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Neurological emergencies

Neurological emergencies. Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh. Coma Hyperacute stroke (<3 hrs) and thrombolytic therapy, post-thrombolytic care Brain edema , herniation and increased intracranial pressure (IICP) Status epilepticus. COMA. Stabilize (ABC)

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Neurological emergencies

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  1. Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

  2. Coma Hyperacute stroke (<3 hrs) and thrombolytic therapy, post-thrombolytic care Brain edema , herniation and increased intracranial pressure (IICP) Status epilepticus

  3. COMA

  4. Stabilize (ABC) • Obtain a history • Physical examination / neurological examination • Laboratory test (including toxin or drug screen) • Find out possible causes (most common causes are toxic and metabolic derangements, which are potentially treatable and reversible) • Neuroimages (CT or MRI)

  5. 瞳孔反應 pupil Midbrain lesion , Uncal herniation , PcomA aneurysm anhidrosis, miosis, ptosis

  6. Brain stem function B.Oculocephalic (or ”doll’s eye” test ) C.Oculovestibular (or Caloric test) A 意識不清者之正常反應: 轉頭時眼位會反射轉到對側 而使眼位保持在頭中央 正常意識清醒的人: 可抑制此轉頭時反射 故不會有眼位偏移 異常: 反射消失 眼位不動 隨頭轉動 正常: 眼位往冷水刺激側偏轉 異常: 反射消失 眼位不動

  7. Abnormal postures • Brain stem lesion or metabolic derangement Bilateral hemispheric lesion, bilateral internal capusle insults or thalamic

  8. Abnormal postures • Brain stem lesion or metabolic derangement Bilateral hemispheric lesion, bilateral internal capusle insults or thalamic

  9. 呼吸現象評估 兩側大腦深部，天幕上巨大病灶，代謝性腦病變 中腦或上橋腦 下橋腦病變

  10. 呼吸現象評估 下橋腦病變 橋腦尾部及延腦上方 延腦

  11. Hyperacute stroke Thrombolytic therapy Post thrombolytic R’x care

  12. History - onset 時間最重要 因為血栓溶解劑的治療一定要在發生的3小時內且越早給予越好! 所以最重要的是要能確定症狀發生時間點!!! (最好可以說出幾點幾分) 若是在睡覺醒來才發生則時間點就無法確定 或者發生時間不明確時,我们要以病人最後一次被觀察到還是正常的時間點來算.

  13. Admission order 1.avoid antiplatelet, anticoagulant agents for 24 hours 2.NPO except oral drug for 24 hours, avoid NG tube insertion 3.absolutely bed rest for 24 hours 4.record I/O q8h 5.vital signs check q15 mins for 2 hours then q30mins for 6 hours then q1h for 16 hours then as ICU routine

  14. 6.GCS, Light reflex, pupil size Q1h for 24 hours then as ICU routine 7.call on duty resident for NIHSS and NE examination at __ (2nd hour) and __ (24th hour) 8.mark ecchymosis site and observation qid 9.urine observation, call resident if hematuira 10.avoid Foley tube insertion in initial 30 mins . if no urine output or bladder distension in 6 hours then consider Foley tube insertion

  15. 12.Emergent management of BP : *1.If SBP >=180-230 or DBP 105-120 mmHg for >= 2 readings 5-10 mins apart : (1) intravenous Trandate 10 mg over 1-2 mins. the dose may be repeated or doubled every 10-20 mins up to a total dose of 150mg (2) monitor BP q 15 mins during Trandate treatment and observe for development of hypotension

  16. *2.If SBP >230 or DBP 121-140 mmHg for >= 2 readings 5-10 mins apart : (1)(2)同上(1)(2) (3) If no satisfactory response , infuse sodium nitroprusside (0.5-10ug/kg/min) (4) continue monitoring BP

  17. Anticoagulation Heparin : not a standard therapy for all stroke subtypes Contraindication: large infarcts uncontrollable arterial hypertension advanced microvascular change in the brain

  18. Brain edema, herniation Increased intracranial pressure (IICP) Brain edema IICP Risks of herniation

  19. Brain edema , herniation increased intracranial pressure (IICP) Brain edema is defined as an increase in brain sodium and water content It occurs in many neurological conditions , such as stroke, trauma, tumors, infections, encephalopathies, and hydrocephalus ICP related to : brain tissue, blood ,CSF. Normal ICP 7-15 cm Hg. CPP=MAP-ICP, CPP should be kept > 70 mmHg.

  20. (1) Cingulate herniation under the falx cerebri, downward, (2) Transtentorial (central) herniation(3) Uncal herniation over the edge of the tentorium(4) Cerebellar tonsillar herniation into the foramen magnum.

  21. Management Stabilize the patient and secure the vital signs. Keep the patient’s head elevated (30 degree). Keep the patient moderately dehydrated (?). Obtain a CT or MRI Hyperventilation : intubate and maintain PCO2 to 25-30 mmHg. Hyperventilation immediately reduced the blood flow (vasoconstriction ) and decreased ICP. Prolonged use of hyperventilation causes further ischemia to the normal and damaged brain area.

  22. Hyperosmolar agents : Mannitol is most commonly used. 0.25-0.5 mg/kg every 4-6 hours. Serum osmolarity maintain <320 Osm/L (side effects: dehydration, e imbalance, renal function impairment) Glycerol : 250 ml q6h (hyperglycemia, fluid overload, hematuria) Hypertonic saline (3%-23.5% NaCl) (monitor Na q6h, EKG; avoid increased 10meq /24 hours which may cause CPM; fluid overload)

  23. Diuretics : furosemide (Lasix) and acetazolmaide (Diamox) may be helpful in pseudotumor or ischemic brain edema. dosage : 20-40 mg IV every 12 hours Corticosteroids : dexamethasone is particularly useful in brain edema caused by primary or metastatic brain tumor or infections (ex TB or bacterial meningitis). dose is 10mg IV followed by 6 mg every 6 hours. The effectiveness in ischemic brain edema or cellular brain edema (hypoxia) is less clear. ICP monitoring is particular useful when a patient has brain edema after head trauma.

  24. Status Epilepticus Definition Causes treatment

  25. Status epilepticus – definition Seizures last longer than 10 minutes or if two or more seizures occur in close succession without recovery of consciousness Consider any seizure with duration greater than 5 minutes , not 30 minutes as historically defined Convulsive or non-convulsive , focal (epilepsy partialis continua ) or generalized

  26. Common etiologies of seizure and SE

  27. Protocol and timetable for treating SE • 0-5 mins • Diagnose; give O2, ABCs; obtain i.v. access; begin ECG monitoring; draw blood for chem-7, Mg, Ca, CBC, AED level; toxicity screen • 6-10 mins • Thiamine 100mg i.v. ; 50 mg of D50 iv unless adequate glucose level known • Lorazepam (Ativan) 4 mg i.v. over 2 mins; repeat once in 8-10min p.r.n • OR, Diazepam (Valium) 10mg i.v. over 2 mins; repeat in 3-5 mins prn

  28. 10-20 mins • If status persists or if it was stopped with diazepam immediately begins Fosphenytoin 20mg/kg iv at 150 mg/min , with blood pressure and ECG monitoring • Phenytoin 15-20 mg/kg, at (<) 50mg/min rate, • target serum level 15-20 mg/dL

  29. 20-30 mins • If status persists , give additional Fosphenytoin 5mg/kg 2 times (total 30mg/kg) • Or Phenytoin 5mg/kg 2 times • target serum level 20-25 mg/dL

  30. 30+ mins • If status persists , intubate and give one of the following (in order of our preference), preferably with EEG monitoring • Phenobarbital 20 mg/kg i.v. at 50-100 mg/min . Additional 5 mg/kg boluses cane be given as needed .(ps: 本院無 IV form) • Or Midazolam (Dormicum) continuous infusion , 0.2mg/kg slow bolus , then 0.1-2.0 mg/kg/hr • Or Propofol continuous infusion , 1-5 mg/kg bolus over 5 mins, then 2-4 mg/kg/hr

  31. Status epilepticus Valproic acid IV form 2 支 loading then 1.5 支 q8h 較少 allergy, 可能對 myoclonic seizure 或一開始就是generalized seizure 有用，可快速達到理想濃度 但需考慮和其他藥物交互作用，以及肝指數及Ammonia濃度上升

  32. Status epilepticus Phenobarbital : 20 mg/kg i.v., 5 mg/kg bolus (本院無 IV form) Gabapentin (Neurontin) Topiramate (Topamax) Rivotril

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