neurological emergencies mackay memorial hospital department of neurology ju-fen yeh

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Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

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Page 1: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

Neurological emergencies

Mackay Memorial Hospital

Department of Neurology

Ju-Fen Yeh

Page 2: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

Coma Hyperacute stroke (<3 hrs) and thrombolytic

therapy, post-thrombolytic care Brain edema , herniation and increased

intracranial pressure (IICP) Status epilepticus

Page 3: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

COMA

Page 4: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

Stabilize (ABC) Obtain a history Physical examination / neurological examination Laboratory test (including toxin or drug screen) Find out possible causes (most common causes are

toxic and metabolic derangements, which are potentially treatable and reversible)

Neuroimages (CT or MRI)

Page 5: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

瞳孔反應 pupil

Midbrain lesion , Uncal herniation , PcomA aneurysm

anhidrosis, miosis, ptosis

Page 6: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

Brain stem function

B.Oculocephalic (or ”doll’s eye” test )

C.Oculovestibular (or Caloric test)

異常 : 反射消失 眼位不動 隨頭轉動

A 意識不清者之正常反應 : 轉頭時眼位會反射轉到對側 而使眼位保持在頭中央

正常意識清醒的人 : 可抑制此轉頭時反射 故不會有眼位偏移

異常 : 反射消失 眼位不動正常 : 眼位往冷水刺激側偏轉

Page 7: Neurological emergencies Mackay Memorial Hospital Department of Neurology Ju-Fen Yeh

Abnormal postures

Bilateral hemispheric lesion, bilateral internal capusle insults or thalamic

Brain stem lesion or metabolic derangement

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Abnormal postures

Bilateral hemispheric lesion, bilateral internal capusle insults or thalamic

Brain stem lesion or metabolic derangement

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呼吸現象評估

兩側大腦深部,天幕上巨大病灶,代謝性腦病變

中腦或上橋腦

下橋腦病變

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呼吸現象評估

橋腦尾部及延腦上方

延腦

下橋腦病變

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Hyperacute stroke Thrombolytic therapy Post thrombolytic R’x care

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History - onset 時間最重要

因為血栓溶解劑的治療一定要在發生的 3 小時內且越早給予越好 ! 所以最重要的是要能確定症狀發生時間點 !!! ( 最好可以說出幾點幾分 )

若是在睡覺醒來才發生則時間點就無法確定 或者發生時間不明確時 , 我们要以病人最後一次被觀察

到還是正常的時間點來算 .

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Admission order

1.avoid antiplatelet, anticoagulant agents for 24 hours 2.NPO except oral drug for 24 hours, avoid NG tube

insertion 3.absolutely bed rest for 24 hours 4.record I/O q8h 5.vital signs check q15 mins for 2 hours then q30mins for 6 hours then q1h for 16 hours then as ICU routine

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6.GCS, Light reflex, pupil size Q1h for 24 hours then as ICU routine

7.call on duty resident for NIHSS and NE examination at __ (2nd hour) and __ (24th hour)

8.mark ecchymosis site and observation qid 9.urine observation, call resident if hematuira 10.avoid Foley tube insertion in initial 30 mins . if no urine

output or bladder distension in 6 hours then consider Foley tube insertion

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12.Emergent management of BP : *1.If SBP >=180-230 or DBP 105-120 mmHg for >=

2 readings 5-10 mins apart :

(1) intravenous Trandate 10 mg over 1-2 mins. the dose may be repeated or doubled every 10-20 mins up to a total dose of 150mg

(2) monitor BP q 15 mins during Trandate treatment and observe for development of hypotension

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*2.If SBP >230 or DBP 121-140 mmHg for >= 2 readings 5-10 mins apart :

(1)(2) 同上 (1)(2)

(3) If no satisfactory response , infuse sodium nitroprusside (0.5-10ug/kg/min)

(4) continue monitoring BP

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Anticoagulation

Heparin : not a standard therapy for all stroke subtypes

Contraindication:

large infarcts

uncontrollable arterial hypertension

advanced microvascular change in the brain

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Brain edema, herniation Increased intracranial pressure (IICP)

1. Brain edema

2. IICP

3. Risks of herniation

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Brain edema , herniation increased intracranial pressure (IICP)

Brain edema is defined as an increase in brain sodium and water content

It occurs in many neurological conditions , such as stroke, trauma, tumors, infections, encephalopathies, and hydrocephalus

ICP related to : brain tissue, blood ,CSF. Normal ICP 7-15 cm Hg. CPP=MAP-ICP, CPP should be kept > 70 mmHg.

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(1) Cingulate herniation under the falx cerebri, downward, (2) Transtentorial (central) herniation(3) Uncal herniation over the edge of the tentorium(4) Cerebellar tonsillar herniation into the foramen magnum.

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Management

Stabilize the patient and secure the vital signs. Keep the patient’s head elevated (30 degree). Keep the patient moderately dehydrated (?). Obtain a CT or MRI Hyperventilation :

– intubate and maintain PCO2 to 25-30 mmHg. Hyperventilation immediately reduced the blood flow (vasoconstriction ) and decreased ICP.

– Prolonged use of hyperventilation causes further ischemia to the normal and damaged brain area.

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Hyperosmolar agents :– Mannitol is most commonly used. 0.25-0.5 mg/kg every 4-6 hours. Serum osmolarity maintain

<320 Osm/L (side effects: dehydration, e imbalance, renal function impairment)

– Glycerol : 250 ml q6h (hyperglycemia, fluid overload, hematuria)

– Hypertonic saline (3%-23.5% NaCl) (monitor Na q6h, EKG; avoid increased 10meq /24 hours which may cause CPM; fluid overload)

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Diuretics : – furosemide (Lasix) and acetazolmaide (Diamox) may be helpful

in pseudotumor or ischemic brain edema.– dosage : 20-40 mg IV every 12 hours

Corticosteroids : dexamethasone is particularly useful in brain edema caused by primary or metastatic brain tumor or infections (ex TB or bacterial meningitis).

– dose is 10mg IV followed by 6 mg every 6 hours.– The effectiveness in ischemic brain edema or cellular brain

edema (hypoxia) is less clear. ICP monitoring is particular useful when a patient has brain

edema after head trauma.

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Status Epilepticus

1. Definition2. Causes3. treatment

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Status epilepticus – definition

Seizures last longer than 10 minutes or if two or more seizures occur in close succession without recovery of consciousness

Consider any seizure with duration greater than 5 minutes , not 30 minutes as historically defined

Convulsive or non-convulsive , focal (epilepsy partialis continua ) or generalized

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Common etiologies of seizure and SE

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Protocol and timetable for treating SE

0-5 mins– Diagnose; give O2, ABCs; obtain i.v. access; begin ECG monitoring;

draw blood for chem-7, Mg, Ca, CBC, AED level; toxicity screen

6-10 mins– Thiamine 100mg i.v. ; 50 mg of D50 iv unless adequate glucose level

known– Lorazepam (Ativan) 4 mg i.v. over 2 mins; repeat once in 8-10min

p.r.n– OR, Diazepam (Valium) 10mg i.v. over 2 mins; repeat in 3-5 mins

prn

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10-20 mins– If status persists or if it was stopped with

diazepam immediately begins Fosphenytoin 20mg/kg iv at 150 mg/min , with blood pressure and ECG monitoring

– Phenytoin 15-20 mg/kg, at (<) 50mg/min rate, – target serum level 15-20 mg/dL

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20-30 mins– If status persists , give additional

Fosphenytoin 5mg/kg 2 times (total 30mg/kg)

– Or Phenytoin 5mg/kg 2 times – target serum level 20-25 mg/dL

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30+ mins– If status persists , intubate and give one of the following (in

order of our preference), preferably with EEG monitoring – Phenobarbital 20 mg/kg i.v. at 50-100 mg/min . Additional 5

mg/kg boluses cane be given as needed . (ps: 本院無 IV form)

– Or Midazolam (Dormicum) continuous infusion , 0.2mg/kg slow bolus , then 0.1-2.0 mg/kg/hr

– Or Propofol continuous infusion , 1-5 mg/kg bolus over 5 mins, then 2-4 mg/kg/hr

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Status epilepticus

Valproic acid IV form

2 支 loading then 1.5 支 q8h 較少 allergy, 可能對 myoclonic seizure 或一

開始就是 generalized seizure 有用,可快速達到理想濃度

但需考慮和其他藥物交互作用,以及肝指數及Ammonia 濃度上升

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Status epilepticus

Phenobarbital : 20 mg/kg i.v., 5 mg/kg bolus

( 本院無 IV form) Gabapentin (Neurontin) Topiramate (Topamax) Rivotril