Neurologic Emergencies

NEUROLOGIC EMERGENCIES 1.

STATUS EPILEPTICUS 2 or more seizures failure to regain consciousness between seizure some define it as 30 mins of continuous seizure without regaining consciousness GTC, Status, Epilepsy ‘Petit mal’ status CNS metabolic consumption rhabdomyolisis Metabolic acidosis and other damage Hypothermia Cardiac and other organ effects 20% mortality alcohol or drug withdrawal, illicit drug ingestion INH intoxication Failure to take / abrupt withdrawal/cessation of anticonvulsants Diabetic non-ketotic hyperglycemia Can have meningoencephalitis esp. Herpes Cerebral anoxia Metabolic derangement (eg. Hypogly, hyponat) Pay attention to ABCs Rapid assessment Basic labs, electrolytes, CBC, Glucose as IV goes in Drug screen CT GOAL: stop the seizure

At the screen ▫ Remove contacts ▫ Lateral semiprone positon, AW ▫ IV diazepam In the ER ▫ Add IV ▫ Diazepam, Phenytoin 15-18 mg/k at 50 mg/min or 20-30 mg/min in elderly ____ 25 ml if hyperglycemic ▫ Thiamine 100 mg if alcoholic Resistant? Transfer to ICU ANTICONVULSANT: DIAZEPAM ▫ Similar load with phenytoin up to 18 mg/kg following maintenance ▫ If seizure if stopped in 30 min add phenobarb ▫ If unsuccessful in 1-2 h, general anes (eg. PROPRANOLOL 20-50 mg intermittent bolus)

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Vignette 1: INH TOXICITY 25 F ED: overdose of unknown drug GTC seizure, cyanotic MD found out: INH TOXICITY

MANAGEMENT: ▫ Give pyridoxine (6mg)

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Vignette 2: GBS - continued MANAGEMENT: ▫ Good nursing care ▫ Monitor VS ▫ DVT prophylaxis ▫ IVIg or pheresis

Vignette 3: SAH- Aneurysm of Post. Commisural Artery on the right ▫ ▫ ▫ ▫ ▫ ▫ ▫ SAH -

GUILLAIN-BARRE Acute, subacute demylinating Numbess typically starts distally or multifocally, significant weakness Bifacial weakness & other cranial findings Areflexia Slow nerve… DANGERS: Failure to recognize may result to: 1. severe weakness 2. respiration 3. respiratory failure 4. autonomic instability  major cause of death  severe sudden hypotension  candi….

likely to cause death or severe damage if unrecognized seizure, progression of neuro deficit and altered sensorium sudden onset headache

PRIMARY Idiopathic thundercap HA Sexual HA Exertional HA Cough HA

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SECONDARY SAH Venous sinus thrombosis Pit. Apoplexy Arterial dissection Meningoencephalitis Acute hydrocephalus Acute HPN Spontaneous intracranial hypotension

Vignette 4: STROKE ▫ ▫ ▫ ▫ ▫ ▫

64 Hx of MI, HPN Onset of L hemi Dysarthria BP: 190/115; PR: 90 Continued deficits

Vignette 5: Acute Mental Syndrome w/ or w/o seizure (Encephalopathy) ▫ ▫ ▫ ▫ ▫ ▫

24 not quite right over the last couple o days mild HA aphasia, altered sensorium stereotyped automatic repetitive movement (automatism) of mouth and R arm the sudden seizure neck mild unsupple

ENCEPHALOPATHY may be vascular disease or failing mild processes

Vignette 2: GBS 55 F 3 PTA: tingling of hands and feet; instability, falling weaker, unable to stand on own or hold utensils lacks all but knee reflexes initially later losing all DTRs

35 F Hx of some headache Severe head pain, vomiting ? lid droop in R w/ slightly larger pupil altered sensorium mildly stiff neck pre-retinal hemorrhage on fundoscopic exam

Vignette 6: Mets to vertebral body ▫ ▫ ▫ ▫

65 M with non-Hodgkin’s lymphoma mild gait urinary incontinence arms are fine but legs have 4/5 power

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reflexes a little hyperactive in LE, possible upgoing toes (Babinski Sign)

EXTRADURAL SPINAL COMPRESSION Rapid progression of LE weakness Spinal MRI SPINAL COMPRESSION Upgoing toes Initially starts as a back pain Dexamethason Neurosurgery Irradiation or decompression

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rina D1 2007

Vignette 7: MYASTHENIA GRAVIS ▫ ▫ ▫ ▫ ▫ ▫

17y diplopia, lid droop, slight swallowing problem impaired swallowing slurred speech ms strength: fairly normal reflexes normal

MG -

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DDx of dis of neuromuscular joint: botulinum, Lambert-Eaton • Cholinergic crises • Myathenic crises May progress rapidly and impair swallowing or respiration Prompt neurologic evaluation

Vignette 10: INC. INTRACRANIAL PRESSURE ▫ ▫

49 M L brain stroke 24h ago

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 responsiveness

MANAGEMENT Mannitol Steroids - Positioning of the head - 20º Hyperventilation Control seizure Surgical decompression - ACUTE ICP: Consider neurosurgical consult for ventriculotomy (?) or hemicraniectomy

Vignette 11: DURAL SINUS THROMBOSIS

Vignette 8: Neuroleptic Malignancy Syn ▫

24y

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Tm: 39-40º C  muscle tone shivering on exam altered sensorium CPK 11000

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CAUSED BY: offending drug = PHENOTHIAZINE Partodel or Dopaminergic agents, Dantrium ?, cooling hydration prevent rhabdomyolysis DDx: • Malignant hyperthermia • Sepsis • Toxins • Tetanus • Dystonia Dx: • Tachycardia, hypersalivation • Sweating, labile BP • Hyperthermia, ms rigidity • Myoglobinuria • Stupor and coma Mx: • Withdrawal of neuroleptic agents • Dehydration • Bromcriptine • Dantrolene Na

RHABDOMYOLYSIS - Caused by Statins

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24 vomiting dehydrated

MANAGEMENT hypercoaguable: genetic, contractives, pregnancy HEPARIN is TOC even when hemorrhage occurs Key is early recognition • Headache • Papilledema • Aphonia • Focal signs • seizure

Vignette 12: VERTEBRAL ARTERY DISSECTION -

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Chiropractic manipulation or neck injury • Pain and head pain Days to weeks with stroke-like symptoms Key is pain ff by stroke with or without trauma Tx: heparin / coumadin

Vignette 13: ORGANIC PHOSPHATE POISONING -

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Diaphoresis, lacrimation, sialorrhea Miosis Seizure ATROPINE 1-2 mg IV = DOC PRALIDOXIME 2 gm Remove source Check RBC CHOLINESTERASE

Vignette 9: VERTEBRO-BASILAR STROKE ▫ ▫ ▫ ▫ ▫ ▫

65y slurred speech vertical diplopia ataxic gait & upper ext vertigo fluctuating weakness

VBS -

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Life threatening Locked-in syndrome in pons

Basilar stroke Anticoagulant rTPA stenting merci-retrieval of thrombus

- aestimateo anima D2007 

rina D1 2007