Dr Trowers

Neurological Emergencies

• Three of the 15 leading causes of death
• Stroke is the third leading cause of death

Risk Factors

• Age
  • Risk more than doubles each decade after age 55
• Gender
  • Female > Male
• Race
  • African Americans, Mexican American, Native Americans have higher predisposition
• Genetic predisposition
  • increased risk if parent, grand parent or sibling had a stroke
• Previous medical condition
  • Prior CVA, TIA, MI, HTN, Atherosclerosis
• History of trauma

History & Physical Exam

• time of onset of symptoms
• focal neurological symptoms
  • cognitive impairment
  • weakness or incoordination of limbs
  • facial weakness
  • numbness of limbs or face
  • cranial nerve palsies
  • dysarthria
• Global symptoms
  • headache
  • nausea and vomiting
  • altered alertness
  • abnormal vital signs

Differential Diagnosis

• Neurologic
  • migraine
  • seizures/Todd’s paralysis
  • neuropathies
• Metabolic
  • hyper/hypoglycemia
  • hyper/hyponatremia
  • uremic encephalopathy
• Infectious
  • meningitis
  • abscess
• Traumatic
  • traumatic hematomas
• Toxins
  • drug overdose
  • botulism
• Vascular
  • TIA
  • Vasculitis
  • Aortic dissection
• Other
  • syncope
  • heat stroke
  • conversion disorder

Stroke Types

Ischemic strokes much more prevalent (80%) than hemorrhagic strokes

Cincinnati Pre-hospital Stroke Scale

• Facial Droop (have patient smile)
  Normal: Both sides of face move equally
  Abnormal: One side of face does not move as well
• Arm Drift (have patient hold arms out for 10 seconds)
  Normal: Both arms move equally or not at all
  Abnormal: One arm drifts compared to the other, or does not move at all
• Speech (have patient speak a simple sentence)
  Normal: Patient uses correct words with no slurring
  Abnormal: Slurred or inappropriate words, or mute

F.A.S.T.

Facial paralysis
Arm weakness
Speech difficulties
Time to act

Physical Exam

• General: posturing, LOC, GCS
• Head, pupils, visual findings
• Speech and language
• Motor function
• Sensation
• Blood sugar
• Chest, abdomen, extremities

Altered LOC

Consider AMS causes – AEIOU-TIPS

Seizures

• Sudden, uncoordinated electrical activity
• Classification: generalized or partial
• Phases: aura, LOC, tonic, clonic, postseizure, postictal
• Causes
• Status epilepticus
  • Protect from injury.
  • Maintain airway patency.
  • Provide oxygen, ventilation assistance.
  • Establish vascular access.
  • Emotional support and transport
  • Anticonvulsant medications

Syncope

• Sudden, temporary LOC
• Causes
  • Vasovagal (young adults)
  • Cardiac dysrhythmias (older adults)

Headaches

• Tension
• Migraine
• Cluster

Multiple Sclerosis

• Alcohol, ingested toxins
• Epilepsy, endocrine, exocrine, electrolytes
• Infection, insulin
• Overdose, opiates, oxygen deprived (hypoxia, hypercarbia)
• Uremia (renal failure)
• Trauma, temperature
• Insulin, infection
• Psychosis, porphyria
• Stroke, shock, space occupying lesions

Metabolic causes

• Glycemic emergencies
• hypoxia
• hypercarbia
• Thiamine deficiency
• Acidosis
• Electrolytes, incl. sodium, calcium, magnesium

Structural causes

• stroke, thrombotic, embolic, hemorrhagic
• Tumor or other space occupying lesions
• Trauma, Brain edema

Drug related causes

• alcohol
• opiates
• hallucinogens
• etc.

Infections

• Meningitis
• Encephalitis
• Sepsis

Endocrine causes

• hypo/hyperthyroidism
• Graves’s disease
• Addison’s disease
• Cushing’s disease
• diabetic emergencies

Last but not least – Psychiatric causes

• Psychosis
• Conversion reactions
• Catatonia
• Munchausen’s Syndrome

Updated 11/18/09