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Neuro Emergencies


Monro-Kellie Doctrine: Total intracranial volume is fixed
Epidural hematoma temporal/temporoparietal; btw skull & dura; usu younger pts (not elder or <2 yo); 80% meningeal art inj; parenchyma compressed to midline; lens shape on CT
Trauma-induced alteration in mental status that may or may not involve a loss of consciousness = Concussion
Concussion Grade I No LOC, transient confusion
Concussion Grade II No LOC, transient confusion; sx last longer (>15 min)
Concussion Grade III LOC of any duration
Layers of SCALP: skin, connective tx, aponeurosis, loose areolar tx, pericranium
EDH s/s lucid interval in 30%; late: ipsilateral fixed/dilated pupil, contra hemiparesis
CPP = MAP - ICP (cerebral perfusion P = mean art P - intracranial P)
SDH = venous blood btw dura & arachnoid; bridging v.; often 2/2 accel/decel, in EtOH/elderly
SDH acute vs chronic acute usu s/s in 24 hr; chronic >2 wks
On CT: concave density adjacent to skull, crosses suture lines = SDH
On CT: biconvex density adj to skull, does not cross suture lines = EDH
Cushing triad HTN, bradycardia, resp irregularity; 2/2 markedly elevated ICP
brain ischemia results from CPP less than: 40 mm Hg
GCS ≥ 13 = mild brain injury
GCS 9-12 = moderate brain injury
GCS ≤ 8 = severe brain injury
GCS eye 1 = no response
GCS eye 2 = to painful stimuli
GCS eye 3 = to verbal command
GCS eye 4 = spontaneously
GCS verbal response 1 = no response
GCS verbal response 2 = incomprehensible sounds
GCS verbal response 3 = inappropriate words
GCS verbal response 4 = confused conversation
GCS verbal response 5 = oriented
GCS motor 1 = no response
GCS motor 2 = decerebrate posturing (arms & legs held straight out, toes pointed downward, & head & neck arched backwards)
GCS motor 3 = decorticate posturing (rigidity, flexion of arms, clenched fists, & extended legs (held out straight); arms are bent inward toward body w/wrists & fingers bent & held on chest)
GCS motor 4 = flexion withdrawal
GCS motor 5 = localizes pain
GCS motor 6 = obeys commands
Most sig cause of mortality in pts with TBI Diffuse axonal injury (DAI)
Types of stroke ischemic (thrombotic, embolic 20%, hypoperfusion); hemorrhagic (intracerebral, subarachnoid)
Contralateral weakness (lower > upper), AMS, incontinence; likely source of stroke = anterior cerebral artery
Contralateral weakness (face/arm > lower), contra sensory deficits, poss dysphasia; likely source of stroke = MCA
Contralateral visual field deficits, AMS, cortical blindness; likely source of stroke = posterior cerebral artery
vertigo/nystagmus, syncope, dysarthria, dysphagia, contralat pain/temp deficits; likely source of stroke = vertebrobasilar arteries
stroke PE neuro, CV (carotid bruit), EKG (A-fib, AMI/hypoperfusion)
meningitis PE fever, HA, photophobia, seizure; petechiae/purpura (60-80% of Neisseria pts), poss AMS, +Kernig & Brudzinski
Hunt-Hess scale grades severity of: SAH (I = mild HA, stiff neck; V = coma)
SAH RFs HTN, smoking, cocaine, FH, prior SAH, PKD, CTD, coarctation
SAH tx control HTN (labetalol / nitroprusside); nimodipine for vasospasm; surg (resect / embolization)
s/p Fall w/ bilateral LE weakness, urinary and rectal incontinence, decreased rectal tone Cauda equina syndrome = neurosurgical consult
Pediatric with fever or Hx URI with encephalopathy, emesis, hyperactive reflexes, hepatomegaly, elevated liver enzymes Reye’s syndrome from URI/post-flu or aspirin use
Orbital blowout fx comminuted floor fx: herniated orbital contents; inf rectus mx entrap or vert diplopia d/t edema; blood in max sinus when orbital trauma
Loss of consciousness requires: Both cerebral hemispheres damaged OR brainstem lesion
Created by: Adam Barnard Adam Barnard