neurological emergen

Neurological EmergenciesNeurological Emergencies

Status EpilepicusStatus Epilepicus

Two or more SeizuresTwo or more Seizures

Failure to regain consciousness Between Failure to regain consciousness Between SeizuresSeizures

Some define it as 30 minutes of Some define it as 30 minutes of continuous seizure without regaining continuous seizure without regaining consciousnessconsciousness

GTC status epilepticusGTC status epilepticus

““petit mal” statuspetit mal” status

Status EpilepicusStatus Epilepicus

Alcohol or Drug Withdrawal, illicit drug ingestionAlcohol or Drug Withdrawal, illicit drug ingestionFailure to take anti-ConvulsantsFailure to take anti-ConvulsantsDiabetic non-ketotic HyperglycemiaDiabetic non-ketotic HyperglycemiaIrritative structural lesionIrritative structural lesion– AbscessAbscess– TumorTumor– HemorrhageHemorrhage– Threatened infarctThreatened infarct

Meningoencephalitis especially HerpesMeningoencephalitis especially HerpesCerebral anoxiaCerebral anoxiaMetabolic derangements eg Hypoglycemia, Metabolic derangements eg Hypoglycemia, hyponatremiahyponatremia

Status epilepticus dangersStatus epilepticus dangers

Increased CNS metabolic consumptionIncreased CNS metabolic consumption

RhabdomyolysisRhabdomyolysis– Renal failureRenal failure– Muscle breakdownMuscle breakdown

Metabolic acidosis and other derangementsMetabolic acidosis and other derangements

HyperthermiaHyperthermia

Heart and other organ effectsHeart and other organ effects

Mortality is around 20%Mortality is around 20%

Status EpilepticusStatus Epilepticus

Pay attention to the BasicsPay attention to the Basics– Airway, breathing, heart, bp, vitalsAirway, breathing, heart, bp, vitals

Rapid assessmentRapid assessment

History during managementHistory during management

Basic Labs, lytes CBC, Glucose as i.v. goes inBasic Labs, lytes CBC, Glucose as i.v. goes in

Drug ScreenDrug Screen

CT scanCT scan

Stop the Seizure!!Stop the Seizure!!

Goals with Status EpilepticusGoals with Status Epilepticus

Stop the SeizureStop the Seizure

Find our what is wrong and correct itFind our what is wrong and correct it

AntiConvulsantsAntiConvulsants

Ativan (Lorazepam)is benzodiazepine of choice 4 mg iv Ativan (Lorazepam)is benzodiazepine of choice 4 mg iv up to 8 mg in 12 hoursup to 8 mg in 12 hoursSimultaneously load with fosphenytoin 18 mg/kg Simultaneously load with fosphenytoin 18 mg/kg phenytoin equivalents foll’d by maintenance dose and phenytoin equivalents foll’d by maintenance dose and levelslevelsIf Seizure is not stopped in 30 mins add phenobarbital If Seizure is not stopped in 30 mins add phenobarbital 15-20 mg/kg and/or Depacon iv. Depacon 1500 mg for nl 15-20 mg/kg and/or Depacon iv. Depacon 1500 mg for nl adult foll’d by levels and maintenance dose.adult foll’d by levels and maintenance dose.If not successful in 1-2 hours, general anesthesia eg If not successful in 1-2 hours, general anesthesia eg propofol 20-50 mg intermittent boluspropofol 20-50 mg intermittent bolusNorcuron may be used to stop movement to obtain CT, Norcuron may be used to stop movement to obtain CT, MRI, helpful to control acidosis, rhabdomyolysis but MRI, helpful to control acidosis, rhabdomyolysis but obviously does not stop seizure up to .1 mg/kg ivobviously does not stop seizure up to .1 mg/kg iv

Vignette 1Vignette 1

55 year old lady55 year old lady

Onset 3 days ago of tingling in hands and Onset 3 days ago of tingling in hands and feet and ankle instability, fallingfeet and ankle instability, falling

Now weaker, unable to stand on own or Now weaker, unable to stand on own or hold utensils reliablyhold utensils reliably

Toes go down. Lacks all but knee reflexesToes go down. Lacks all but knee reflexes

Guillian- BarreGuillian- Barre

Acute, subacute demyelinating multifocal Acute, subacute demyelinating multifocal immune mediated radiculoneuropathyimmune mediated radiculoneuropathy

Numbness typically starts distally or Numbness typically starts distally or multifocally, significant weaknessmultifocally, significant weakness

Bifacial weakness and other cranial nerve Bifacial weakness and other cranial nerve findingsfindings

ArreflexiaArreflexia

Guillian Barre DiagnosisGuillian Barre Diagnosis

Spinal FluidSpinal Fluid– Elevated ProteinElevated Protein– Few Cells (cyto-albuminologic dissociation)Few Cells (cyto-albuminologic dissociation)

Slow Nerve Conduction VelocitiesSlow Nerve Conduction Velocities

Guillian Barre dangersGuillian Barre dangers

Failure to recognize may cause deathFailure to recognize may cause death– Severe weaknessSevere weakness– AspirationAspiration– Respiratory failureRespiratory failure– Autonomic instabilityAutonomic instability

Major cause of deathMajor cause of death

Severe sudden hypotensionSevere sudden hypotension

Cardiac arrhythmiaCardiac arrhythmia

Guillian Barre managementGuillian Barre management

Always admit to hospitalAlways admit to hospital

Neurological consultationNeurological consultation

CBC, sed rate, lyme antibody titre, tox CBC, sed rate, lyme antibody titre, tox screen if indicatedscreen if indicated

Monitor vital capacity and respiratory Monitor vital capacity and respiratory parametersparameters

DVT prophylaxisDVT prophylaxis

IVIg or pheresisIVIg or pheresis


36 year old woman with history of some 36 year old woman with history of some headaches has very severe head pain, headaches has very severe head pain, vomitingvomiting? Lid droop in right with slightly larger pupil ? Lid droop in right with slightly larger pupil noticed by nursenoticed by nurseAltered sensoriumAltered sensoriumMildly stiff neckMildly stiff neckPre-retinal hemorrhage on fundoscopic Pre-retinal hemorrhage on fundoscopic examexam

Sub-Arachnoid hemorrhageSub-Arachnoid hemorrhage

Likely to cause death or severe damage if Likely to cause death or severe damage if unrecognizedunrecognized

Seizures, progression of neurological Seizures, progression of neurological deficit and altered sensoriumdeficit and altered sensorium

Sub-arachnoid hemorrhageSub-arachnoid hemorrhage

Neurosurgical consultationNeurosurgical consultationAttention to basics, airway vital signs etcAttention to basics, airway vital signs etcTreat severe hypertensionTreat severe hypertensionDecadron, Dilantin, Codeine for painDecadron, Dilantin, Codeine for painHOB up 30%HOB up 30%NimodipineNimodipineAbsolute bedrestAbsolute bedrestPrevent valsalva and constipationPrevent valsalva and constipation

SUDDEN ONSET HEADACHESUDDEN 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.

SENSITIVITY OF CT SCAN IN SENSITIVITY OF CT SCAN IN SUBARACHNOID HEMORRHAGE SUBARACHNOID HEMORRHAGE

(SAH)(SAH)

van Gijn J, van Dongen KJ. Neuroradiology. 1982.Kassell NF et al. J Neurosurg. 1990.

TIME AFTER TIME AFTER HEADACHE HEADACHE

ONSETONSET

PROBABILITYPROBABILITY(%)(%)

DAY 0DAY 0 9595

DAY 3DAY 3 8080

1 WEEK1 WEEK 5050

2 WEEKS2 WEEKS 3030

3 WEEKS3 WEEKS ~0~0


64 year old man, hx of MI, htn64 year old man, hx of MI, htn

Wife brings him in promply after onset of Wife brings him in promply after onset of left hemiplegia, dysarthrialeft hemiplegia, dysarthria

Bp 190/115 pulse 90Bp 190/115 pulse 90

Continued deficitContinued deficit

New StrokeNew Stroke

Prompt CT scanPrompt CT scan

Immediate neurological consultationImmediate neurological consultation

Briskly try to control bp either nipride or Briskly try to control bp either nipride or labetolol to keep bp under 185/120labetolol to keep bp under 185/120

Altepase (t-PA)Altepase (t-PA)

T-PA exclusionsT-PA exclusions

Unable to decrease bp < 185 systolicUnable to decrease bp < 185 systolicWithin 2 weeks of surgery that may have Within 2 weeks of surgery that may have predispose to bleedpredispose to bleedRecent strokeRecent strokeINR >1.1 (already on Coumadin)INR >1.1 (already on Coumadin)Onset with seizure or LOCOnset with seizure or LOCRapidly clearing or minimal deficitRapidly clearing or minimal deficitAny bleeding diathesis, hematologic or ulcer etc.Any bleeding diathesis, hematologic or ulcer etc.Brain hemorrhage or tumorBrain hemorrhage or tumor


24 year old man brought in by wife24 year old man brought in by wife

Not quite right over last couple of daysNot quite right over last couple of days

Mild headache Mild headache

Aphasia, altered sensoriumAphasia, altered sensorium

Stereotyped automatic repetitive Stereotyped automatic repetitive movements (automatisms) of mouth and movements (automatisms) of mouth and right arm then sudden seizureright arm then sudden seizure

Neck may be mildly unsuppleNeck may be mildly unsupple

Acute mental syndrome with or Acute mental syndrome with or without seizure (encephalopathy)without seizure (encephalopathy)

Quick exam, vital signsQuick exam, vital signs

Glucose, thiamine, NarcanGlucose, thiamine, Narcan

Drug history, drug screen and basic labsDrug history, drug screen and basic labs

CT or MRI scan in ERCT or MRI scan in ER

EEGEEG

Prompt Lumbar puncture unless diagnosis Prompt Lumbar puncture unless diagnosis is apparent from above measuresis apparent from above measures

Acute Mental SyndromeAcute Mental Syndrome

If not metabolic, drug induced or If not metabolic, drug induced or connected with structural brain disease connected with structural brain disease cause is likely to be meningoencephalitiscause is likely to be meningoencephalitis

May be vascular disease or fairly mild May be vascular disease or fairly mild process superimposed on chronic brain process superimposed on chronic brain disease in elderlydisease in elderly


65 year old man with non-Hodgkin's 65 year old man with non-Hodgkin's lymphoma complains of a mild gait lymphoma complains of a mild gait disturbance, urinary urge incontinencedisturbance, urinary urge incontinence

Arms are fine but legs have 4/5 powerArms are fine but legs have 4/5 power

Reflexes a little hyperactive in lower Reflexes a little hyperactive in lower extremities, possible upgoing toesextremities, possible upgoing toes

Extradural spinal compressionExtradural spinal compression

Rapid or very rapid progression of lower Rapid or very rapid progression of lower extremity weaknessextremity weakness

Failure to act promptly results in permanent Failure to act promptly results in permanent paraplegia or worse. paraplegia or worse.

Key: trunkal motor level of weakness and Key: trunkal motor level of weakness and sensory level with or without pain. Upper motor sensory level with or without pain. Upper motor neuron weakness in lower extremities.neuron weakness in lower extremities.

Get prompt imaging studies esp spinal MRI and Get prompt imaging studies esp spinal MRI and Neurological or neurosurgical consultation.Neurological or neurosurgical consultation.

Spinal CompressionSpinal Compression

Key to diagnosis – Sensory LevelKey to diagnosis – Sensory Level

May be lower than compressionMay be lower than compression

Also motor level over trunkAlso motor level over trunk

Reflex exam – diminished at level, Reflex exam – diminished at level, increased below levelincreased below level

Upgoing toesUpgoing toes

Cord CompressionCord Compression

Dexamethasone 100 mg ivDexamethasone 100 mg iv

Neurosurgical/orthopaedic consultNeurosurgical/orthopaedic consult

Irradiation or decompressionIrradiation or decompression


17 year old girl complains of diplopia, lid 17 year old girl complains of diplopia, lid droop, may have slight problem droop, may have slight problem swallowing. swallowing.

Speech may be slightly slurred. Muscle Speech may be slightly slurred. Muscle strength seems fairly normal. Reflexes are strength seems fairly normal. Reflexes are normalnormal

MyastheniaMyasthenia

DDX diseases of neuromuscular junctionDDX diseases of neuromuscular junction– Botulism, Lambert-Eaton (rare)Botulism, Lambert-Eaton (rare)

May progress rapidly and impair swallow May progress rapidly and impair swallow or respirationor respiration

Prompt neurological evaluation Prompt neurological evaluation

MyastheniaMyasthenia

Begins with Eye movt abnomalitiesBegins with Eye movt abnomalities

Foll’d by bulbar weaknessFoll’d by bulbar weakness– DysarthriaDysarthria– DysphagiaDysphagia

Peripheral weaknessPeripheral weakness

Myasthenia diagnosisMyasthenia diagnosis

Repetitive muscle testingRepetitive muscle testing

Tensilon TestTensilon Test– Edrophonium 10 mg. 2mg then 8mg find eye Edrophonium 10 mg. 2mg then 8mg find eye

mov’t or muscles to focus onmov’t or muscles to focus on

Striated muscle, ACh receptor antibodyStriated muscle, ACh receptor antibody

CT scan of chest for thymusCT scan of chest for thymus

Myasthenia treatmentMyasthenia treatment

Mestinon 30-60 mg tid to qidMestinon 30-60 mg tid to qid– 1/301/30thth dose iv dose iv

PrednisonePrednisone

Azathiaprine, CyclosporineAzathiaprine, Cyclosporine

Pheresis or IVIg Pheresis or IVIg

Thymectomy Thymectomy


36 year old Camp Hill inmate admitted 36 year old Camp Hill inmate admitted with temp of 104with temp of 104

Increased muscle tone noted and Increased muscle tone noted and shivering on examshivering on exam

Altered sensoriumAltered sensorium

CPK 11000CPK 11000

Neuroleptic malignant syndromeNeuroleptic malignant syndrome

phenothiazine use (Dopamine antagonists)phenothiazine use (Dopamine antagonists)May be in situation preventing coolingMay be in situation preventing coolingSevere sequellae if not recognized/treated Severe sequellae if not recognized/treated (death)(death)d/c offending agentd/c offending agentParlodel (bromocriptine) or dopaminergic Parlodel (bromocriptine) or dopaminergic agents, Dantrium, cooling, hydration, prevent agents, Dantrium, cooling, hydration, prevent rhabdomyolysisrhabdomyolysisDDx: malignant hyperthermia, thyroid storm, DDx: malignant hyperthermia, thyroid storm, sepsis, toxins, strychnine, tetanus, dystoniassepsis, toxins, strychnine, tetanus, dystonias


65 year old man with slurred speech65 year old man with slurred speech

Vertical diplopiaVertical diplopia

Ataxic gait and upper extremitiesAtaxic gait and upper extremities

VertigoVertigo

Fluctuating weaknessFluctuating weakness

Vertebro-basilar strokeVertebro-basilar stroke

DiplopiaDiplopia

DysarthriaDysarthria

DysphagiaDysphagia

““Crossed” sensory or motor syndromeCrossed” sensory or motor syndrome

May be life threateningMay be life threatening

““Locked-in” syndrome in ponsLocked-in” syndrome in pons

Basilar strokeBasilar stroke

Anti-coagulationAnti-coagulation

T-PAT-PA

Consider StentingConsider Stenting


49 year old man with left brain stroke 24 49 year old man with left brain stroke 24 hours ago. Nurse calls you at 2 AMhours ago. Nurse calls you at 2 AM

Decreased responsivenessDecreased responsiveness

Left pupil is larger than rightLeft pupil is larger than right

Bp is 210/120 pulse 50Bp is 210/120 pulse 50

You can’t arouse him and there is You can’t arouse him and there is papilledemapapilledema

Acute increased ICPAcute increased ICP

Begin Mannitol or Lasix and MannitolBegin Mannitol or Lasix and Mannitol

Get a CT scan Get a CT scan

Remove to ICURemove to ICU

Consider Neurosurgical Consult for Consider Neurosurgical Consult for ventriculostomy, hemicraniectomy or other ventriculostomy, hemicraniectomy or other interventionintervention


24 year old woman post-partum24 year old woman post-partum

VomitingVomiting

dehydrationdehydration

Severe headacheSevere headache

DiplopiaDiplopia

SeizuresSeizures

Dural Sinus thrombosis Dural Sinus thrombosis

Key is early recognitionKey is early recognition– Headache, papilledema, aphasia, focal signs, Headache, papilledema, aphasia, focal signs,

seizuresseizures

Hypercoagulable: genetic, contraceptives, Hypercoagulable: genetic, contraceptives, pregnancypregnancy

Heparin is treatment of choice even when Heparin is treatment of choice even when hemorrhage occurshemorrhage occurs

Dural Sinus ThrombosisDural Sinus Thrombosis

HeadacheHeadache

PapilledemaPapilledema

Focal SignsFocal Signs

Altered level of consciousnessAltered level of consciousness

SeizuresSeizures

Setting of hypercoagulable stateSetting of hypercoagulable state

Vertebral Artery DissectionVertebral Artery Dissection

Chiropractic manipulation or neck injuryChiropractic manipulation or neck injury

Neck and head painNeck and head pain

Followed in days to 2 weeks with stroke Followed in days to 2 weeks with stroke like symptomslike symptoms

Key is pain foll’d by stroke with or without Key is pain foll’d by stroke with or without traumatrauma

Treatment: Heparin/coumadinTreatment: Heparin/coumadin

Organophosphate poisoningOrganophosphate poisoning

Diaphoresis, lacrimation, Diaphoresis, lacrimation, sialorrhea, miosissialorrhea, miosis

Smooth and skeletal Smooth and skeletal muscle contraction, muscle contraction, diarrhea, vomitingdiarrhea, vomiting

Seizure, delirium, Seizure, delirium, diplopia, ataxiadiplopia, ataxia

Bronchospasm, Bronchospasm, tachycardia, hypo or tachycardia, hypo or hypertensionhypertension

Atropine 1-2 mg ivAtropine 1-2 mg iv

Pralidoxime (2-PAM) 1-2 Pralidoxime (2-PAM) 1-2 gm in 250 ml iv over 10 gm in 250 ml iv over 10 mins.mins.

Remove source such as Remove source such as clothesclothes

Check RBC Check RBC cholinesterasecholinesterase

neurological emergen

Documents

status epilepticus dangers

seizures failure

guillian barre dangers

guillian barre management

status epilepicus alcohol

severe damage

severe hyp

guillian barre acute