Neurologic Emergencies

Neurologic Emergencies - Neurologic Emergencies :...

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Unformatted text preview: Neurologic Emergencies : Neurologic Emergencies Quick & Dirty Points Quick • Generalized Convulsive Status Generalized • • • • Epilepticus Epilepticus Stroke Acute Cord Compression Intracranial Hemorrhage Subarachnoid Hemorrhage • David Riley, MD • Director of Emergency Ultrasonography & Director Ultrasonography • • • Resident Didactics Resident Department of Emergency Medicine St. Luke’s Roosevelt Hospital Center Columbia University College of Physicians & Columbia Surgeons Surgeons Cases Cases • 50 y/o man presents to ED w/ 30 min of 50 continuous seizure tonic/clonic activity, IV continuous activity, in place, 5 mg IV valium given x2, pt still convulsing convulsing • 49 y/o woman develops slurred speech 49 and right sided weakness at the dinner table 45 minutes before arriving in the ED by EMS by Cases Cases • 23 y/o man is shot in the back and he 23 can’t move his legs, has no rectal tone, and the bulbocavernosus reflex is absent bulbocavernosus • 70 y/o NH woman w/ HTN Hx presents 70 Hx presents with pinpoint pupils, GCS of 7, 230/140 with • 45 y/o woman w/migraine Hx presents 45 Hx presents with a 11/10 headache, emesis times 3, and syncope and Generalized Convulsive Status Epilepticus Epilepticus • Definition: recurrent seizures w/o full Definition: recovery : >30 minutes, whether or not consciousness is impaired consciousness • Causes: electrolyte abnormalities, renal Causes: failure, sepsis, CNS infection, head trauma, drug toxicity, hypoxia, breakthrough sz, low anti-sz drug levels, sz drug SAH, ICH, stroke SAH, Generalized Convulsive Status Epilepticus Epilepticus • What should always be checked What in a patient with GCSE? in Subtle: GCSE Subtle: • More severe form, in very sick patients • Profound coma, encephalopathy • Subtle motor signs, ie twitches of eye lid, Subtle ie twitches jaw twitching jaw • Rx: very aggresive Rx: aggresive Rx: GCSE Rx: • 1. A, B, C’s, IV, monitor, oxygen • 2. Normal Saline Only (unless 2. fosphenytoin) fosphenytoin • 3. Check glucose • 4. IV ativan 0.1mg/kg = best drug 4. ativan 0.1mg/kg (shorter serum t1/2 yet longer CNS t1/2 due to lower lipid solubility) due • 5. IV dilantin: 18mg/kg load @ 50mg/min 5. dilantin 18mg/kg (150mg/min fosphenytoin) fosphenytoin Rx: GCSE Rx: • 6. Phenobarbital: 20mg/kg @ 6. <100mg/min slow push <100mg/min • 7. Repeat ativan, consider intubation 7. ativan consider intubation • 8. Pentobarbital, propofol, or versed 8. propofol or coma, ideally with EEG recording with a goal to flatline the EEG (best outcome if flatline the for 48-72 hours) for Stroke Stroke • Only TWO Treatments: ASA & TPA • ASA: CAST Trial, Lancet 349:1641,1997 • ASA alone, NNT=100 to prevent death ASA & non-fatal recurrences in 1st month non • TPA alone: NINDS study: 2 parts, only TPA 291 patients 291 – 1. Early 24 hr benefits: NONE – 2. 3 month outcome: 30% greater 2. improvement in neurologic functioning neurologic Stroke Stroke • NINDS • Inclusion criteria: >18y/o, defined onset Inclusion w/I 180 min, deficit, CT: no ICH w/I • Exclusion criteria: INR >1.7, >185/110, Exclusion ICH, platelets <100,000, no heparin w/I 24 hrs, Glucose <50 & >400, CT showing > 1/3 MCA territory cerebral edema(blurring of gray-white junction) edema(blurring white ie mild vs moderate edema, BP ie mild vs moderate >185/110 >185/110 Stroke Stroke • Any role for TPA + ASA? • Any role for Heparin? Stroke Stroke • Any role for TPA + ASA?: No ASA in the Any first 24 hours after TPA, increased risk of ICH & death ICH • Any role for Heparin?: Considered in Any patients at high risk for stroke progression: crescendo TIA’s, TIA’s cardioembolic source(Afib). NEVER in cardioembolic ). ENDOCARDITIS ENDOCARDITIS Stroke Stroke • 24 hrs after stroke- CT: gray-black black ischemic tissue ischemic • Newer RX: Newer – Intraarterial thrombolysis – Angioplasty & stenting Angioplasty stenting Acute Cord Compression: Big 4 Acute • 50% Trauma • Infections • Tumor • Degenerative: acute disc Acute Cord Compression Acute • Acute Disc: UMN signs (LMN if cauda Acute cauda equina: lloss of perianal sensation, loss of oss perianal sensation, rectal tone, overflow bladder dribbling, decreased reflexes) decreased – needs surgery(most anteriorly now) needs anteriorly – get stat MRI Acute Cord Compression Acute • How do you diagnose conus How conus medularis syndrome? Acute Cord Compression Acute • Trauma • Cervical = # 1 area • Thoracic = tend to be the worst for Thoracic cord injury due to most narrow canal: greatest # of complete lesions greatest • $>1,000,000 • High school football “spearing” banned: High only 1/3 of wt load required to cause injury injury Acute Cord Compression Acute • Trauma: RX • Blunt: solumedrol 30mg/kg IV 1st hr, Blunt: solumedrol 30mg/kg then 5.4mg/kg/hr over the next 23 hrs then – higher wound infection rate – more pneumonia – Questionable Benefit? • Surgery: acute SCI: no clear benefit, Surgery: yet w/ progressive cord compression surgery is clearly of benefit surgery Acute Cord Compression Acute • How to clear a C-spine?? – Awake – AP, lat, open mouth – flex/ext: always let the pt move themselves – CT – MRI: best for ligament injury, SCIWORA Acute Cord Compression Acute • Penetrating Trauma: GSW/knife: IV Penetrating solumedrol iis NOT indicated, no solumedrol s improved outcome, and higher infection risks risks • CSF fistula: only indication for surgery CSF w/penetrating trauma w/penetrating • Infection: Epidural abscess, Infection: osteomyelitis osteomyelitis – surgery: neuro deficit, kyphosis, med Rx surgery: neuro deficit, kyphosis med not working, Dx=TB/fungal Dx Acute Cord Compression Acute • Spine Osteomyelitis: IVDA, HIV, DM, Etoh Spine Osteomyelitis IVDA, Etoh – TB: of the spine, RECOVERS VERY WELL, TB: after surgery, even if present in the spine a long time long • Tumor: Rx=surgery + radioRx Tumor: radioRx – ED: DECADRON 10MG IV Intracranial Hemorrhage: How did this happen? happen? This is How! This Intracranial Hemorrhage Intracranial • Blacks 1.5 times more likely due to HTN • KILLER: 30 day mortality 35-52% • Outcome predictors: volume of blood; Outcome GCS @ presentation, volume of ICH, IVH IVH • Rx: evaluate swallowing/gag; GCS 8 or Rx: less can’t protect airway = smoke the plastic cigar plastic – avoid hyperthermia & restore volume avoid status status Intracranial Hemorrhage Intracranial • CPP = MAP(40-160 autoreg zone) - ICP 160 aut zone) • Most pts have increased MAP: to treat or not Most • • to treat? to Rx: yes - increased BP can promote Rx: increased increased bleeding; MAP<125 better outcome outcome Rx: no - decreased CBF around the ICH zone Rx: decreased of marginal viability of Intracranial Hemorrhage Intracranial • ED Rx: If ED • MAP>125, 20% reduction in 1st hr, ie: labetolol 10ie labetolol 20mg IV q 1020min NO NIPRIDE: NO causes cerebral vasodilation & vasodilation increased ICP increased Intracranial Hemorrhage Intracranial • Rx. Anticonvulsants: dilantin yes: load in Rx. dilantin yes: the ED because seizures w/I 1st 24 hrs the • Goal keep ICP <20 & CPP >70 • Patients who are deteriorating or who Patients have a GCS<9 : need an ICP bolt to monitor ICP monitor • Rx: Hyperventilation pCO2=30-35; 35; mannitol 0.5-1 gm/kg IV over 20min mannitol Intracranial Hemorrhage Intracranial • Rx. Surgery: serum extravasating from Rx. extravasating from hematoma worsens cerebral edema hematoma – benefit in moribund patients • CEREBELLAR HEMATOMA’S • >3.0 CM >3.0 • DEFINITE INDICATION FOR DEFINITE SURGERY SURGERY Subarachnoid Hemorrhage Subarachnoid • 80% aneurysms: risk factors: age, HTN, 80% atherosclerosis, cigs, cocaine, OCP’s OCP’s • 96/100,000 in Japan • 11/100,000 in Rochester • 50% have warning sentinel bleed • 7% CVA due to vasospasm • 25% ED MISS RATE!! Subarachnoid Hemorrhage Subarachnoid • Clinical profile: “worst headache of my life”, Clinical w/or w/o focal deficits; altered mental status, nausea & vomiting, syncope, 3rd nerve palsy w/ ptosis, pupillary dilation, nerve w/ ptosis pupillary dilation, impaired ocular movements due to compression of the third nerve by PCOM aneurysm, retinal subhyaloid bleeds, ACOMsubhyaloid vision optic chiasm Sx & frontal vision optic frontal intraparenchymal bleed intraparenchymal • Basilar artery aneurysm: third and sixth Basilar nerve palsies, ataxia nerve Subarachnoid Hemorrhage Subarachnoid • Key Things to Know • 1. Time of bleed • 2. Hunt/Hess grade • 3. Hydrocephalus +/• 4. Location of bleed on CT scan • 5. Pre-morbid conditions • Dx: CT & if neg LP mandatory CT neg Subarachnoid Hemorrhage Subarachnoid • Hunt/Hess Grade • I: awake w/ no sx, or mild HA or stiff neck I: sx • II: Awake w/mod-severe HA or stiff neck • III: Drowsy, confused, +/- focal deficits • IV: Stuporous, w/mod-severe hemiparesis, & IV: Stuporous severe hemiparesis signs of increased ICP signs • V: Comatose w/signs of severe increased ICP Subarachnoid Hemorrhage Subarachnoid • Hunt/Hess Grade & Prognosis • Grade deterioration Rebleed •I 5% 10-15% • II 20% 10-15% • III 25% 10-20% • IV 50% 20-25% •V 80% 25-30% death 3-5% 6-10% 10-15% 40-50% 50-70% Subarachnoid Hemorrhage Subarachnoid • Grade I & II: surgical candidates • Grade III: angio, medical Rx until grade Grade angio medical improves, and surgical risk decreases improves, • Grade IV & V: poor prognosis, medical Rx Grade until their grade improves until Subarachnoid Hemorrhage Subarachnoid • Systemic Complications – fever: rx aggressively; due to blood inflammatory fever: rx aggressively; response in CSF, UTI, pneumonia response – hyponatremia: SIADH: don’t fluid restrict-replace replace volume losses with 5% albumin volume – ECG : prol QTc, T-wave inversion ECG prol – neurogenic pulmonary edema • CNS Complications – vasospasm – acute hydrocephalus – seizures Subarachnoid Hemorrhage Subarachnoid • Rx: Big ? To Clip or Coil? • Clip: cure for life, decreased mass effect, no Clip: recurrences recurrences • Coil: can use heparin, there are recurrences • Vasospasm: 20%; usually 4-7 days after bleed; days must first detect(exam/HA, angio, SPECT, PET, angio SPECT, continuous EEG monitoring, 2 point drop in the GCS) then aggressively treat: “triple H” therapy = Hemodilution, HTN, and Hypervolemia; Hemodilution HTN, Hypervolemia nimodipine 60 mg po q4 hr/21days; angioplasty nimodipine 60 po Subarachnoid Hemorrhage Subarachnoid • Hydrocephalus: 25% incidence – 10% ventriculostomy 10% ventriculostomy – Hunt/Hess I-III: no ventriculostomy III: ventriculostomy – Hunt/Hess IV-V(don’t follow commands): V(don’t ventriculostomy ventriculostomy – daily CSF checks, q 5 day shunt changes in daily the operating room the Subarachnoid Hemorrhage Subarachnoid • Fever: increases vasospasm – must aggresively control must aggresively – causes increased extracellular causes extracellular glutamine(excitatory amino acid), that is amino reversed with cooling reversed – Neurogenic fever: Rx-indomethacin • Nimodipine: #1 for cerebroprotection iin #1 cerebroprotection n SAH SAH ...
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This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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