Neurological emergencies
0.0 / 5
- Created by: z
- Created on: 14-03-16 19:58
Meningitis
- clinical syndrome characterised by inflammation of the meninges
- acute, severe headache, stiff neck, photophobia fever, vomiting drowsy, unresponsive, rash
- Kernig's sign - pain on hip flexion w/ bent knee (supine)
- Brudzinski's sign- pain on head lifting when knees lifted (supine)
- non-blanching rash- meninfococcal septcaemia- start immediate Tx
- causes of meningitis:
- neisseria meningitides 'meningococcus'
- step. pneumoniae 'pneumococcus'
- listeria monocytogenes (>50yrs)
- Hib, staph aureus, Gm -ves (e.coli, klebsiella etc). M. tb
- Rfs
- extremes of age
- immunosuppresion (DM), splenectomy, malignancy
- alcoholism, cirrhosis, IVDU
- dural defect (traumatic, surgical, congenital etc)
1 of 11
Meningitis: investigations
- if suspect bacterial mei=nigitis esp meningococcus - TREAT IMMEDIATElY
- benzopenicillin at GP before hosp transfer
- CT if impaored GCS or focal signs (hemiparesis, ophthalmoparesis, papilloedmema)
- Bloods- FBC, U&E, CRP, culture, clotting screen
- LP (CT first, check ICP for coning risk)
- insert b/w spinous processes into subarachnoid space- L3/4 or L4/5
- N=B, early V; L=TB, late V, prot+++=B, decr gluc=B, (V)
2 of 11
Meningitis treatment
- bacterial meningitis
- urgent benzylpenicillin at GP if suspected
- consider dexamethasone before 1st does in adults unless meningococcal septicaemia
- unknown cause - cefotaxime/ceftrioxone
- meningococus - cefotaxime or benzylpenicillin
- pneumococcus - cefotaxime
- listeria - amoxicillin/ampicin + gentamicin
- H. influenza - cefotaxime
- staph. aureus - rifampicin
- bets-lactam sllergy - chloramphenicol
- tb meningitis
- NB onset- gradual (1-9/12), CN signs (VI>III>IV), papilloedema, sudden deterioration
- RIPE + steroids for 2 months
- RI for 12 months
- viral meningitis
- antipyretics + reassurance
3 of 11
Encephalitis
- symptoms
- headache, fever, focal neurolofy (esp dysphasia), sezures
- untreated mortality 70%
- causes:
- typically viral: HSV, varicella (imm comp pts), CMV, EBV
- bacterial: listeria, tb, malaria, vasculitis
- AI: limbic encephalitis, anti-NDMA receptor encephalitis
- sympt: psychosis, behavioural issues, mvmt disorder
- HSV encephalitis
- Rx w/ acyclovir
- EEG
- CT/MRI
- HSV PCR
4 of 11
Acute flaccid weakness differential Dx
- nerve
- guillain-barre syndrome
- vasculitis
- toxic - lead, thallium
- metabolic - porphyria (abnormal haem synthesis resulting in porphyrin build up)
- muscle
- inflammatory- poliomyositis, dermatomyositis
- metabolic - acid maltase, periodic paralysis
- neuromuscular junction
- myasthenia gravis (AI attack on AChR of skeletal m.)
- toxins
- botulin: inhibits ACh release at NMJ-
- symmetrical descending paralysis
- lambert-eaton myasthenia gravis (AI against presynaptic voltage gated Ca channel)
5 of 11
Guillain barre syndrome
- most common cause of acute neuromuscular weakness
- inflammatory radiculopathy- most common type= AIDP (AI demyelinating polyneuropathy)
- antecedent infection in 75% (Campylobacter jejuni)
- back pain in 50%
- distal UL/proximal LL weakness, facial and bulbar involvement, ophthalmoparesis rare
- investigations
- LP - no pleocytosis (AKA incr cell count), incr protein
- nerve conduction study
- may be normal early
- later: F wave latencies, conduction block, decreased conduction velocity
- bad prognostic factors:
- short time to nadir
- evidence of axonal loss
- campylobacter positivity
- old age
- Tx - IV immunoglobulin/plasma exchange, supportive (ventilation/O2 etc)
6 of 11
Myasthenia gravis
- Ab against acetylcholine nicotinic postsynaptic R at NMJ of skeletal muscles
- AChR Abs or MuSK Abs
- demographics: bimodal- young people or 60/70yro; F:M, 2:1
- muscles affected: ocular, bulbar, neck proximal limb, distal limb, respiratory
- risk of resp failure- best way to check resp func is FVC
- no autonomic features
- investigation:
- ice test
- tensilon test (short acting acetylcholinesterase inhibitor- v. short sympt improvement)
- repetitive stimulation EMG
- serology (AChR abs +ve in 90%, MuSH abs +ve in only 5%)
- Rx
- symptomatic - pyridostigmine (cholinesterase inhibitor)
- immunosuppressant - prednisolone/azathioprine/methotrexate
- +/- thymectomy
- acute > plasma exchange, IV Ig
7 of 11
Status epilepticus
- continuous seizures for 30mins or serial seizures over 30mins w/o regaining consciousness
- causes: non-compliance, alcohol, OD, stroke, metabolic, hypoxia, tumours, trauma etc
- Mx
- ABC (+supportive measures e.g. O2, fluids)
- treat cause/remove precipitant
- 50mls of 20% IV glucose if BM low
- lorazepam 1-2mg IV
- phenytoin 15-30mg load then 100mg tds (fosphenytoin infuses faster)
- thiopentane/propofol infusion- paralyse and ventilate (ITU)
- collateral Hx
- exam- general medical + neurological (?focal signs, ?papilloedema)
- Ix
- bloods- FBC, U&E, BM, Ca, Mg, BGs
- AED levels (anti-epileptic drug monitoring)
- ?MSSU, blood culture
- ?CT brain scan, ?LP, EEG monitor
8 of 11
Coma causes
- neuro
- infective
- meningitis/encephalitis/brain abscess
- vasc (SAH,infarc, intracerebral haem, subdural/sagittal sinus thrombosis)
- neoplastic (primary/met, malignant meningitis)
- epilespy
- trauma
- inflammatory - MS
- vasculitis
- systemic
- metabolic- Na, Ca, gluc, )2, pH, porphyria, thiamine
- endocrine- thyroid, Cushing's, hyperPT
- infection - UTI, LRTI
- extrinsic
- drugs- anti-cholinergics, steroids, GAs, withdrawal
- toxins- solvents, CO, heavy metals
9 of 11
Coma examination and assessment
- general medical (ABC)
- HR- ?arrythmia
- BP- ?septicaemia/Addison's)
- breath- ?alcohol
- temp (fever,hypothermia)
- neck stiffness/kernig's sign
- rash, cyanosis, jaundice
- neuro
- head, neck, ear drums
- fundi
- level of conc (GCS)
- brainstem- pupils, oculocephalic reflexes
- limbs- power and reflexes
- respiration - Cheyne-stokes (cycling b/w apnea and heavy breathing)
- Ix- urgent FBC, U&E, glucose, poisons screen, BGs
- ?CT brain, ?LP. ?EEG, ?specific tests (e.g. HSV PCR)
10 of 11
Assessment of comatose patient
- oculocephalic (Doll's eye) reflex
- normal=positive=brainstem intact
- move head left, eyes move right
- head in centre, eyes central
- move head right, eyes move left
- NB may be exaggerate if metabolic coma
- normal=positive=brainstem intact
- caloric responses- ice cold water in ear
- normal- move eyes towards stimulus
- asymmetrical- move one eye towards stimulus
- negative response- eyes remain fixed and central
- pupil state
- small, reactive- non-structural/metabolic coma
- fixed/dilated/down&out- CNIII damage
- mid position, fixed- midbrain lesion
- large, fixed- tectal
- pinpoint- pontine
11 of 11
Related discussions on The Student Room
- Neurologist education path »
- Physiotherapy degree Vs neuroscience degree »
- Neurology path »
- Physiotherapy VS Sport therapy/ rehab »
- wanting to get into vascular neurology »
- What should I do? (Career/a level subjects crisis) »
- Suggest some universities »
- Finding an university »
- Finding an university »
- MSc Clinical Neuroscience UCL vs KCL? »
Similar Medicine resources:
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
0.0 / 5
Comments
No comments have yet been made