amy gutman md [email protected] neurological emergencies

Amy Gutman MD [email protected] NEUROLOGICAL EMERGENCIES

In the next 2 hours: Anatomy & Physiology Focused Assessment & Examination Differential Diagnosis Management & Critical Thinking What we will not cover in the next 2 hours: Trauma patients with neurological findings Psychiatric emergencies OVERVIEW

Neurology (Greek):V (neuron), (study); medical specialty studying diagnosis & treatment of nervous system disorders Neuron:Single nerve cell Neurotransmitter: Chemicals allowing impulses to travel between neurons Ipsi / Unilateral:Same-sided, one sided Contralateral:Opposite-sided Paralysis:Complete loss of function Paresis:Limited function Anesthesia:Complete loss of sensation Paresthesias:Abnormal sensation Lesion:Focus for neurological abnormality TERMINOLOGY

Neurons & Neurotransmitters Protective Structures Brain Spinal Cord ANATOMY & PHYSIOLOGY - CNS

Billions of neurons allow body functions via neurotransmitters Neurotransmitters are excitatory or inhibitory Excitatory: acetylcholine, norepinephrine Inhibitory: dopamine, serotonin, GABA Each neurotransmitter directly or indirectly influences specific type(s) of neuron NEURONS & NEUROTRANSMITTERS

Nerve impulse travels from neuron through axon to terminal & synaptic knob Synaptic knob communicates with dendrite of neighbor neuron via neurovesicles that store & release neurotransmitters into synapse If stimulated in a lock & key manner, the next neuron picks up & continues the impulse Seizures: continuous release / stimulation of impulses = spasm Botulism: neurotransmitters bound so no impulses = flaccidity NEURONS & NEUROTRANSMITTERS

Depressants Increase GABA (inhibitory neurotransmitter), decreasing nervous system activity Barbiturates, Benzodiazepines If combined other depressants can be fatal Abrupt discontinuation leads to withdrawal & seizures Stimulants Increase norepinephrine, dopamine to increase nervous system & catecholamine response Dexromethorphan, methylphenidate, cocaine CNS PHARMACOLOGY

CNS PROTECTIVE STRUCTURE - SKULL

CNS PROTECTIVE STRUCTURES VERTEBRAE (SPINE)

CNS PROTECTIVE STRUCTURES - MENINGES

Frontal Lobe Thinking, planning Executive functions Motor execution Parietal Lobe Somatosensory perception Integration of visual & somatospatial information Temporal Lobe Language function Auditory perception Memory Emotion Occipital Lobe Visual perception & processing CNS - BRAIN

CNS VASCULAR SUPPLY

CNS SPINAL NERVES & DERMATOMES

ROOT MOTOR SENSORY C3 Diaphragm, Trap Lower neck C4 Diaphragm Clavicle C5 Bicep & deltoid Below clavicle C6 Bicep Thumb, forearm C7 Tricep Index, middle fingers C8 Finger flexors Pinky T1 Hand intrinsics Medial Arm CERVICAL DERMATOMES C 3 4 5 keeps the diaphragm alive

1Olfactory 2Optic 3Oculomotor 4Trochlear 5 Trigeminal 6Abducens 7Facial 8 Vestibulocochlear 9Glossopharyngeal 10 Vagus 11Spinal Accessory 12 Hypoglossal "On Old Olympus's Towering Tops, A Fine- Vested German Viewed Some Hops" "Oh, Oh, Oh, To Touch And Feel, A Good Velvet, Spot in Heaven" Motor (M), sensory (S), or both (B) "Some Say Money Matters But My Brother Says Big Brains Matter Most" CRANIAL NERVES

Autonomic Nervous System Sympathetic: Fight or Flight Parasympathetic: Feed or breed, Rest & Repair Clinically: Point & Shoot Peripheral Nerves 43 pairs of nerves originate from CNS to form PNS 12 pairs of cranial nerves from brain 31 pairs of spinal nerves from spinal cord ANATOMY & PHYSIOLOGY - PNS

PREHOSPITAL ASSESSMENT

Altered Mental StatusFocal Neurological Complaints THE BIG PICTURE Sick vs Not Sick

Exact quotes words are clues The room is spinning vs I feel like Im spinning My vision is blurred vs I have double vision Obtain from pt, witnesses, family while beginning assessment & management CC, HPI & exam should focus on neurological aspects, without overlooking non-neurological processes causing AMS or deficits CHIEF COMPLAINT

Provokes / Progression / Palliation Quality Region/radiation Severity Time of onset Family/Social history Allergies Medications PMH Sz, trauma, HA, HTN, DM, infections, tumors Cardiac, renal, hepatic, neuro, psychiatric diseases Last oral intake Events leading up to event Environmental clues Indoors or outdoors? Any unusual odors? Suicide notes? HISTORY OF PRESENT ILLNESS

Level of consciousness Memory & amnesia AVPU / GCS Focal neurological exam Affect/mood Speech Behavior & posture Cognition Mood, Thought, Perception, Judgment, Memory & Attention Grooming & personal hygiene NEUROLOGICAL EXAM - ASSESSMENT

Eye Opening 4 = Spontaneous 3 = To Voice 2 = To Pain 1 = None Verbal 5 = Oriented 4 = Confused 3 = Inappropriate words 2 = Inappropriate sounds 1= None Motor 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to pain 3 = Decorticate 2 = Decerebrate 1 = None GLASGOW COMA SCALE (3-15) The number is less important than the category & what you do with it!

Speech and language Hear them talk, watch them talk, & look at their eyes; thats 90% of the brain (Henry, 2004) Normal speech inflected, clear, fluent, articulate, varies in volume Language Dysphonia: Inability to make laryngeal sounds Dysprosody: Inflection, pronunciation, pitch or rhythm (cerebellum) Dysarthria: Difficulty making individual sounds (motor integration) Aphasia: absence of speech Dysphasia: word finding difficulty (cortex) Expressive aphasia: understands but cannot speak (frontal Brocas) Receptive aphasia: words clear, content scrambled (parietal Wernickes) Apraxia: difficulty in both forming & phonating NEUROLOGICAL EXAM - SPEECH

BP: Hypotension Hypertension Cushings Triad: Hypertension Bradycardia Bradypnea Respirations Hyperventilation Hypoventilation Cheyne-Stokes: crescendo- decrescendo then apnea Ataxic: irregular rate & depth Apneustic: inspiratory pause Temperature: Infection Hemorrhage Seizure (cause or effect) Heat stroke Metabolic VITAL SIGNS

Head Skull: trauma; infants bulging membranes Mouth: odors, bites to lateral tongue Neck Meningismus Skin Trauma, rash, IVDA, temperature Lungs, Cardiac, Abdomen Systemic illnesses and secondary effects of CNS insults Extremities Trauma, deformity, pulses PHYSICAL EXAM

Pupil size, symmetry, reactivity Miosis Mydriasis Extraocular movements Resting eye position Deviation Nystagmus / direction Conjugate movement NEUROLOGICAL EXAM - EYES

Cranial nerves Reflexes Cerebellar Gait Finger pointing Psychiatric Posturing Any asymmetry Seizure activity Look at eyes NEUROLOGICAL EXAM MOTOR & SENSORY

Test glucose & you have the Miami / LA Stroke Scale

DIFFERENTIAL DIAGNOSIS / NEUROLOGICAL EMERGENCIES

Altered Mental StatusFocal Neurological Complaints THE BIG PICTURE Sick vs Not Sick

AEIOU TIPS A Alcohol / Drugs / Toxins E Endocrine, Exocrine, Electrolyte I Insulin O Opiates, OD U Uremia T Trauma, Temperature I Infection P Psychiatric disorder S Seizure, Stroke, Shock, Space occupying lesion CAUSES OF AMS

History often initially more important than exam What is MOST important question with a neuro deficit or AMS? Physical Exam Keys Odors Respiration Eyes Trauma? IVDA? Serial GCS If

Hypothermia: AMS / coma 42.0C Environmental Sepsis Drug reaction Neuroleptic malignant syndrome TEMPERATURE

Most Common Hypo / hyperglycemia Hypo / hyperkalemia Hyponatremia Thyroid storm Cause vs effect AMS Seizures Syncope Often related to arrhythmias EXOCRINE / ENDOCRINE / ELECTROLYTE

STROKE EPIDEMIOLOGY Disability affects 75% survivors #1 cause adult disability in the US & Europe #3 cause death worldwide after CAD & cancer 10% deaths worldwide US Management costs $43 billion annually Incidence increases exponentially >30 yrs Etiology varies by age 95% of strokes occur in people >45 yo 75% of strokes occur in people >65 yo Rule of two thirds 2/3 all strokes ischemic 2/3 of those thrombotic

STROKE - GENDER DIFFERENCES Men 1.25 x more likely to suffer strokes than women However, 60% of deaths from stroke occur in women Since women live longer than men, they are older on average when they have their strokes & therefore more often killed Some risk factors for stroke apply only to women: Pregnancy Childbirth Menopause HRT

STROKE - RISK FACTORS Advanced age Previous stroke or TIA Diabetes High cholesterol Cigarette smoking Atrial fibrillation HRT Migraines Thrombophilia Patent foramen ovale HTN Most important & modifiable

STROKE - MIMICS Seizure Infection Hypoglycemia Syncope Brain abscess or tumor Drug Overdose Head Trauma Vascular Lesions HTN Encephalopathy Migraine

Thrombotic Slow, progressive onset Causes: Atherosclerosis (#1 cause) Infective Inflammatory (vasculitis) Hypercoaguable states Embolic Abrupt onset Maximal deficit may improve over time as embolus breaks Causes Mural thrombus (#1 ) Aortic plaques Endocarditis Long bone injuries Dysbarism STROKE PATHOPHYSIOLOGY - ISCHEMIC

Altered neuro status that resolves completely

Answer to ALL must be YES: >18yo Acute ischemic stroke causing a measurable non- improving neurologic deficit NO clinical suspicion for SAH Time of onset to treatment is

ABCs + Glucose Protect penumbra Keep SBP >90mmHg Keep CPP >60mmHg Hypothermia Oxygenate HOB 30 degrees (reverse T-berg if C spine in question) Frequent repeat neuro checks!! Reassess GCS! STROKE - MANAGEMENT *CPP = MAP - ICP

1 2% general population Primary / Idiopathic Onset ages 10-20 Often outgrow their medications Secondary precipitated by something Intracranial: trauma, mass, abcess, infarction Trauma, mass, abscess, infarct Extracranial: toxins, metabolic, HTN, eclampsia SEIZURES - EPIDEMIOLOGY

Grand Mal: Aura, tonic-clonic, LOC, apnea, incontinence, post-ictal Petit Mal Absence Myoclonic Simple Partial Seizures Involve one body area Can progress to generalized seizure Complex Partial Seizures Characterized by auras Typically 12 minutes in length Loss of contact with surroundings SEIZURE CLASSIFICATION

ECLAMPSIA Any pregnant patient who seizes, regardless of prior history Often secondary to undertreated / undiagnosed pre-eclampsia Medical emergency for both mother & child Management: IV, O2, Monitor Left lateral recumbent position Rapid Transport Magnesium sulfate

MAGNESIUM SULFATE Pregnancy-induced HTN, pre-eclampsia, eclampsia Decreases CNS activity & release of ACH Vasodilator (decreases systemic BP, improves placental blood flow) Side Effects Muscle weakness Respiratory depression Hypotension & slowed cardiac conduction/AV blocks Antidote Calcium gluconate

ABCs + C spine + Glucose + Pregnancy IV, O2, Monitor HPI Timeframe? Prior history? Pregnancy? DM? Trauma? Infection? Serial neuro exams SEIZURE - MANAGEMENT

Seizure >5 mins OR 2 seizures between which there is incomplete recovery of consciousness Management: ABCs IV, O2, Monitor Benzodiazepines Treat other causes: Glucose Magnesium Pyridoxine (B6) SEIZURE - STATUS EPILEPTICUS

Acute & temporary loss of consciousness Pre-syncope: No LOC Pt often states I thought I was going to pass out Syncope is a symptom, not a diagnosis DDX: Cardiovascular: a rrhythmias, valve stenosis, hypotension Noncardiovascular: m etabolic, neurological, psychiatric Idiopathic Pearls: Extended unconsciousness is NOT syncope All drunks have head & C spine injuries if unconscious + fall SYNCOPE

ABCs & support ventilations Maintain airway IV, O2, Monitor, Glucose Look for other causative / contributive factors Heat stroke MI CVA CHI Dehydration SYNCOPE MANAGEMENT

SEIZURE VS SYNCOPE

US Incidence 1.5 per 100,000 Rare in young pts (Hflu & pneumovax vaccines)* CDC: median age 39 years; in 1986, it was 15 months Mortality/Morbidity Depends on pathogen, age, general physical state & severity of acute illness Pneumococcal mortality 21%, morbidity 15% Mortality 90% if severe neurologic impairment at time of presentation even with immediate medical treatment INFECTIOUS - MENINGITIS *PLEASE immunize your kids!

Bacterial Rapid onset of symptoms Fever, HA, photophobia, meningismus, AMS Etiology varies by age / exposure / PMH Neisseria meningitis associated with diffuse, purpuric rash Aseptic/ Viral/ Lymphocytic Gradual onset over 1-7 days Less virulent Atypical PMH / HPI critical as onset insidious TB(#1) Fungal: coccidiomycosis / crytococcus INFECTIOUS - MENINGITIS

Brain inflammation Cases self-limited unless virulent strain/immunocompromised Presents similarly to meningitis Viral / tick-borne etiology most common West Nile Herpes Simplex (HSV) Varicella Zoster (VZV) Arboviruses Eastern Equine viruses St. Louis Encephalitis INFECTIOUS - ENCEPHALITIS

Acutely ill patient + fever in a dPT deficient patient Bleeding membranous pharyngitis Exotoxin causes multi-organ system failure Myocarditis/AV Block Nephritis Hepatitis Neuritis with bulbar / peripheral paralysis Ptosis, strabismus, loss of DTRs Management ABCs, intubation, volume resuscitation IN ED: PCN, emycin, horse serum antitoxin, pressors INFECTIOUS CORNYBACTERIUM DIPTHERIA

Triad: diplopia, ophthalmoplegia, ptosis Descending neurologial deficits causing respiratory paralysis Normal mentation / sensation Infant FTT / floppy baby Raw honey contains C. botulinum Management: ABCs, intubation In ED: trivalent serum antitoxin INFECTIOUS CLOSTRIDIUM BOTULINUM

Trismus, Tetany, Twitching, Tightness Risus sardonicus Sympathetic overstimulation Tachycardia, hyperpyrexia, diaphoresis Management: ABCs, intubation In ED: Human Tetanus Immunoglobulin (HTIG), dT toxoid, metronidazole INFECTIOUS CLOSTRIDIUM TETANI

Most common acute polyneuropathy 2/3s have preceding URI or gastroenteritis Generalized paresthesias then ascending paralysis Miller-Fischer variant: ataxia, areflexia, and ophthalmoplegia 1976 swine flu tainted vaccine caused 25 deaths from GBS & the foundation for current anti-vaccine sentiment Management: ABCs, intubation INFECTIOUS GUILLAIN-BARRE SYNDROME

Facial nerve paralysis affecting entire unilateral face In supranuclear lesions like a cortical stroke (UMN defect), the upper 1/3 of the face spared while lower 2/3 paralyzed Orbicularis, frontalis & corrugator muscles innervated bilaterally, which explains facial paralysis pattern Eye closure on affected side impaired Bell Phenomenon: on attempting to close eye, the eye on the affected side rolls upward & inward Ramsay-Hunt: zoster vesicles along ear canal, pinna, mouth INFLAMMATORY - BELLS PALSY

Migraine (w/ wo aura)* Cluster Traumatic Inflammatory History: Worst HA? Onset? Fever / AMS? Trauma? Prior history? Management: IV, O2, antiemetics Cool, dark environment Abortive therapy Believe it or not, narcotics actually make headaches worse physiologically HEADACHE *Pet peeve

Though to be related to neurogenic inflammation & abnormalities of serotonergic transmission* HA either preceded by a visual aura or motor disturbance N/V, photophobia, sound sensitivity Provocation factors: Menstruation Sleep/food deprivation Physical activity Foods Contraceptive estrogens HEADACHE - MIGRAINE *i.e. neurologists really have no freakin clue why they occur

Cluster: Resemble CVAs Unilateral & persistent Thought to be a form of seizures by some neurologists Temporal Arteritis Temporal artery inflammation (branch of external carotid) Unilateral HA with temporal artery tenderness & decreased vision in middle-aged white females Rapid initiation of steroids will save patients vision Be concerned with any HA plus fever, confusion, nausea, vomiting or rash HEADACHES - OTHER

Common Causes: Labrynthitis Cerumen Impaction OM / OE URI Menieres Disease: tinnitus, hearing loss, vertigo History: Acute onset of severe dizziness, N/V Positional worsening of symptoms Often recent URI or prior vertiginous episodes Exam: Fatigable horizontal nystagmus URI SSX PERIPHERAL VERTIGO

10-15% cases of vertigo Causes: Brainstem ischemia or infarction Cerebellar hemorrhage Vertebralbasilar insufficiency MS Brainstem /cerebellar lesions SSX: Disequilibrium N/V Nonfatigable nystagmus Focal findings: Ptosis Facial palsy Dysarthria Cerebellar findings Ataxia Vertigo Management IV, O2, Monitor Antiemetics Cannot be differentiated from a posterior circulation CVA in the field Always treat as if a CVA CENTRAL VERTIGO

Underlying disease with extensive differential diagnosis Often the presenting symptom of CVA, MI, sepsis Pay attention to weak & dizzy with: Nystagmus Nausea/vomiting Focal neuro deficits AMS Management: I, O2, Monitor, Glucose, EKG WEAK & DIZZY

Alzheimers Dementia Most frequent cause of dementia in the elderly Brain atrophy due to cerebral cortex neuron death Muscular Dystrophy Characterized by progressive ascending muscle weakness Multiple Sclerosis Unpredictable Resulting from deterioration of myelin sheath Dystonias Often related to psychiatric medications OTHER NEUROLOGICAL DISORDERS

Parkinsons Disease Tremor, rigidity, bradykinesia, postural instability Amytrophic Lateral Sclerosis Myoclonus Spina Bifida Poliomyelitis Chronic Alcoholism Wernickes Syndrome Korsakoffs Psychosis OTHER NEUROLOGICAL DISORDERS

ABC + Glucose Ensure patent airway maintaining C-spine Limited airway protection may lead to vomiting / aspiration IV, O2, Monitor Serial examinations Rapid recognition of underlying neurological emergencies Sick vs Not Sick Pre-notification Time is brain! GENERAL NEUROLOGICAL EMERGENCIES MANAGEMENT PRINCIPLES

Anatomy and Physiology Pathophysiology General Assessment Findings Differential Diagnosis Management of Nervous System Emergencies SUMMARY

QUESTIONS? [email protected]

amy gutman md [email protected] neurological emergencies

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