1	Neurological Emergencies
2	Status Epilepicus Two or more Seizures Failure to regain consciousness Between Seizures Some define it as 30 minutes of continuous seizure without regaining consciousness GTC status epilepticus “petit mal” status
3	Status Epilepicus Alcohol or Drug Withdrawal, illicit drug ingestion Failure to take anti-Convulsants Diabetic non-ketotic Hyperglycemia Irritative structural lesion Abscess Tumor Hemorrhage Threatened infarct Meningoencephalitis especially Herpes Cerebral anoxia Metabolic derangements eg Hypoglycemia, hyponatremia
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5	Status epilepticus dangers Increased CNS metabolic consumption Rhabdomyolysis Renal failure Muscle breakdown Metabolic acidosis and other derangements Hyperthermia Heart and other organ effects Mortality is around 20%
6	Status Epilepticus Pay attention to the Basics Airway, breathing, heart, bp, vitals Rapid assessment History during management Basic Labs, lytes CBC, Glucose as i.v. goes in Drug Screen CT scan Stop the Seizure!!
7	Goals with Status Epilepticus Stop the Seizure Find our what is wrong and correct it
8	AntiConvulsants Ativan (Lorazepam)is benzodiazepine of choice 4 mg iv up to 8 mg in 12 hours Simultaneously load with fosphenytoin 18 mg/kg phenytoin equivalents foll’d by maintenance dose and levels If Seizure is not stopped in 30 mins add phenobarbital 15-20 mg/kg and/or Depacon iv. Depacon 1500 mg for nl adult foll’d by levels and maintenance dose. If not successful in 1-2 hours, general anesthesia eg propofol 20-50 mg intermittent bolus Norcuron may be used to stop movement to obtain CT, MRI, helpful to control acidosis, rhabdomyolysis but obviously does not stop seizure up to .1 mg/kg iv
9	Vignette 1 55 year old lady Onset 3 days ago of tingling in hands and feet and ankle instability, falling Now weaker, unable to stand on own or hold utensils reliably Toes go down. Lacks all but knee reflexes
10	Guillian- Barre Acute, subacute demyelinating multifocal immune mediated radiculoneuropathy Numbness typically starts distally or multifocally, significant weakness Bifacial weakness and other cranial nerve findings Arreflexia
11	Guillian Barre Diagnosis Spinal Fluid Elevated Protein Few Cells (cyto-albuminologic dissociation) Slow Nerve Conduction Velocities
12	Guillian Barre dangers Failure to recognize may cause death Severe weakness Aspiration Respiratory failure Autonomic instability Major cause of death Severe sudden hypotension Cardiac arrhythmia
13	Guillian Barre management Always admit to hospital Neurological consultation CBC, sed rate, lyme antibody titre, tox screen if indicated Monitor vital capacity and respiratory parameters DVT prophylaxis IVIg or pheresis
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15	Vignette 2 36 year old woman with history of some headaches has very severe head pain, vomiting ? Lid droop in right with slightly larger pupil noticed by nurse Altered sensorium Mildly stiff neck Pre-retinal hemorrhage on fundoscopic exam
16	Sub-Arachnoid hemorrhage Likely to cause death or severe damage if unrecognized Seizures, progression of neurological deficit and altered sensorium
17	Sub-arachnoid hemorrhage Neurosurgical consultation Attention to basics, airway vital signs etc Treat severe hypertension Decadron, Dilantin, Codeine for pain HOB up 30% Nimodipine Absolute bedrest Prevent valsalva and constipation
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19	SUDDEN ONSET HEADACHE
20	SENSITIVITY OF CT SCAN IN SUBARACHNOID HEMORRHAGE (SAH)
21	Vignette 3 64 year old man, hx of MI, htn Wife brings him in promply after onset of left hemiplegia, dysarthria Bp 190/115 pulse 90 Continued deficit
22	New Stroke Prompt CT scan Immediate neurological consultation Briskly try to control bp either nipride or labetolol to keep bp under 185/120 Altepase (t-PA)
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24	T-PA exclusions Unable to decrease bp < 185 systolic Within 2 weeks of surgery that may have predispose to bleed Recent stroke INR >1.1 (already on Coumadin) Onset with seizure or LOC Rapidly clearing or minimal deficit Any bleeding diathesis, hematologic or ulcer etc. Brain hemorrhage or tumor
25	Vignette 4 24 year old man brought in by wife Not quite right over last couple of days Mild headache Aphasia, altered sensorium Stereotyped automatic repetitive movements (automatisms) of mouth and right arm then sudden seizure Neck may be mildly unsupple
26	Acute mental syndrome with or without seizure (encephalopathy) Quick exam, vital signs Glucose, thiamine, Narcan Drug history, drug screen and basic labs CT or MRI scan in ER EEG Prompt Lumbar puncture unless diagnosis is apparent from above measures
27	Acute Mental Syndrome If not metabolic, drug induced or connected with structural brain disease cause is likely to be meningoencephalitis May be vascular disease or fairly mild process superimposed on chronic brain disease in elderly
28	Vignette 5 65 year old man with non-Hodgkin's lymphoma complains of a mild gait disturbance, urinary urge incontinence Arms are fine but legs have 4/5 power Reflexes a little hyperactive in lower extremities, possible upgoing toes
29	Extradural spinal compression Rapid or very rapid progression of lower extremity weakness Failure to act promptly results in permanent paraplegia or worse. Key: trunkal motor level of weakness and sensory level with or without pain. Upper motor neuron weakness in lower extremities. Get prompt imaging studies esp spinal MRI and Neurological or neurosurgical consultation.
30	Spinal Compression Key to diagnosis – Sensory Level May be lower than compression Also motor level over trunk Reflex exam – diminished at level, increased below level Upgoing toes
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32	Cord Compression Dexamethasone 100 mg iv Neurosurgical/orthopaedic consult Irradiation or decompression
33	Vignette 6 17 year old girl complains of diplopia, lid droop, may have slight problem swallowing. Speech may be slightly slurred. Muscle strength seems fairly normal. Reflexes are normal
34	Myasthenia DDX diseases of neuromuscular junction Botulism, Lambert-Eaton (rare) May progress rapidly and impair swallow or respiration Prompt neurological evaluation
35	Myasthenia Begins with Eye movt abnomalities Foll’d by bulbar weakness Dysarthria Dysphagia Peripheral weakness
36	Myasthenia diagnosis Repetitive muscle testing Tensilon Test Edrophonium 10 mg. 2mg then 8mg find eye mov’t or muscles to focus on Striated muscle, ACh receptor antibody CT scan of chest for thymus
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38	Myasthenia treatment Mestinon 30-60 mg tid to qid 1/30^th dose iv Prednisone Azathiaprine, Cyclosporine Pheresis or IVIg Thymectomy
39	Vignette 6 36 year old Camp Hill inmate admitted with temp of 104 Increased muscle tone noted and shivering on exam Altered sensorium CPK 11000
40	Neuroleptic malignant syndrome phenothiazine use (Dopamine antagonists) May be in situation preventing cooling Severe sequellae if not recognized/treated (death) d/c offending agent Parlodel (bromocriptine) or dopaminergic agents, Dantrium, cooling, hydration, prevent rhabdomyolysis DDx: malignant hyperthermia, thyroid storm, sepsis, toxins, strychnine, tetanus, dystonias
41	Vignette 7 65 year old man with slurred speech Vertical diplopia Ataxic gait and upper extremities Vertigo Fluctuating weakness
42	Vertebro-basilar stroke Diplopia Dysarthria Dysphagia “Crossed” sensory or motor syndrome May be life threatening “Locked-in” syndrome in pons
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44	Basilar stroke Anti-coagulation T-PA Consider Stenting
45	Vignette 8 49 year old man with left brain stroke 24 hours ago. Nurse calls you at 2 AM Decreased responsiveness Left pupil is larger than right Bp is 210/120 pulse 50 You can’t arouse him and there is papilledema
46	Acute increased ICP Begin Mannitol or Lasix and Mannitol Get a CT scan Remove to ICU Consider Neurosurgical Consult for ventriculostomy, hemicraniectomy or other intervention
47	Vignette 9 24 year old woman post-partum Vomiting dehydration Severe headache Diplopia Seizures
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49	Dural Sinus thrombosis Key is early recognition Headache, papilledema, aphasia, focal signs, seizures Hypercoagulable: genetic, contraceptives, pregnancy Heparin is treatment of choice even when hemorrhage occurs
50	Dural Sinus Thrombosis Headache Papilledema Focal Signs Altered level of consciousness Seizures Setting of hypercoagulable state
51	Vertebral Artery Dissection Chiropractic manipulation or neck injury Neck and head pain Followed in days to 2 weeks with stroke like symptoms Key is pain foll’d by stroke with or without trauma Treatment: Heparin/coumadin
52	Organophosphate poisoning Diaphoresis, lacrimation, sialorrhea, miosis Smooth and skeletal muscle contraction, diarrhea, vomiting Seizure, delirium, diplopia, ataxia Bronchospasm, tachycardia, hypo or hypertension Atropine 1-2 mg iv Pralidoxime (2-PAM) 1-2 gm in 250 ml iv over 10 mins. Remove source such as clothes Check RBC cholinesterase