Transcript Neurology Intern Boot Camp

Neurology Intern Boot Camp
BRYAN BONDER
Objectives
1) Review the neurological exam
2) Learn to recognize neurological emergencies
3) Learn the initial management of neurological emergencies
Localization
Central
◦ Brain
◦ Spinal cord
Peripheral
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Nerve root
Plexus
Peripheral nerve
Neuromuscular junction
Muscle
Must distinguish central lesion
from a peripheral lesion!
Localization
Upper motor neuron
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Mildly reduced bulk
Increased tone
Mild/moderate weakness
Hyperreflexia
Babinski present
Lower motor neuron
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Severely reduced bulk
Fasciculations
Reduced tone
Severe weakness
Hyporeflexia
Localization
Neuropathy
Myopathy
Myelopathy
NMJ disorder
Weakness
Distal >
proximal
Proximal >
distal
Below level of
lesion
Fluctuating
weakness
Reflexes
Reduced
Usually
preserved
Increased
Normal
Sensory
Distal >
proximal
Preserved
Discrete
sensory level
Preserved
Grading muscles and reflexes
Muscle Power
5: Full strength
4: Movement against some
resistance (can give this +/-)
3: Movement against gravity only
2: Movement with gravity eliminated
1: Fasciculations or trace contraction
0: No movement
Reflexes
5: Sustained clonus
4: Clonus
3: Hyperactive or spread
2: Normal
1: Diminished
0: Absent
Reflexes
C5/6
C7/8
L3/4
S1/2
Case 1
77 y/o woman PMH DM, HTN, active smoker here
for hyperosmolar hyperglycemic state suddenly
develops left facial droop, left arm weakness.
Neuro exam:
Alert, able to follow commands, no aphasia but
dysarthric
Right gaze preference, left facial droop
0/5 strength LUE, 5/5 strength RUE
Is not aware of being touched on the left
Stroke Signs and Symptoms
Stroke is a sudden onset neurological deficit
◦ Sudden numbness or weakness of the face, arm
or leg
◦ Sudden trouble speaking or understanding
◦ Sudden trouble seeing out of one or both eyes
◦ Sudden difficulty walking, dizziness, loss of
balance or coordination
◦ Sudden severe headache with no known cause
Stroke types
Ischemic
◦ Thrombotic
◦ Embolic – maximum symptoms at onset
◦ Lacunar
Hemorrhagic
◦ ICH – Frequently related to HTN
◦ Subarachnoid – Trauma most common, aneurysmal second most common
Initial Management of Stroke
Focused history with medications
Time of “last seen normal/well?”
Vital signs
NIHSS Examination
Blood glucose, CBC, basic electrolytes, troponin, pregnancy test
EKG
STAT CT Brain (make sure disk goes with them if at VA)
IV access
IV TPA Eligibility checklist
At UH Call BAT 41111
At VA UH transfer center 216-844-1111 to consult with stroke neurology for potential
transfer
Focused history with
medications
What symptoms are you having? When did you notice them?
Ever had a stroke before? When? What kind? What symptoms? How
were they treated?
Stroke risk factors?
History of seizures or spells?
On warfarin? DOAC? Heparin?
NIH Stroke Scale
www.nihstrokescale.org
Get certified and recertify every 2 years.
Eligibility for TPA
< 3 hours exclusion criteria:
◦ SBP > 185, DBP > 110 (control it!)
◦ Minor or isolated deficit (relative)
◦ Spontaneous resolution
◦ Suggest post ictal impairment
◦ Evidence of trauma, internal bleeding, fracture
◦ Hx of ICH or known intracerebral neoplasm, AVM or
aneurysm
◦ Recent intracranial or intraspinal surgery
◦ Hx head trauma or prior stroke within 3 months
◦ Hx of MI within 3 months (relative)
Eligibility for TPA
< 3 hours exclusion criteria continued:
◦ Hx of GI or urinary tract hemorrhage within 21 days
(relative)
◦ Major surgery or trauma in the prior 14 days (relative)
◦ Arterial puncture at a noncompressible site within 14
days
◦ Blood glucose < 50
◦ Hemorrhage on CT or hypodensity > 1/3 MCA territory
◦ Thrombocytopenia suspected or platelet count < 100
◦ Warfarin use suspected or INR> 1.7, heparin use with in
48 hours, LMWH within 3 days
Eligibility for TPA
3-4.5 hours exclusion criteria:
◦ Age equal to or greater than 80
◦ Not on anticoagulants regardless of INR
◦ NIHSS < 25
◦ No hx of diabetes AND stroke
Eligibility for TPA
4.5-6 hours:
Consider endovascular reperfusion
◦ Major artery occlusion
◦ NIHSS > 6
◦ Non-disabled at baseline
◦ CTH with no major early infarct changes
Give TPA?
Give TPA?
Case 2
48 year old man PMH HTN, cocaine use, here for
accelerated hypertension suddenly begins complaining of
his right side not “working right” then becomes drowsy. BP
210/130.
Neuro exam:
Drowsy, not following commands
Mild right facial droop
Not withdrawing as quickly to pain on his right side
Babinski present on the right
Give TPA?
Hemorrhagic strokes
ICH
◦ Start with noncontrast CTH
◦ Reversal agents if on anticoagulation (talk to hematology
or pharmacy if unsure)
◦ Goal SBP < 160
◦ Contact Neurosurgery 30153
◦ Transfer to NSU at UH
Case 2 continued
On the way back from CT the patient’s breathing becomes
extremely irregular and he becomes comatose. His BP is
190/80, his HR is 31.
Neuro Exam:
Comatose
Right pupil fixed and dilated
Not withdrawing to pain in any extremity
Increased ICP
Intubate the patient
Drain CSF if possible
Start hyperosmolar therapy (mannitol 20% 0.25-1.5 g/kg q
2-6 hours) OR 3% - 23.4% NaCl to target Na 150-160 (note
these are temporizing)
Avoid hypovolemia
Need ICP monitor
Normoventilation and use hyperventilation for ICP spikes
Hypothermia
Subarachnoid Hemorrhage
Start with noncontrast CTH, do LP if suspicion persists
Goal SBP < 160
Contact Neurosurgery
Transfer to NSU at UH
Common stroke mimics
Encephalopathy especially with sepsis
Seizure
Pain medication overdose/drugs
Dementia with delirium
When in doubt call a BAT!
Case 3
37 year old man with a PMH of alcoholism and
epilepsy is admitted for alcohol detoxification. His
last drink was 1 hour ago. The nurse calls you
because he became very fearful, his right arm
began “shaking” with his head turning to the right
and eyes forced to the right. He then developed
whole body “stiffening and shaking” which has
continued off and on for the last 6 minutes.
Neuro: obtunded, no facial asymmetry, normal
tone, reflexes 3/4, plantar reflex downgoing
Convulsive Status Epilepticus
Definition: 5 minutes or more of continuous seizures or 2
discrete seizures between which there is incomplete
recovery of consciousness
Common causes:
◦ Acute or remote structural brain lesion (stroke,
meningitis, tumor)
◦ Antiseizure drug nonadherence
◦ Withdrawal from alcohol, barbituates etc.
◦ Metabolic abnormalities
Convulsive Status Epilepticus
0-5 min Stabilization Phase
Stabilize the patient (ABCD)
Place the patient in a safe position
Time the seizure from onset, monitor vital signs
Assess oxygenation, consider intubation if needed
Initiate telemetry monitoring
Perform a finger stick glucose, if < 60 give 100 mg IV
thiamine and then D50
Obtain IV access and obtain CBC, RFP, toxicology screen and
anticonvulsant levels
5-20 min Initial Therapy Phase
Give one of the following (all Level A evidence)
◦ IM midazolam 10 mg > 40 kg, 5 mg for 13-40 kg OR
◦ IV lorazepam 0.1 mg/kg/dose, max 4 mg/dose, may repeat
once OR
◦ IV diazepam 0.15-0.2 mg/kg/dose, max 10 mg/dose may
repeat once
If none available may use
◦ IV phenobarbital 15 mg/kg/dose, single dose
◦ Rectal diazepam 0.2-0.5 mg/kg, max 20 mg/dose, single dose
◦ Intranasal midazolam or buccal midazolam
20-40 min Second Therapy
Phase – Seizure continues
No evidence based preferred second choice of therapy
Choose one of the following and give a single dose
◦ IV fosphenytoin 20 mg/kg, max 1.5 grams OR
◦ IV valproic acid 40 mg/kg, max 3 grams OR
◦ IV levetiracetam 60 mg/kg, max 4.5 grams
Notes on Side Effects:
Fosphenytoin: P450 inducer, may cause
bradycardia/hypotension (slow rate)
Valproic acid: CYP inhibitor, avoid in liver dysfunction
Levetiracetam: Consider renal clearance
40-60 min Third Therapy
Phase – Seizure continues
No clear evidence as to next therapy
Consider repeat of second line therapy (fosphenytoin,
valproic acid, levetiracetam) OR
Anesthetic doses of midazolam, pentobarbital, or propofol
Patient at this point should be sent to NSU at UH for
continued EEG monitoring
Tips for admitting patients
with epilepsy
Continue home meds unless a contraindication
Check available levels of antiepileptic drugs
If making the patient NPO for a procedure, consult
with pharmacy converting PO to IV
If unable to convert PO to IV consult neurology
Case 4
37 year old man who presented with 3 day history of weakness and
numbness in the feet which now involves the hands. He had a viral
illness 1 week ago.
Neuro Exam:
Cranial nerves intact, ocular muscles intact, no facial asymmetry
5/5 strength in upper extremities except for 4/5 strength in finger
flexors/extensors, 3/5 strength in lower extremities distally, 4/5 strength
proximally
Decreased tone
Decreased sensation to pinprick and light touch
Plantar reflex downgoing bilaterally
Guillain-Barre Syndrome
Immune mediated damage to the nervous system which typically
follows infection, classicly with areflexia and ascending
weakness/numbness
Commonly follows infection
◦ Campylobacter, CMV, EBV, mycoplasma pneumoniae
Move to a telemetry floor (watch for arrhythmias!)
Perform LP to look for cytoalbuminological dissocation
Ask RT to perform NIF and VC every 8 hours
Order EMG/NCS
Send GM1 antibodies or GQ1b antibodies as relevant
Neuro consult
Case 5
80 year old man with chronic arthritis and dementia here for delirium
secondary to a UTI falls after getting up unassisted. At baseline patient
is ambulatory. You are called to assess the patient.
Neuro Exam:
Awake, answers questions, oriented x2 (baseline)
Cranial nerves intact
5/5 strength in the upper extremities, 2/5 strength in both lower
extremities
Decreased sensation to pinprick below the C6
Reflexes 3+ in biceps, 0+ in bilateral patella, plantar reflex extensor
Rectal exam with loss of rectal tone
MRI of the cervical spine
Acute spinal cord compression
Most important prognostic factor is pretreatment neurological status
Call 4111, MRI of the entire spine STAT
Traumatic –
◦ Consult neurosurgery/ortho spine
◦ Steroids are controversial due to complications
Tumor –
◦ Consult radiation oncology, neurosurgery/ortho spine
◦ Give 10 mg IV dexamethasone then 4 mg every 6 hours
Epidural abscess (usually SA) –
◦ Consult neurosurgery/ortho spine
◦ Draw cultures
◦ Broad spectrum antibiotics (start empirically)
Case 6
A 32 year old man is brought in by his family with one day history of
headache, fevers and lethargy.
Neuro Exam:
Lethargic but arousable
Significant difficulty flexing neck to chin
5/5 strength throughout
Sensation normal to pinprick throughout
Meningitis
May be bacterial (S. pneumoniae, N. meningitides, L. monocytogenes),
fungal or viral
Initial management for suspected bacterial:
Start empiric antibiotics: Vancomycin, Ceftriaxone, Ampicillin
Use Meropenem or Cefepime if impaired cellular immunity or health
care associated
If beta lactam allergy desensitize and Vancomycin plus moxifloxacin plus
trimethoprim-sulfamethoxazole
Give dexamethasone 0.15 mg/kg every 6 hours starting with first dose if
suspected pneumococcal infection
If concern for encephalitis add acyclovir
Meningitis continued
Blood cultures
CT scan before LP if:
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Immunocompromised
Hx of CNS disease (stroke, brain met etc.)
New onset seizure
Papilledema
Altered consciousness
Focal neurological deficit
Perform LP!
Consider ID consult
Case 7
21 year old woman admitted for SOB, generalized weakness, productive
cough with concern for CAP. Started on azithromycin and ceftriaxone in
the ED. Patient begins complaining of difficulty swallowing and double
vision.
Neuro Exam:
Bilateral ptosis worsening with upgaze, face symmetric, dysarthric,
drooling
Difficulty flexing and extending neck
3/5 strength in UE proximally, 4/5 strength in UE distally
Sensation intact to LT, pinprick, DTR 2/4 throughout
Babinski absent
Myasthenic Crisis
Autoimmune disease caused by antibodies against Ach receptors
Initial management:
RT consult for NIF, VC
DC offending agents if possible (aminoglycosides, -mycin, quinolones,
lithium, phenytoin, beta blockers, procainamide, statins)
If already on anticholinesterase drug (pyridostigmine) hold the drug
Move to ICU for monitoring and place on telemetry
Avoid steroids in the acute setting
Neurology consult
Summary
1) Reviewed the neurological exam
2) Reviewed neurological emergencies including:
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Stroke
Elevated ICP
Status epilepticus
Guillain-Barre Syndrome (AIDP)
Acute spinal cord compression
Meningitis
Myasthenic crisis
Thank you and good luck on
wards!
Questions?