ul><ul><li>Pre-retinal hemorrhage on fundoscopic exam </li></ul>
    14. 16. Sub-Arachnoid hemorrhage <ul><li>Likely to cause death or severe damage if unrecognized </li></ul><ul><li>Seizures, progression of neurological deficit and altered sensorium </li></ul>
    15. 17. Sub-arachnoid hemorrhage <ul><li>Neurosurgical consultation </li></ul><ul><li>Attention to basics, airway vital signs etc </li></ul><ul><li>Treat severe hypertension </li></ul><ul><li>Decadron, Dilantin, Codeine for pain </li></ul><ul><li>HOB up 30% </li></ul><ul><li>Nimodipine </li></ul><ul><li>Absolute bedrest </li></ul><ul><li>Prevent valsalva and constipation </li></ul>
    16. 19. SUDDEN ONSET HEADACHE Primary Secondary SAH Pituitary apoplexy Venous sinus thrombosis Arterial dissection Meningoencephalitis Acute hydrocephalus Acute hypertension Spontaneous intracranial hypotension Idiopathic thunderclap headache (TCH) Exertional headache Cough headache Sexual headache deBruijn, SF, et al. Lancet . 1996; Lancet . 1998.
    17. 20. SENSITIVITY OF CT SCAN IN SUBARACHNOID HEMORRHAGE (SAH) van Gijn J, van Dongen KJ. Neuroradiology . 1982. Kassell NF et al. J Neurosurg. 1990. ~0 3 WEEKS 30 2 WEEKS 50 1 WEEK 80 DAY 3 95 DAY 0 PROBABILITY (%) TIME AFTER HEADACHE ONSET
    18. 21. Vignette 3 <ul><li>64 year old man, hx of MI, htn </li></ul><ul><li>Wife brings him in promply after onset of left hemiplegia, dysarthria </li></ul><ul><li>Bp 190/115 pulse 90 </li></ul><ul><li>Continued deficit </li></ul>
    19. 22. New Stroke <ul><li>Prompt CT scan </li></ul><ul><li>Immediate neurological consultation </li></ul><ul><li>Briskly try to control bp either nipride or labetolol to keep bp under 185/120 </li></ul><ul><li>Altepase (t-PA) </li></ul>
    20. 24. T-PA exclusions <ul><li>Unable to decrease bp < 185 systolic </li></ul><ul><li>Within 2 weeks of surgery that may have predispose to bleed </li></ul><ul><li>Recent stroke </li></ul><ul><li>INR >1.1 (already on Coumadin) </li></ul><ul><li>Onset with seizure or LOC </li></ul><ul><li>Rapidly clearing or minimal deficit </li></ul><ul><li>Any bleeding diathesis, hematologic or ulcer etc. </li></ul><ul><li>Brain hemorrhage or tumor </li></ul>
    21. 25. Vignette 4 <ul><li>24 year old man brought in by wife </li></ul><ul><li>Not quite right over last couple of days </li></ul><ul><li>Mild headache </li></ul><ul><li>Aphasia, altered sensorium </li></ul><ul><li>Stereotyped automatic repetitive movements (automatisms) of mouth and right arm then sudden seizure </li></ul><ul><li>Neck may be mildly unsupple </li></ul>
    22. 26. Acute mental syndrome with or without seizure (encephalopathy) <ul><li>Quick exam, vital signs </li></ul><ul><li>Glucose, thiamine, Narcan </li></ul><ul><li>Drug history, drug screen and basic labs </li></ul><ul><li>CT or MRI scan in ER </li></ul><ul><li>EEG </li></ul><ul><li>Prompt Lumbar puncture unless diagnosis is apparent from above measures </li></ul>
    23. 27. Acute Mental Syndrome <ul><li>If not metabolic, drug induced or connected with structural brain disease cause is likely to be meningoencephalitis </li></ul><ul><li>May be vascular disease or fairly mild process superimposed on chronic brain disease in elderly </li></ul>
    24. 28. Vignette 5 <ul><li>65 year old man with non-Hodgkin's lymphoma complains of a mild gait disturbance, urinary urge incontinence </li></ul><ul><li>Arms are fine but legs have 4/5 power </li></ul><ul><li>Reflexes a little hyperactive in lower extremities, possible upgoing toes </li></ul>
    25. 29. Extradural spinal compression <ul><li>Rapid or very rapid progression of lower extremity weakness </li></ul><ul><li>Failure to act promptly results in permanent paraplegia or worse. </li></ul><ul><li>Key: trunkal motor level of weakness and sensory level with or without pain. Upper motor neuron weakness in lower extremities. </li></ul><ul><li>Get prompt imaging studies esp spinal MRI and Neurological or neurosurgical consultation. </li></ul>
    26. 30. Spinal Compression <ul><li>Key to diagnosis – Sensory Level </li></ul><ul><li>May be lower than compression </li></ul><ul><li>Also motor level over trunk </li></ul><ul><li>Reflex exam – diminished at level, increased below level </li></ul><ul><li>Upgoing toes </li></ul>
    27. 32. Cord Compression <ul><li>Dexamethasone 100 mg iv </li></ul><ul><li>Neurosurgical/orthopaedic consult </li></ul><ul><li>Irradiation or decompression </li></ul>
    28. 33. Vignette 6 <ul><li>17 year old girl complains of diplopia, lid droop, may have slight problem swallowing. </li></ul><ul><li>Speech may be slightly slurred. Muscle strength seems fairly normal. Reflexes are normal </li></ul>
    29. 34. Myasthenia <ul><li>DDX diseases of neuromuscular junction </li></ul><ul><ul><li>Botulism, Lambert-Eaton (rare) </li></ul></ul><ul><li>May progress rapidly and impair swallow or respiration </li></ul><ul><li>Prompt neurological evaluation </li></ul>
    30. 35. Myasthenia <ul><li>Begins with Eye movt abnomalities </li></ul><ul><li>Foll’d by bulbar weakness </li></ul><ul><ul><li>Dysarthria </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><li>Peripheral weakness </li></ul>
    31. 36. Myasthenia diagnosis <ul><li>Repetitive muscle testing </li></ul><ul><li>Tensilon Test </li></ul><ul><ul><li>Edrophonium 10 mg. 2mg then 8mg find eye mov’t or muscles to focus on </li></ul></ul><ul><li>Striated muscle, ACh receptor antibody </li></ul><ul><li>CT scan of chest for thymus </li></ul>
    32. 38. Myasthenia treatment <ul><li>Mestinon 30-60 mg tid to qid </li></ul><ul><ul><li>1/30 th dose iv </li></ul></ul><ul><li>Prednisone </li></ul><ul><li>Azathiaprine, Cyclosporine </li></ul><ul><li>Pheresis or IVIg </li></ul><ul><li>Thymectomy </li></ul>
    33. 39. Vignette 6 <ul><li>36 year old Camp Hill inmate admitted with temp of 104 </li></ul><ul><li>Increased muscle tone noted and shivering on exam </li></ul><ul><li>Altered sensorium </li></ul><ul><li>CPK 11000 </li></ul>
    34. 40. Neuroleptic malignant syndrome <ul><li>phenothiazine use (Dopamine antagonists) </li></ul><ul><li>May be in situation preventing cooling </li></ul><ul><li>Severe sequellae if not recognized/treated (death) </li></ul><ul><li>d/c offending agent </li></ul><ul><li>Parlodel (bromocriptine) or dopaminergic agents, Dantrium, cooling, hydration, prevent rhabdomyolysis </li></ul><ul><li>DDx: malignant hyperthermia, thyroid storm, sepsis, toxins, strychnine, tetanus, dystonias </li></ul>
    35. 41. Vignette 7 <ul><li>65 year old man with slurred speech </li></ul><ul><li>Vertical diplopia </li></ul><ul><li>Ataxic gait and upper extremities </li></ul><ul><li>Vertigo </li></ul><ul><li>Fluctuating weakness </li></ul>
    36. 42. Vertebro-basilar stroke <ul><li>Diplopia </li></ul><ul><li>Dysarthria </li></ul><ul><li>Dysphagia </li></ul><ul><li>“ Crossed” sensory or motor syndrome </li></ul><ul><li>May be life threatening </li></ul><ul><li>“ Locked-in” syndrome in pons </li></ul>
    37. 44. Basilar stroke <ul><li>Anti-coagulation </li></ul><ul><li>T-PA </li></ul><ul><li>Consider Stenting </li></ul>
    38. 45. Vignette 8 <ul><li>49 year old man with left brain stroke 24 hours ago. Nurse calls you at 2 AM </li></ul><ul><li>Decreased responsiveness </li></ul><ul><li>Left pupil is larger than right </li></ul><ul><li>Bp is 210/120 pulse 50 </li></ul><ul><li>You can’t arouse him and there is papilledema </li></ul>
    39. 46. Acute increased ICP <ul><li>Begin Mannitol or Lasix and Mannitol </li></ul><ul><li>Get a CT scan </li></ul><ul><li>Remove to ICU </li></ul><ul><li>Consider Neurosurgical Consult for ventriculostomy, hemicraniectomy or other intervention </li></ul>
    40. 47. Vignette 9 <ul><li>24 year old woman post-partum </li></ul><ul><li>Vomiting </li></ul><ul><li>dehydration </li></ul><ul><li>Severe headache </li></ul><ul><li>Diplopia </li></ul><ul><li>Seizures </li></ul>
    41. 49. Dural Sinus thrombosis <ul><li>Key is early recognition </li></ul><ul><ul><li>Headache, papilledema, aphasia, focal signs, seizures </li></ul></ul><ul><li>Hypercoagulable: genetic, contraceptives, pregnancy </li></ul><ul><li>Heparin is treatment of choice even when hemorrhage occurs </li></ul>
    42. 50. Dural Sinus Thrombosis <ul><li>Headache </li></ul><ul><li>Papilledema </li></ul><ul><li>Focal Signs </li></ul><ul><li>Altered level of consciousness </li></ul><ul><li>Seizures </li></ul><ul><li>Setting of hypercoagulable state </li></ul>
    43. 51. Vertebral Artery Dissection <ul><li>Chiropractic manipulation or neck injury </li></ul><ul><li>Neck and head pain </li></ul><ul><li>Followed in days to 2 weeks with stroke like symptoms </li></ul><ul><li>Key is pain foll’d by stroke with or without trauma </li></ul><ul><li>Treatment: Heparin/coumadin </li></ul>
    44. 52. Organophosphate poisoning <ul><li>Diaphoresis, lacrimation, sialorrhea, miosis </li></ul><ul><li>Smooth and skeletal muscle contraction, diarrhea, vomiting </li></ul><ul><li>Seizure, delirium, diplopia, ataxia </li></ul><ul><li>Bronchospasm, tachycardia, hypo or hypertension </li></ul><ul><li>Atropine 1-2 mg iv </li></ul><ul><li>Pralidoxime (2-PAM) 1-2 gm in 250 ml iv over 10 mins. </li></ul><ul><li>Remove source such as clothes </li></ul><ul><li>Check RBC cholinesterase </li></ul>