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內科加護病房常見之 神經科問題

內科加護病房常見之 神經科問題. 神經內科 林俊豪. 何時緊急找 Neurologist ?. Mental change Weakness of limbs Fever with headache Convulsion. 何時緊急找 Neurologist ?. Unilateral limbs weakness +/- facial asymmetry or slurred speech ,easy choking  stroke, brain tumor….

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內科加護病房常見之 神經科問題

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  1. 內科加護病房常見之神經科問題 神經內科 林俊豪

  2. 何時緊急找 Neurologist ? • Mental change • Weakness of limbs • Fever with headache • Convulsion

  3. 何時緊急找 Neurologist ? • Unilateral limbs weakness +/- facial asymmetry or slurred speech ,easy choking  stroke, brain tumor…. • Weakness of bilateral legs or four limbs without cranial nerve dysfunction spinal cord lesion, AIDP, myopathy • Fever with headache or mental change CNS infection

  4. 意識改變的原因 • 造成意識改變的原因有許多都不是先從腦部疾病造成的 • 例如藥物中毒,缺氧,肝昏迷,內分泌如血糖過高或過低,酸鹼不平衡,敗血症,高血壓腦病變… • 其他腦部疾病包括腦出血，腦梗塞，腦脫疝，腦膜炎或腦炎

  5. 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

  6. 呼吸現象評估 橋腦尾部及延腦上方 延腦

  7. 瞳孔反應 • 簡單來說 光刺激由第二對視神經傳入 瞳孔收縮由第三對動眼神經執行 瞳孔擴張經由交感神經路徑控制

  8. 瞳孔反應

  9. 眼位與身體姿勢及無力 • 意識不清，單側肢體無力又兩眼偏移：極有可能是腦部問題 眼球偏向無力側—對側橋腦 眼球偏離無力側---大腦病灶，位在無力肢體對側 --->記住一點，通常腦部病灶在無力肢體對側 • 癲癇也會造成眼球偏移

  10. 角膜反射 • 使用棉花尖端碰觸角膜，經第五對三叉神經傳入，在橋腦及延腦間傳遞，再經由兩側顏面神經傳出而眨眼

  11. stroke • Infarction • Hemorrhage— SAH ICH • Headache, vomiting, seizure, coma---hemorrhage is more likely • TIA – transient ischemic attack

  12. Stroke Management • Diagnostic tests brain CT—如懷疑brain stem infarction, focus posterior fossa ECG clinical chemistry--- complete blood count and platelet count, PT,INR, PTT serum electrolytes, blood glucose, ABG, Hepatic and renal chemical analysis

  13. Thrombolytic treatment – rt-PA • rt-PA : 0.9 mg/kg,10% bolus in one minutes • Time window : 3 hours切記 • NIH stroke scale 6-25 • Exclusion: age <18 y/o or >80 y/o 非絕對 bleeding tendency or other active bleeding BP : SBP > 185 or DBP >110mmHg blood sugar : < 50 or > 400 mg/dL

  14. Stroke Management • The European Stroke Initiative Executive Committee and the EUSI Writing Committee Update 2003

  15. General stroke treatment • Vital signs • Glasgow coma scale • NIH stroke scale • Pupil size and light reflex ( large infarction or brain stem infarction in evolution)

  16. Pulmonary function and airway protection • oxygen supply at low flow rates ：沒有證據在human brain infarction 有幫助 • Little evidence that stroke patients benefit from hyperbaric oxygen therapy • Intubation : unconscious patient (GCS<8 ?) at high risk for aspiration

  17. Blood pressure management • Many patients with acute stroke have elevated BP • Cerebral blood flow autoregulation may be defective in an area of evolving infarction ischemic penumbra is passively dependnet on the mean arterial pressure abrupt drops in blood pressure must be avoided

  18. Blood pressure management • Prior hypertension: 180/100-105 mmHg • Other cases: 160-180/90-100 mmHg • SBP over 220-230 mmHg DBP over 120-130 mmHg  indication for early but cautious drug therapy

  19. Blood pressure management • Treatment may be appropriate in the setting of concomitant: acute myocardial infarction cardiac insufficiency acute renal failure aortic arch dissection • Thrombolysis or heparin administration • Large infarct area with brain edema?

  20. Blood pressure management--drugs • Avoid sublingual nifedipine !!! possible ischemic steal • Captopril • Labetalol • Sodium nitroprusside

  21. Glucose metabolism • An increase in serum glucose level at hospital admission may be frequently found. • High glucose levels are harmful in stroke. • Temporary insulin treatment may become necessary.

  22. Body temperature • Hyperthermia increases infarct size. • Although there are no prospective data,one may consider to treat fever as early as the temperature reaches 37.5 °C.  Acetaminophen

  23. Fluid and electrolyte management • Some degree of dehydration on admission is frequent and may be related to bad outcome. • Presence of brain oedema  a slightly negative fluid balance • Hypotonic solution (NaCl 0.45% or glucose 5%) are contra-indicated due to the risk of brain oedema increase.

  24. Aspirin • Aspirin given within 48 hors after stroke : reduce mortality and rate of recurrent stroke minimally, but statistically significantly • Dose :160- 300 mg

  25. anticoagulation • Heparin : not a standard therapy for all stroke subtypes • Contraindication: large infarcts uncontrollable arterial hypertension advanced microvascular change In the brain

  26. Special treatment • Haemodilution : failed to demonstrate a decline in mortality or disability • Neuroprotection : no evidence • Seizure: post-stroke epilepsy may develop in 3-4% of cases • Prophylactic anticonvulsant: no evidence

  27. Brain oedema and elevated ICP • CPP=MAP-ICP, should be kept > 70 mmHg • Management head position :elevation 30° pain relief appropriate oxygenation supply Mannitol : 25-50 g every 3-6 h Glycerol : 250 ml q6h Hypertonic saline (3% NaCl)

  28. Brain oedema and elevated ICP • Hyperventilation PCO2 25-30 mmHg • Hypothermia:32-33 °C

  29. Status epilepticus • Seizures last longer than 10 minutes or if two or more seizures occur in close succession without recovery of consciousness • Convulsive or non-convulsive

  30. Status epilepticus • Ativan 4mg iv in 2 min, max 8 mg • Valium 10 mg iv in 2 min ,max 20 mg • 以上需注意呼吸抑制 • Phenytoin 20 mg/kg, bolus 5mg/kg 可兩次 60 kg patient 4-5 支iv drip , < 50 mg/min (fosphenytoin, 150 mg/min, minimal irritaton)

  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) • Midazolam (Dormicum) : 15mg/3mL 例 60 kg 病人, 4 vial in 48 ml N/S1mg/mL 0.2mg/kg bolus then 0.1-2.0 mg/kg/hr  1 vial loading ,then run 6-120 c.c./hr

  33. Status epilepticus • Propofol : 1-5 mg/kg bolus then 2-4 mg/kg/hr 60 kg 病患 , 1 amp 200mg/20 mL  6-30 c.c bolus then run 12-24 c.c./hr • Gabapentin (Neurontin) • Topiramate (Topamax) • Rivotril

  34. Spinal cord lesion • Disc herniation • Tumor • Myelitis • Hemorrhage • Infarction • Epidural abscess

  35. Spinal cord lesion • Paraplegia • Tetraplegia • Hemiplegia with contra-lateral sensation loss • Urine or stool retention ：AIDP 少見 • Sensory level + ：myopathy 不會有 • DTR increase

  36. Spinal cord lesion • Neurologic emergency  Once paralysis, forever paralysis • Image study : MRI, as soon as possible • Treatment: steroid Solu-Medrol 1000 mg /qd IV drip for 3 days Decadron 5-10mg q8h-q6h IV

  37. CNS infection • Meningitis • Brain abscess: 未必需施行lumbar puncture • Encephalitis :CSF 未必異常 • Diagnosis brain CT lumbar puncture :IICP is not contraindication

  38. Lumbar puncture • Normal pressure : 100-180 mmH2O • Cells: less than 5 lymphocyte • Protein : less than 45 mg/dL • Glucose: 0.6-0.7 of serum concentration • Traumatic tapping: 500-1000 RBC / 1 WBC

  39. Lumbar puncture • 檢體需速件處理 • 最好於飯後兩小時左右施行 • 記得check serum glucose • 如ICP 太高（約300 mmH2O 以上），先給予Mannitol

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