Approach to Neurologic Emergencies

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Approach to Neurologic Emergencies

• Mark Granner, MD
• Department of Neurology
• University of Iowa

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(No Transcript)
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General Principles

• ABCs
• Protect the patient
• Rapid clinical assessment
• Order diagnostic tests
• Treat the underlying cause

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Emergent Clinical Assessment

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

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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
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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

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Emergent Clinical Assessment (cont.)

• In non-comatose patients
• Language
• Vision
• Sensation

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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

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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

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Causes of Coma

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

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Causes of Coma (cont.)

• Focal posterior fossa lesion
• May produce global dysfunction via hydrocephalus
• Psychogenic
• A diagnosis of exclusion

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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)

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Management of Increased ICP

• Treatment
• Shrink CSF space (ventriculostomy)
• Shrink blood compartment (hyperventilation)
• Shrink brain
• osmotic agents (manitol)
• surgical decompression

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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)

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Duration of Complex Partial Seizures
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Status Epilepticus

• Goals
• Protect the patient
• Stop the seizure
• Treat the underlying cause
• Diagnosis
• Clinical (unresponsive, movements)
• EEG (especially useful in NCSE)

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Status Epilepticus

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

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Status Epilepticus

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

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Acute Spinal Cord Compression

• Caused by trauma or a mass (tumor, abscess)
• Goal is to prevent permanent dysfunction

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Acute Spinal Cord Compression

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

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Acute Spinal Cord Compression

• Treatment
• IV corticosteroids
• Surgical decompression
• XRT (neoplasm)

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CNS Infections

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

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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

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Acute Neuromuscular Failure

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

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Acute Neuromuscular Failure

• Causes
• Peripheral nerve (e.g. Guillain-Barré)
• Neuromuscular junction (e.g. myasthenia gravis
• Muscle (rare)

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Acute Neuromuscular Failure

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

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Acute Neuromuscular Failure

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