emergency in neurology in neurology.pdf · Emergency in Neurology • Emergency condition at ER...

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1 Emergency in Neurology: Lesson from Experience Somsak Tiamkao http://epilepsy.kku.ac.th (my) How we learn ? • 10% of what we read • 30% of what we see • 50% of what we do • 70% of what we do,see and read Evidence base medicine Emergency in Neurological Disease emergency ? Emergency ? case emergency? Emergency ? Emergency Emergency / Emergency Emergency interest (Dr.)

Transcript of emergency in neurology in neurology.pdf · Emergency in Neurology • Emergency condition at ER...

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Emergency in Neurology:Lesson from Experience

Somsak Tiamkao

http://epilepsy.kku.ac.th

(my)

���������� ������������

How we learn ?

• 10% of what we read

• 30% of what we see

• 50% of what we do

• 70% of what we do,see and read

�����������• ������������ �������

• Evidence base medicine

• ������� ����

Emergency in Neurological Disease

� ��������� emergency �����?

� Emergency ����������?

� ��� case !"� emergency?

Emergency ?

� Emergency #�$%

� Emergency &������&'���()'!*��/,�&$

� Emergency &��-.���/0&12

� Emergency interest (Dr.)

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Topic : true emergency � Stroke � Alteration of consciousness � Severe headache� Seizures � Motor weakness� Respiratory failure

Emergency in Neurology

• Emergency condition at ER

• Emergency condition at Ward

• Emergency investigation : CT-brain

��������������������/���� ������������� �!��"�#��� ���������"�� ���$%��& '!$���� '���(�(���) � ��� ?????

Emergency condition : ER

• Coma, alteration of consciousness

• Motor weakness

• Seizures

• Respiratory failure

• Vertigo

• Severe headache

Emergency condition: Ward

•Delirium

•Deterioration of stroke

•Status epilepticus

•Brain herniation

Emergency condition at ward

Status epilepticus

• ������������ ��� ��� ���!�!��"� 5 !�$�

• ���������� ����"�!$���%"�&'�(�)*���� imaging

• Valium 10 mg iv ���*�"�)+�����,-�*������!.���� ,�

• Dilantin 15-20 mg/kg, ������/�*�"���!50 mg/min (�,-�*�� 1 �� ,�)

• Phenobarbital 20 mg/kg, can repeat every seizures

• �)"��3����)� maintenance, TDM ,IV form

• Subtle SE/non-convulsive SE

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Brain herniation

• Central herniation

• Uncal herniation

• On ET-tube, hyperventilation 24 hr

• Osmotic agent

• CT-brain ��%����+

• Early detection

Brain herniation

• Central herniation

• Uncal herniation

• On ET-tube, hyperventilation 24 hr

• Osmotic agent

• CT-brain ��%����+

• Early detection

Deterioration of stroke

• Intracranial cause•Recurrent, progressive

•Brain edema

•Hemorrhagic infarction

•Obstructive hydrocephalus

• Metabolic cause

• Drugs

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Delirium• Delirium is an acute, fluctuating transient disorder of consciousness and cognition with disorientation and memory impairment

• May be caused by a general medical condition, substances and/or multiples of both

• Also known as acute confusion, acute brain syndrome, metabolic encephalopathy, toxic psychosis and acute brain failure

Clinical features

• Disturbance of consciousness

• reduced ability to focus, sustain or shift attention

• Cognitive impairment• memory deficits, disorientation (for time, place and person),

language disturbances

• Perceptual disturbances

• misinterpretations, illusions and hallucinations (usually visual)

• Disturbance in sleep-wake cycle

• Altered psychomotor activity

• increased or decreased

• Disorganized thinking with incoherence and

delusions

Etiology

• Organic aetiology identified in 95%

• D I M T O P

• Multifactorial in origin•Organic factors

•Psychosocial stressors

•Unfamiliar surroundings

•Excessive or diminished sensory input

D I M T O P• D-Drugs

• Sedatives, hypnotics, hypoglycaemics, steroids, antihypertensives, alcohol, heavy metal and toxins

• I-Infection• UTI, bronchopneumonia

• M-Metabolic• Uraemia, hypo/hyperglycaemia, dehydration

• T-Trauma / Toxins• Head injury, post-operative, subdural haematoma

• O-Oxygen deficits• Cardiac and respiratory conditions

• P-Psychological/perceptual or post-ictal

Treatment• Specific measures

• Identify and treat the underlying condition

• Thorough medical history, physical and neurological examination, lab tests

• General measures• Ensure sleep

•Maintain fluid and nutritional state

• Provide support and nursing care

• Rest in a quiet, well-lit

• Maintain orientation

• Sedate the agitated, fearful patient

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Severe headache at ER : organic cause

� SAH

� CNS infection

� Cerebellar hemorrhage

� SDH, ICH

� Vertigo

Emergency condition at ER

Severe headache• �� ,����, �+!���$��%+��! ����: SAH

• *��, ��� �, ����/�: meningitis

•Anticoagulant : hemorrhage

• %'���)+ : subdural hematoma

• �����.� :cluster, post-coital

•Weakness : ICH

Severe headache : ����� !�"�#��$ � Vital signs, BP, ��' � Eye ground � Visual field � Stiff neck � Motor weakness � Ocular movement, pupil � Long tract signs

Severe headache : CT-brain

� HIV patient � Heavy alcohol � Liver/renal failure � �S'�� anticoagulant � Neuro deficit � Severe injury

Severe headache: LP

� �$�$#U1�

� CNS infection� SAH �/0 CT-brain ��'(XXY

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Respiratory failure

• Ventilatory failure

• Pa CO2 ���%'������ 40

• ��� ET-tube with respirator

• %����+�� �•NMJ

•Brain stem

•Brain herniation

Vertigo• Peripheral/central

• Neuro - defict• Cerebellar

– FTN nose to nose

– Heel – to - knee

• Nystagmus

• �3�!�

• Hearing,

• Risk factors(atherosclerosis)

• Symptomatic

• Imaging, CT, MRI-brain

Seizures

•First seizure

•Underlying epilepsy

• ����'����3,����!

• �)+� �/SE

• ��%����+

•Imaging, emergency?

Seizures � Acute seizures

� Cluster of seizures

� Status epilepticus ZGTC SE

ZNCSE

Acute seizures � ���\S1�]X'�^��� ER ^����X1�#�S1�_2`�

Z ���S1���12]��

Z !"�a��X�S1�

� S1�&12]&bY'�� ��.c ER �d�1S1�Z �1�e�]YY SE

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���� ���$�� ER• *�"�-��8!�����%" ET tube $+���)

• *�"�-��8!������� valium $+���)

• *�"�-��8!���� load dilantin IV $+���)

• ��� �������) � �� ,� SE

Cluster of seizures

� S1��X����12&$\% �1�

� �1�e�]YY SE

Status epilepticus � �/Y��'�� ^�0���\S1���'�\' �d��/0-�\� Valium 10 mg ivx2 ��12��� 10 ���/� Phenytoin loading � Pb loading � !�� �$��������#��'\/� ��b#`� !"�&'�-b ET-tube ������� ����1�e���'�/Y !j\��1-��1��/

���&��# X�\�10��!

� CBC, BUN, Cr, electrolyte, Ca, Mg, PO4, LFT

� X��-b !"�Y����

� 98% !�&$

Motor weakness• Hemiparesis

•Brain

• Para, quadri•Spinal cord

•LMN

• Stroke, MG, GBS

• Investigation

Stroke ()'!*��--1� stroke q���� 72 S�.

Other diagnosis

�1��b&��# CT-brain &��# CT-brain ]X'�

Cerebral infarction

Cerebral infarction

ICH

!�c�e�s1X�����

Proper management Admission

Med

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Stroke � ()'!*�����������&'&��# CT-brain �1��/

� .'���b�\'&��# CT-brain ��'�̀� SSS

� Admit ������.'��/ &/�

� Close observation

� Control blood sugar: BP

Antiplatelet

� ()'!*�� cerebral thrombosis

� ASA ���\ 160 ��. �c2��!

� ��b&'�X1� hemorrhagic infarction

� Antiplatelet S�$\�0��1��b�/���sc�e��� acute stroke

Anticoagulant � ()'!*�� cardiogenic cerebral embolism

� AF valvular heart disease

� S10�2`���1�����b��'\//�' -/�

� �'\/��!v�1� recurrent stroke

� �' -/��� hemorrhagic infarction

���. /.01. �12345678�

� SBP 220 ��.!��

� DBP 120 ��.!��

� �� �'� AMI, CHF, hypertensive encephalopathy, other

Coma

• Intracranial causes

• Extracranial causes

• Neuro - deficit?

• � �����3,����! ABC

• �����)��$ ,� 2 %����+

• CT-brain �!��:�$��*�"� �!���"��� intracranial?

Alteration of conscious

� �Y���!���1&$a��!��#`�&1� Z Liver/renal failure, DM, epilepsy

� !���1&$����S'-�� -^&$\, �� (anticoagulant) � \)�b��/a��-����S'-��^$e� Heavy alcohol/alcoholic dependent?� Head injury � Sepsis

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Management

• Essential history

• Physical examination

• Pupil size and react to light

• Ocular movement

• Nystagmus

• Eye ground

• Spontaneous movement

• Long tract signs

Alteration of conscious � &��#\)�b��/ neuro deficit? � \)��� �X�0���� ]����� \) pupil size, react tolight? � \) ocular movement � \) BBK, clonus� \) stiff neck

Alteration of conscious : CT-brain

� Liver/renal failure

� HIV patient

� Anticoagulant, PT prolong

� Neurological deficit

� Metabolic causes ��bx$Y��

Alteration of conscious : LP

� Meningitis, encephalitis

� Septic encephalopathy

� ��b#̀� !"�&' CT-brain �b�������

Alteration of conscious : EEG

� Non-convulsive status epilepticus: NCSE

� !���1&$a��X�S1�

� �/!���1&$S1��`����b��/0#���\-&$��12�/2

� \)&��b��/ nystagmus, tonic deviation?

CT-brain : emergency

• Stroke

• Seizures

• Meningitis

• Encephalitis

• Coma

• Severe headache

• Alteration of consciousness

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CT-brain in stroke

• $-�$+���)�! acute stroke

• Siriraj Stroke Score

• $-�$+���)�!��:�*�"� �!���"��8! stroke?

• &'�(�)*�� anticoagulant ������ new neurodeficit, ��� ����

• *�"�-��8!����;�� contrast $+���)

• ������ impression/where is lesion

CT-brain in seizures presenting at ER• Status epilepticus �� ��������+�*������

• Seizures with head injury

• Seizures $��%�% )��� encephalitis

• Seizures in HIV , CRF, liver patients

• Seizures �!&'�%'���)+���� post-ictal paralysis

CT-brain in encephalitis

• $-�$+���)�"�! LP

• �<3���'���������� LP

• �<3�������!��; )�)�=���3�!�

• �<3�����%����+��� encephalitis

•JE

•HSE

CT-brain in meningitis

• *�"�-��8!����$-�$+���)�"�! LP

• ���$-��! renal, liver failure

• ����$-��! HIV, anticoagulant, neuro deficit, conscious seizures within 1 week

CT-brain in Severe Headache

• Sudden severe headache

• Neck stiffness without fever

• Severe headache with alteration of

conscious, seizures

• Severe headache with neuro-deficit

CT-brain in Coma/Alteration of conscious

• *�"*���� ���!" �

• Acute onset, neuro-deficit

• HIV,anticoagulant,renal,liver failure

• ��%����+��� metabolic *�"<�

• ����� LP?

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What is a diagnosis ? Scenario 1

• Severe and progressive headache

• Valvular heart disease

• Fever for 2 weeks

• PE: no weakness

mild dysarthia

papilledema

Brain abscess

Scenario 2

•Acute left hemiparesis

•No underlying disease

•Heavy smoking

Brain metastasis

• Secondary GTC

• No underlying disease

• No history of head injury

• No history of febrile convulsion

Scenario 3

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Meningioma

• Young lady

• Acute left hemiparesis

• Previous history of blurred vision

• History of intractable hiccup

Scenario 4

Multiple sclerosis•First seizure

•Post partum

•Swelling of left leg

Scenario 5

Venous sinus thrombosis

•Progressive paraparesis

•Difficult to void

•Frequent blood transfusion

Scenario 6

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Thalassemia

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4. .'���b�10��#����/�`�.������/Y!�c�e���b���/0 �/0���'�1��/

Thank you for your interest