Neurological Neurological Emergencies Emergencies
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
Vignette 2Vignette 2
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
Vignette 3Vignette 3
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
Vignette 4Vignette 4
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
Vignette 5Vignette 5
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
Vignette 6Vignette 6
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
Vignette 6Vignette 6
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
Vignette 7Vignette 7
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
Vignette 8Vignette 8
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
Vignette 9Vignette 9
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