Pre-Extern Tutorial, 14
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Transcript of Pre-Extern Tutorial, 14
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Neurology extern should know
Headache Medical coma and confusional state Acute stroke
Tonic-clonic seizure and status
epilepticus
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Patient presents with
complaint of a headache
Critical first step:Hx taking, physicalexam
Red flag signs or
alarming signs
Meets criteria for
primary headache
disorder?
Migraineheadache
Tension-typeheadache
Clusterheadacheand other
TACs
Red flag signs
Investigation
Secondaryheadachedisorder
Other (rare)headachedisorder
(+)(-)
(+)
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Headache: Key
1. Identify serious causeRed flag sign?
2. Know common primary headache Feature of migraine, TTH,
trigeminal neuralgia3. Consult specialist :
secondary headachenon responder
no idea
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Normal neurological
examination
Abnormal neurologicalexamination
Focal neurologic s/s
other than typical
visual or sensory aura
Papilledema
Temporalprofile
Concurrentevent
Provokingactivity
Age
Age> 50
Sudden onset-SAH, ICH, masslesion (posteriorfossa)
Worseningheadache-Mass lesion, SDH,MOH
Pregnancy, postpartum-Cerebral veinthrombosis, carotiddissection, pituitaryapoplexy
Headache withcancer, HIV,systemic illness(fever, arteritis,collagen vasculardisease)
Neck stiffness
Triggered bycough, exertion orValsava-SAH, mass lesion
Worse in the
morning-IICPWorse onawakening-Low CSFpressure
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!"#$%&'(")*$+,-.,/0(123
4&536678Tension type
headache
Migraine Clusterheadache
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Unilateral Throbbing
Nausea
Blur vision with zig zag line
Sensitive to light
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Treatment
Life style modification
Acute treatment
Prophylactic treatment
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!"#$%&'()*+,-.%&+(trigger factors)
/0%01
%0&+/+
/020&
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!"#$%&'()*+,-.%&+
(trigger factors)
./&012
3!$4*5.!01$%6"#+&78.297+
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Pharmacotherapy of acute
migraine attack
Non-specific Acetaminophen,
NSAIDs caffeine opioids neuroleptic
Specific Ergotamine(Cafergot) Triptan
Ergotamine tartrate+ Caffeine
Ibuprofen (400)/
Naproxen (250),
Diclofenac(25)
1 tab prn headache
Cafergot1 tab prn headache
(moderate to severe)
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Recommendedmedication for
migraine preventionEFNS guideline
2009
Evers, S et al.
European Journal of Neurology 2009, 16: 968981
Started when high
headache frequency,
high severity
Duration 3-6 months
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TTH diagnostic criteria
Featureless headache
Headache with bilateral location,pressing/tightening character, noother associated symptoms
Common triggered by stress
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Treatment of TTH
Life style modification: stress
Acute medication: simple analgesic,NSAIDs, muscle relaxant
Prophylactic medication: TCAs,Depakine
Non-pharmacologic intervention
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COMAand
ACUTE CONFUSIONALSTATE
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Alter mental status
Coma/alter level ofconsciousness Other: delirium,
aphasia, psychiatricproblem
Hx taking/physical
exam
clinical classification1. coma with localizing sign2. coma without localizing sign but with meningeal sign3. coma without both localizing and meningeal sign
4. coma with seizure
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2 component of consciousness: arousal and awarenesscoma, vegetative state, minimally conscious state, and locked-in syndrome.
VARIOUS STATE OF CONSCIOUSNESSDelirium
Acute confusional
state
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Practical a roach
History taking
as the patient can not talk, then ask their relative or witness underlying disease is important (DM, atherosclerotic risk,
HIV) symptoms before and during coma(neurological complain)
Physical exam CPOMR (conscious level, pupil, ocular movement, motorresponse, respiration) Meningeal sign, seizure, other neurological symptoms?
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clinical classification1. coma with localizing sign2. coma without localizing sign
but with meningeal sign3. coma without both localizing
and meningeal sign
4. coma with seizure
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COMALocalizing sign-noMeningeal sign-yes
Severe meningitisorMeningitis with complication;hydrocephalus, vasculitis, infarct
Encephalitis
Subarachnoid
hemorrhage
- CT Brain
with contrast- Lumbarpuncture
CT with CM in bacterialmeningitis
CT without CM in SAH
MRI Brain in viral encephalitis
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Non-structural lesion caused
coma Exogenous- drug, toxin (lead,thallium, cyanide, methanol,CO), addict substance (heroin,amphetamine)
Endogenous- metabolic; Ca,Na, glucose, hypoxemia,hypercapnia, hypothyroid :::internal toxin; uremia, hepatic
encephalopathy
Thesecausesarereversible;ifnolocalizingsign;labscreenfirstGlucose,CBCwithPlt,BUN,Cr,Elyte,Ca,Mg,PO,Oxygensat
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Keep in Externs Mind
Alter mental state
1. Ask history; if obvious history suggest cause, treatimmediately (hypoglycemia in DM patient, toxin
ingestion)2. Restore vital signs (Oxygen, BP)...then taking lab(glucose immediately, and other basic lab)3. Physical exam: CPOMR + Meningeal sign-) if coma with no both focal or meningeal sign: metabolic, toxic,
drug, diffuse intracranial lesion-) if coma with meningeal sign; do CT brain emergency-) if coma with focal sign; do CT brain emergency-) if coma with sign suggesting to seizure: start AED
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Delirium, Acute confusional state
- good wakefulness- impair orientation- fluctuation of consciousness(usually occur at night)- broader cause than coma
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Etiologies - I WATCH DEATH
! I = Infection
! W = Withdrawal
! A = Acute Metabolic
! T = Trauma
! C = CNS Pathology
! H = Hypoxia
! D = Deficiencies(especially vitamin)
! E = Endocrinopathies
! A = Acute Vascular
! T = Toxins
! H = Heavy metals
D li i t
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Delirium management
Monitor VS and I/O
Ensure good oxygenation
D/C nonessential medications
Minimize opioids, Benzodiazepine, etc
Repeat PE, further lab, radiologic studies if cause not yet identified
! Antipsychotic Dosing in Elderly
! Use clinical judgment depending on severity of symptoms for
starting dose:
! Haloperidol
! 0.5mg mild
! 1mg moderate
! 2mg severe
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Acute stroke
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when we suspect stroke
when the patient has sudden neurological deficit;symptoms depend on where is the brain is
involved weak, numb brain stem sign cerebellar sign cortical sign alter mental state
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3.1%
3.6%
18.2%
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%
seizures
toxic/metabolic
PN palsy
tumour
SDH
confusional state
migraine
psychogenic
dementia
syncope/presyncope
MS
vertigo
TGA
SAH
miscellaneous
% of all stroke mimics (n=670)
Condition that mimic stroke
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Stroke can be...
Ischemic 75%
Hemorrhagic(25%);
subarachnoid,intracerebral
Large-artery atherosclerosis(emboli/thrombosis)
Cardioembolism(high-risk/medium-risk)
Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology
TOAST,TrialofOrg10172inAcuteStrokeTreatment.HP Adams, Jr, BH Bendixen,Stroke 1993;24;35-41
TOAST classification
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Anterior vs Posteriorcirculation
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Standard treatment in acute
ischemic stroke
IV rtPA within 3 hrs : NNT=10 (now 3-4.5hrs)
Stroke unit : NNT = 30-40 ASA within 48 hrs : NNT 140
Early decompressive surgery for malignant
MCA infarction : NNT =2 for death prevent
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D1E
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Brain herniation
Subfalcine (A) Uncal (B) Central (C) Extradural (D) Tonsillar (E)
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Herniation syndrome
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Treatment IICP
-G;1;2:Y$V8Z/8[);>;L1
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Treatment IICP
Kc:+d2
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Keep in Externs mind
Stroke
1. when the sudden neurological deficit occur;
suspect stroke...every case2. check time and onset (eligible for rt-PA??) and
exclude mimicker cause (hypoglycemia, seizure)3. if within 4.5 hours; call resident/neurologistactivate FAST TRACT can request CT brain
emergency4. check v/s, assess severity, check and follow up
neurological signs
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Seizure and statusepilepticus
P ti t ith li i ll
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Patient come with clinicallysuspected seizure
Known caseepilepsy with
recurrent seizure
First diagnosed
seizure
Statusepilepticus
Seizuremimicker
Cause? Treatment optionsTreatment cause
AED?
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Seizure or Not seizure
Seizure mimicker pseudo-seizure convulsive syncope movement disorder: myoclonus,
chorea, paroxysmal dyskinesia hypnic jerk
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Seizure vs Syncope
Bhidayasiri R. et al. Neurological differential diagnosis 2005
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Identify cause of seizure
(symptomatic seizure)
Acute symptomatic
seizure Stroke Metabolic
disturbances CNS infection Trauma Drug Toxicity Hypoxia
Remote symptomatic
seizure Pre-existing epilepsy Ethanol abuse Old CVA Relatively long-
standing tumors
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New proposed
definition of SE Status Epilepticus Cooperative Study
group (1998) SE > 10 minutes
Lowenstein DH (1999) SE > 5 minutes
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Management of SE
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Key
treat early as possible
step up AED is depended on stage of
SE add on therapy is needed
monitor EEG regularly, even if noobvious seizure
D fi t f th
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Define stage of the
status epilepticus
Pre-monitory status(0-5 min)
Early status(5-30 min) Established status(30-60 min) Refractory status(>60 min)
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Drug used
diazepam, phenytoin(Dilantin), valproicacid(Depakine), levetirazetam(Keppra)
Phenobarbital, propofol, midazolam,thiopental
Topiramate(feed)
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drug use depend on stage of status
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Diazepam
diazepam 10 mg (2-5mg/min) max 10 mg per dose can be repeated 2 doses
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Phenytoin
Vial: 250 mg/5 ml/vial 0.9% NaCl (dont use infusion pump)
starting dose: 20 mg/kg (rate < 1 mg/kg/min)
maintenance: 5-8 mg/kg/day e.g. weight 50 kg
Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20min. then Dilantin 100 mg+0.9%NSS 100 cc ivdrip in 15 min
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Valproic acid
Vial: 400 mg/4 ml/vial 0.9% NaCl or 5% Dextrose
starting dose: 20-30 mg/kg (rate < 50 mg/min) maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day) e.g. weight 50 kg
Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30min. then Depakine 100 mg/hr (10 cc/hr)
warning: hepatotoxicity
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Midazolam
Vial: 1 mg/ml/vial, 5 mg/ml/vial, 15mg/ 3ml 0.9% NaCl or 5% Dextrose/w
starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min) maintenance: 0.05-0.4 mg/kg/hr e.g. weight 50 kg
Midazolam 5 mg iv bolus then + Midazolam (1:1)ivdrip 5 cc/hr (0.1 mg/kg/hr)
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Levetiracetam
(Keppra) Vial: 500 mg/5 ml 0.9% NaCl or 5% Dextrose/w 100 ml starting dose: 2,000-4,000 mg/kg in 15 min maintenance: 10-30 mg/12 hr e.g. weight 50 kg
Keppra 2000 mg iv in 15 min then 1000 mg iv q 12hour
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Propofol
Vial: 10 mg/ml 5% Dextrose/w
starting dose: 2 mg/kg bolus
maintenance: 5-10 mg/kg/hr e.g. weight 50 kg
Propofol (2:1) iv 100 mg then 250 mg/hr
Consult *#2"is required
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Thiopentone
Vial: 1 g/vial
starting dose: 100-250 mg in 20 min then 50 mg q2-3 min until seizure stop
maintenance: 3-5 mg/kg/hr
Consult *#2"is required
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Phenobarbital
Vial: 200 mg/4 ml in sterile water 10 ml 5% Dextose
starting dose: 20 mg/kg (rate < 100 mg/min) maintenance: 1-4 mg/kg/day
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Topiramate
for SE
Clinical trial: 500 mg every 12 hoursnoso/orogastric feed for 2 days then150 mg-750 mg every 12 hours
Effective dose: 300-1600 mg/day
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Monitoring
Tapering off AED seizure stop > 24 hours Burst suppression on EEG > 24
hours Slow tapering off AED if seizure recur, increase AED dose
enough to control seizure
Keep in Externs Mind
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Keep in Extern s Mind
Seizure1. Seizure or not seizure: history, neuro exam2. Identify cause, ABCD management3.Start AEDs if seizure tend to be recurrent4. if seizure is going to be status; need to be
quick, and follow up the status epilepticusguideline therapy
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