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Approach to Neurologic Emergencies

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Approach to Neurologic Emergencies Mark Granner, MD Department of Neurology University of Iowa General Principles ABC s Protect the patient Rapid clinical ... – PowerPoint PPT presentation

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Title: Approach to Neurologic Emergencies


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

2
(No Transcript)
3
General Principles
  • ABCs
  • Protect the patient
  • Rapid clinical assessment
  • Order diagnostic tests
  • Treat the underlying cause

4
Emergent Clinical Assessment
  • Vital signs
  • General medical exam
  • Trauma exam
  • Assess for meningeal irritation
  • subarachnoid blood, meningitis
  • Glasgow Coma Scale

5
Glasgow Coma Scale
  • 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
  • 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 lt9 severe injury, 50
mortality 9-11 moderate severity gt11 minor
injury
6
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

7
Emergent Clinical Assessment (cont.)
  • In non-comatose patients
  • Language
  • Vision
  • Sensation

8
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

9
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

10
Causes of Coma
  • Toxic/metabolic encephalopathy
  • Medications
  • Glucose, sodium, renal, hepatic
  • Focal supratentorial lesion
  • Tumor, stroke, hemorrhage
  • Focal signs likely

11
Causes of Coma (cont.)
  • Focal posterior fossa lesion
  • May produce global dysfunction via hydrocephalus
  • Psychogenic
  • A diagnosis of exclusion

12
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), Cushings response (? BP, ?
    pulse)

13
Management of Increased ICP
  • Treatment
  • Shrink CSF space (ventriculostomy)
  • Shrink blood compartment (hyperventilation)
  • Shrink brain
  • osmotic agents (manitol)
  • surgical decompression

14
Status Epilepticus
  • Definition
  • A single prolonged seizure (gt10-30 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)

15
Duration of Complex Partial Seizures
16
Status Epilepticus
  • Goals
  • Protect the patient
  • Stop the seizure
  • Treat the underlying cause
  • Diagnosis
  • Clinical (unresponsive, movements)
  • EEG (especially useful in NCSE)

17
Status Epilepticus
  • Initial Management
  • ABCs
  • IV access
  • Check labs
  • Glucose, electrolytes, CBC, AED levels, urine
    drug screen, BAL
  • Give IV glucose thiamine

18
Status Epilepticus
  • Treatment
  • IV lorazepam 0.1 mg/kg
  • IV phenytoin 20 mg/kg
  • If refractory, pentobarbital or Propofol coma

19
Acute Spinal Cord Compression
  • Caused by trauma or a mass (tumor, abscess)
  • Goal is to prevent permanent dysfunction

20
Acute Spinal Cord Compression
  • Diagnosis
  • Symptoms
  • Back or neck pain, incontinence
  • Signs
  • Fever (abscess), gait trouble, weakness or
    sensory deficit below lesion
  • Imaging
  • MRI

21
Acute Spinal Cord Compression
  • Treatment
  • IV corticosteroids
  • Surgical decompression
  • XRT (neoplasm)

22
CNS Infections
  • Infectious prodrome usually present
  • Neurologic symptoms can evolve rapidly
  • May produce global (encephalitis) or focal
    (abscess) signs

23
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

24
Acute Neuromuscular Failure
  • Progressive weakness of limb muscles and
    ventilation
  • Impending respiratory failure will manifest first
    with ? FVC and tachypnea
  • ABG changes late

25
Acute Neuromuscular Failure
  • Causes
  • Peripheral nerve (e.g. Guillain-BarrĂ©)
  • Neuromuscular junction (e.g. myasthenia gravis
  • Muscle (rare)

26
Acute Neuromuscular Failure
  • Diagnosis
  • Decreased strength
  • Decreased FVC
  • Hypotonia
  • Decreased/absent reflexes (neuropathy)
  • No or little sensory loss
  • No upper motor neuron signs

27
Acute Neuromuscular Failure
  • Treatment
  • Ventilatory support (if FVC lt 10cc/kg and
    falling)
  • Immune modulation (plasma exchange, IVIG)
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