Neurological Emergencies

1. Neurological Emergencies Amy Gutman MD prehospitalmd@gmail.com

2. Overview • In the next 2 hours: • Anatomy & Physiology • Focused Assessment & Examination • Differential Diagnosis • Management & Critical Thinking • What we will not cover in the next 2 hours: • Trauma patients with neurological findings • Psychiatric emergencies

3. terminology • Neurology (Greek): “Vεῦρον” (neuron), “λογία” (study); medical specialty studying diagnosis & treatment of nervous system disorders • Neuron: Single nerve cell • Neurotransmitter: Chemicals allowing impulses to travel between neurons • Ipsi / Unilateral: Same-sided, one sided • Contralateral: Opposite-sided • Paralysis: Complete loss of function • Paresis: Limited function • Anesthesia: Complete loss of sensation • Paresthesias: Abnormal sensation • Lesion: Focus for neurological abnormality

4. Anatomy & Physiology - cns • Neurons & Neurotransmitters • Protective Structures • Brain • Spinal Cord

5. Neurons & neurotransmitters • Billions of neurons allow body functions via neurotransmitters • Neurotransmitters are excitatory or inhibitory • Excitatory: acetylcholine, norepinephrine • Inhibitory: dopamine, serotonin, GABA • Each neurotransmitter directly or indirectly influences specific type(s) of neuron

6. Neurons & neurotransmitters • Nerve impulse travels from neuron through axon to terminal & synaptic knob • Synaptic knob communicates with dendrite of neighbor neuron via neurovesicles that store &release neurotransmitters into synapse • If stimulated in a “lock & key” manner, the next neuron picks up & continues the impulse • Seizures: continuous release / stimulation of impulses = spasm • Botulism: neurotransmitters bound so no impulses = flaccidity

7. Cns pharmacology • Depressants • Increase GABA (inhibitory neurotransmitter), decreasing nervous system activity • Barbiturates, Benzodiazepines • If combined other depressants can be fatal • Abrupt discontinuation leads to withdrawal & seizures • Stimulants • Increase norepinephrine, dopamine to increase nervous system & catecholamine response • Dexromethorphan, methylphenidate, cocaine

8. CNS protective structure - skull

9. Cns protective structures – vertebrae (spine)

10. Cns protective structures - meninges

11. CNS - Brain • Temporal Lobe • Language function • Auditory perception • Memory • Emotion • Occipital Lobe • Visual perception &processing • Frontal Lobe • Thinking, planning • Executive functions • Motor execution • Parietal Lobe • Somatosensory perception • Integration of visual & somatospatialinformation

12. Cns - brain

13. Cns – vascular supply

14. Cns – spinal nerves & dermatomes

15. Cervical dermatomes ROOT MOTOR SENSORY C3 Diaphragm, Trap Lower neck C4 Diaphragm Clavicle C5 Bicep & deltoid Below clavicle C6 Bicep Thumb, forearm C7 Tricep Index, middle fingers C8 Finger flexors Pinky T1 Hand intrinsics Medial Arm “C 3 4 5 keeps the diaphragm alive”

16. Cranial nerves • "On Old Olympus's Towering Tops, A Fine-Vested German Viewed Some Hops" • "Oh, Oh, Oh, To Touch And Feel, A Good Velvet, Spot in Heaven" • Motor (M), sensory (S), or both (B) • "Some Say Money Matters But My Brother Says Big Brains Matter Most" • 1 Olfactory • 2 Optic • 3 Oculomotor • 4 Trochlear • 5 Trigeminal • 6 Abducens • 7 Facial • 8 Vestibulocochlear • 9 Glossopharyngeal • 10 Vagus • 11 Spinal Accessory • 12 Hypoglossal

17. Anatomy & Physiology - PNS • Autonomic Nervous System • Sympathetic: “Fight or Flight” • Parasympathetic: “Feed or breed”, “Rest & Repair” • Clinically: “Point & Shoot” • Peripheral Nerves • 43 pairs of nerves originate from CNS to form PNS • 12 pairs of cranial nerves from brain • 31 pairs of spinal nerves from spinal cord

18. Anatomy & physiology - pns

19. Prehospitalassessment

20. The big picture Altered Mental Status Focal Neurological Complaints “Sick” vs “Not Sick”

21. Chief complaint • Exact quotes – words are clues • “The room is spinning” vs “I feel like I’m spinning” • “My vision is blurred” vs “I have double vision” • Obtain from pt, witnesses, family while beginning assessment & management • CC, HPI & exam should focus on neurological aspects, without overlooking non-neurological processes causing AMS or deficits

22. History of present illness • Allergies • Medications • PMH • Sz, trauma, HA, HTN, DM, infections, tumors • Cardiac, renal, hepatic, neuro, psychiatric diseases • Last oral intake • Events leading up to event • Environmental clues • Indoors or outdoors? • Any unusual odors? • Suicide notes? • Provokes / Progression / Palliation • Quality • Region/radiation • Severity • Time of onset • Family/Social history

23. Neurological exam - assessment • Level of consciousness • Memory & amnesia • AVPU / GCS • Focal neurological exam • Affect/mood • Speech • Behavior & posture • Cognition • Mood, Thought, Perception, Judgment, Memory & Attention • Grooming &personal hygiene

24. Glasgow COMA Scale (3-15) • Eye Opening • 4 = Spontaneous • 3 = To Voice • 2 = To Pain • 1 = None • Verbal • 5 = Oriented • 4 = Confused • 3 = Inappropriate words • 2 = Inappropriate sounds • 1= None • Motor • 6 = Obeys commands • 5 = Localizes pain • 4 = Withdraws to pain • 3 = Decorticate • 2 = Decerebrate • 1 = None The number is less important than the category & what you do with it!

25. Neurological exam - speech • Speech and language • “Hear them talk, watch them talk, &look at their eyes; that’s 90% of the brain” (Henry, 2004) • Normal speech inflected, clear, fluent, articulate, varies in volume • Language • Dysphonia: Inability to make laryngeal sounds • Dysprosody: Inflection, pronunciation, pitch or rhythm (cerebellum) • Dysarthria: Difficulty making individual sounds (motor integration) • Aphasia: absence of speech • Dysphasia: word finding difficulty (cortex) • Expressive aphasia: understands but cannot speak (frontal Broca’s) • Receptive aphasia: words clear, content scrambled (parietalWernicke’s) • Apraxia: difficulty in both forming & phonating

26. Vital signs • Respirations • Hyperventilation • Hypoventilation • Cheyne-Stokes: crescendo-decrescendo then apnea • Ataxic: irregular rate & depth • Apneustic: inspiratory pause • Temperature: • Infection • Hemorrhage • Seizure (cause or effect) • Heat stroke • Metabolic • BP: • Hypotension • Hypertension • Cushing’s Triad: • Hypertension • Bradycardia • Bradypnea

27. Physical Exam • Head • Skull: trauma; infants – bulging membranes • Mouth: odors, bites to lateral tongue • Neck • Meningismus • Skin • Trauma, rash, IVDA, temperature • Lungs, Cardiac, Abdomen • Systemic illnesses and secondary effects of CNS insults • Extremities • Trauma, deformity, pulses

28. Neurological exam - eyes • Pupil size, symmetry, reactivity • Miosis • Mydriasis • Extraocular movements • Resting eye position • Deviation • Nystagmus / direction • Conjugate movement

29. Neurological exam –motor & sensory • Cranial nerves • Reflexes • Cerebellar • Gait • Finger pointing • Psychiatric • Posturing • Any asymmetry • Seizure activity • Look at eyes

30. Test glucose & you have the Miami / LA Stroke Scale

31. Differential diagnosis / neurological emergencies

32. The big picture Altered Mental Status Focal Neurological Complaints “Sick” vs “Not Sick”

33. Causes of ams • AEIOU TIPS • A Alcohol / Drugs / Toxins • E Endocrine, Exocrine, Electrolyte • I Insulin • O Opiates, OD • U Uremia • T Trauma, Temperature • I Infection • P Psychiatric disorder • S Seizure , Stroke, Shock, Space occupying lesion

34. AMS Pearls • History often initially more important than exam • What is MOST important question with a neuro deficit or AMS? • Physical Exam Keys • Odors • Respiration • Eyes • Trauma? • IVDA? • Serial GCS • If <8, INTUBATE!

35. Alcohol / drugs / toxins • Drunk + ground = head & C spine injury until proven otherwise • Multiple toxidromes& drug reactions cause AMS or focal deficits • Common: • Organophosphates • CO • Sympathomimetics / withdrawal • Opiates / Withdrawal • Hypoglycemic agents • Cardiac agents • Psych Meds (TCAs, SSRIs) • Another day, another lecture!

36. temperature • Hypothermia: AMS / coma <32.0 C • Hyperthermia: AMS / coma >42.0C • Environmental • Sepsis • Drug reaction • Neuroleptic malignant syndrome

37. Exocrine / endocrine / electrolyte • Cause vs effect • AMS • Seizures • Syncope • Often related to arrhythmias • Most Common • Hypo / hyperglycemia • Hypo / hyperkalemia • Hyponatremia • Thyroid storm

38. Stroke –Epidemiology • Disability affects 75% survivors • #1 cause adult disability in the US & Europe • #3 cause death worldwide after CAD & cancer • 10% deaths worldwide • US Management costs $43 billion annually • Incidence increases exponentially >30 yrs • Etiology varies by age • 95% of strokes occur in people >45 yo • 75% of strokes occur in people >65 yo • Rule of two thirds • 2/3 all strokes ischemic • 2/3 of those thrombotic

39. Stroke - Gender Differences • Men 1.25 x more likely to suffer strokes than women • However, 60% of deaths from stroke occur in women • Since women live longer than men, they are older on average when they have their strokes & therefore more often killed • Some risk factors for stroke apply only to women: • Pregnancy • Childbirth • Menopause • HRT

40. Advanced age Previous stroke or TIA Diabetes High cholesterol Cigarette smoking Atrial fibrillation HRT Migraines Thrombophilia Patent foramen ovale HTN Most important & modifiable Stroke - Risk Factors

41. Seizure Infection Hypoglycemia Syncope Brain abscess or tumor Drug Overdose Head Trauma Vascular Lesions HTN Encephalopathy Migraine Stroke - Mimics

42. Stroke Pathophysiology - ischemic • Thrombotic • Slow, progressive onset • Causes: • Atherosclerosis (#1 cause) • Infective • Inflammatory (vasculitis) • Hypercoaguable states • Embolic • Abrupt onset • Maximal deficit may improve over time as embolus breaks • Causes • Mural thrombus (#1 ) • Aortic plaques • Endocarditis • Long bone injuries • Dysbarism

43. Stroke syndromes - TIA / rind • Altered neuro status that resolves completely <24hrs (TIA) or <72hrs (RIND) • 30% will have a major stroke event within 3 years • Treat as CVA

44. Stroke Pathophysiology – hemorrhagic • Spontaneous rupture leads to subarachnoid hemorrhage • HTN • Congenital abnormality (AV malformation, berry aneurysm) • Blood dyscrasia / anticoagulants • Infection • Neoplasm • Classic Presentation: 35-65 yo M with h/o HTN with undiagnosed berry aneurysm • Abrupt onset of “worst headache of life” • Nuchal rigidity, photophobia, vomiting, retinal hemorrhages • Atypical: hemorrhagic transformation of embolic stroke

45. Stroke pathophysiology - Systemic Hypoperfusion • Reduction of blood flow to all parts of the body • Causes: • Pump failure: cardiac arrest, arrhythmias • Reduced cardiac output: MI, PE, hemorrhage, shock • Hypoxemia • Entire brain affected, especially penumbra / "watershed"

46. Stroke Syndromes – cerebral blood flow • Anterior Circulation: • 80% cerebral blood flow • Originates from carotids • Supplies fronto-parietal, anterior temporal, optic nerve • Posterior Circulation: • 20% cerebral blood flow • Originates from vertebrobasilararteries • Supplies thalamus, brainstem, occipital cortex, cerebellum, upper cord, ears • Circle of Willis: • Connects ant & post circulations

47. Stroke - Symptoms • Generally Unilateral • Stroke site on opposite side than clinical ssx • LOC, HA, & vomiting more common in hemorrhagic than ischemic (higher ICP) • Cerebral Cortex: • Occipital: Visual field defect • Temporal: Memory deficits • Parietal: Hemineglect, aphasia • Frontal: Disorganized thinking, confusion, hypersexuality

48. Symptoms • Brainstem / Cranial Nerves: • Altered smell, taste, hearing, or vision • Ptosis, diplopia, pupil reactivity • Decreased gag, tongue movement, facial sensation & muscle weakness • Balance problems & nystagmus • Altered breathing & pulse • Cerebellum • Altered coordination • Vertigo or disequilibrium

49. Time is Brain • From the time a patient first experiences ssx there is a 3* hrwindow to administer tPA • That window includes: • Recognition of symptoms • Call to 911 & activation of EMS • EMS response, assessment, management & transport • ED assessment & CT scan to rule out hemorrhagic stroke • Stroke team activation & screening for TPA • 11% increase in measureable (+) symptom improvement • TPA only given to 1-2% of stroke patients *Debatable & Changing

50. Stroke management – thrombolytic checklist Answer to ALL must be YES: Answer to ALL MUST be NO: CT proven hemorrhage Active internal bleeding <21 days Bleeding diasthesis: Plts<100,000 Heparin <48 hrs w/high PTT Warfarin use with high PT Prior surgery or ischemic CVA <3 mos Major surgery <14 days AMI, arterial stick/LP <7 days Prior ICH, AVM, tumor, aneurysm or seizure + stroke SBP >185mmHg or DBP >110Hg No septic emboli • >18yo • Acute ischemic stroke causing a measurable non- improving neurologic deficit • NO clinical suspicion for SAH • Time of onset to treatment is <180 mins