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Approach to Neurologic Emergencies

Approach to Neurologic Emergencies. Mark Granner, MD Department of Neurology University of Iowa. General Principles. ABC’s Protect the patient Rapid clinical assessment Order diagnostic tests Treat the underlying cause. Emergent Clinical Assessment. Vital signs General medical exam

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Approach to Neurologic Emergencies

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  1. Approach to Neurologic Emergencies Mark Granner, MD Department of Neurology University of Iowa

  2. General Principles • ABC’s • Protect the patient • Rapid clinical assessment • Order diagnostic tests • Treat the underlying cause

  3. Emergent Clinical Assessment • Vital signs • General medical exam • Trauma exam • Assess for meningeal irritation • subarachnoid blood, meningitis • Glasgow Coma Scale

  4. Eye Opening (E) 4 spontaneous 3 to speech 2 to pain 1 no response Best Verbal Response (V) 5 oriented & converses 4 disoriented & converses 3 inappropriate words 2 incomprehensible sounds 1 no response Glasgow Coma Scale • Best Motor Response (M) 6 to verbal command 5 localizes pain 4 flexion-withdrawal 3 flexion-abnormal 2 extension 1 no response Score = E + M + V = 3-15 <9 = severe injury, 50% mortality 9-11 = moderate severity >11 = minor injury

  5. Emergent Clinical Assessment (cont.) • Neurologic Examination • Level of consciousness • Respiratory pattern • Pupillary size & light response • Ocular movements, cold water calorics • Corneal response • Gag reflex • Motor response • Reflexes

  6. Emergent Clinical Assessment (cont.) • In non-comatose patients • Language • Vision • Sensation

  7. Coma • A state of decreased or absent consciousness • A state of awareness of self and environment • Arousal • Content • Global vs. focal causes • History is often absent, incomplete or misleading

  8. Coma • Due to diffuse cerebral or RAS dysfunction • Most structural lesions do not cause coma • If so, consider edema, hemorrhage or herniation • Absence of brainstem reflexes implicates RAS dysfunction • Coma is a continuum

  9. Causes of Coma • Toxic/metabolic encephalopathy • Medications • Glucose, sodium, renal, hepatic • Focal supratentorial lesion • Tumor, stroke, hemorrhage • Focal signs likely

  10. Causes of Coma (cont.) • Focal posterior fossa lesion • May produce global dysfunction via hydrocephalus • Psychogenic • A diagnosis of exclusion

  11. Management of Increased ICP • Causes • Large structural lesion, edema, hydrocephalus • Reasons for coma • Compartment shifts, decreased cerebral perfusion, herniation • Symptoms and signs • Headache, N/V, decreased level of consciousness, papilledema (late), Cushing’s response ( BP,  pulse)

  12. Management of Increased ICP • Treatment • Shrink CSF space (ventriculostomy) • Shrink blood compartment (hyperventilation) • Shrink brain • osmotic agents (manitol) • surgical decompression

  13. Status Epilepticus • Definition • A single prolonged seizure (>10-30 minutes) • Recurrent seizures without return to baseline • Neuronal injury occurs in 30-60 minutes • Systemic factors (hypoxia, hypercarbia, hypotension, lactic acidosis) • Central factors (glutamate, free radicals, apoptosis)

  14. Duration of Complex Partial Seizures

  15. Status Epilepticus • Goals • Protect the patient • Stop the seizure • Treat the underlying cause • Diagnosis • Clinical (unresponsive, movements) • EEG (especially useful in NCSE)

  16. Status Epilepticus • Initial Management • ABC’s • IV access • Check labs • Glucose, electrolytes, CBC, AED levels, urine drug screen, BAL • Give IV glucose + thiamine

  17. Status Epilepticus • Treatment • IV lorazepam 0.1 mg/kg • IV phenytoin 20 mg/kg • If refractory, pentobarbital or Propofol coma

  18. Acute Spinal Cord Compression • Caused by trauma or a mass (tumor, abscess) • Goal is to prevent permanent dysfunction

  19. Acute Spinal Cord Compression • Diagnosis • Symptoms • Back or neck pain, incontinence • Signs • Fever (abscess), gait trouble, weakness or sensory deficit below lesion • Imaging • MRI

  20. Acute Spinal Cord Compression • Treatment • IV corticosteroids • Surgical decompression • XRT (neoplasm)

  21. CNS Infections • Infectious prodrome usually present • Neurologic symptoms can evolve rapidly • May produce global (encephalitis) or focal (abscess) signs

  22. CNS Infections • Diagnosis • Meningeal irritation (meningitis) • Systemic signs (e.g. rash in meningococcus) • Imaging (CT) if focal signs • Blood cultures • CSF exam • Treatment • Specific to cause

  23. Acute Neuromuscular Failure • Progressive weakness of limb muscles and ventilation • Impending respiratory failure will manifest first with  FVC and tachypnea • ABG changes late

  24. Acute Neuromuscular Failure • Causes • Peripheral nerve (e.g. Guillain-Barré) • Neuromuscular junction (e.g. myasthenia gravis • Muscle (rare)

  25. Acute Neuromuscular Failure • Diagnosis • Decreased strength • Decreased FVC • Hypotonia • Decreased/absent reflexes (neuropathy) • No or little sensory loss • No upper motor neuron signs

  26. Acute Neuromuscular Failure • Treatment • Ventilatory support (if FVC < 10cc/kg and falling) • Immune modulation (plasma exchange, IVIG)

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