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Flashcards in non-traumatic neurological complaints in the ED Deck (144):
1

big question if you suspect a seizure

primary: without provocation-epliepsy

secondary: response to something

2

what does a post ictal state look like both in presentation and specifically with regards to chemistry panel

Disorientation, sleepy, amnesia, HA,

lactic acidosis (from the clonic muscle movements)

high PC02 metabolic acidosis

3

how long does a post ictal state last

Commonly lasts 30min-1hr – LOC gradually improves

4

grand mal seizures have been replaced by

generalized seizures

5

tell the store of a generalized convulsive seizure

the person experiences LOC

tonic movement followed by clonic

resolves spontaneously with post ictal state

6

rhythmic jerking of seizure pt

clonic phase

if they bit down they can
swallow it and swallow

7

what can you see that would point to a generalized seizure in a pt that has loc

stigmata of a seizure

urinary incontinence and tongue biting

8

generalized non-convulsant seizures

aka absense

like daydreaming

lasts seconds

formerly petit mal

9

simple partial seizure is now known as

focal aware seizure

10

three things key in focal aware seizure

awareness consciouness and memory preserved

11

sxs of focal aware seizures


Awareness, memory, consciousness is preserved

Uncontrolled movement, visual, auditory sx, autonomic sx’s

12

focal impaired awareness seizures aka

used to be a complex partial

13

focal impaired awareness

déjà vu,
jamais vu (You are in your house but you don’t know where you are; the familiar becomes the unfamiliar), sounds,
smell (“who is smoking a cigar right now? Nobody, we are in church”),
taste,
numbness,
automatisms,
fear/panic

14

Partial what is this and what are the 2 types

Limited area of brain

Sx’s match area affected


simple and complex or focal imparied and focal aware

15

Status Epilepticus

Seizure activity lasting > 5min
or repetitive seizures without CLEARING of mental state in between

16

what is the probelm with seizing for more than 5 minutes

Seizures >5min are unlikely to spontaneously resolve

17

Often result of secondary cause, so start looking... with status epilepticus

Electrolytes (especially: glucose (hypoglycemic), sodium, magnesium (hypomagnesemic))

Intracranial bleed, trauma


Tox, OD-until it is eliminated will not stop

18

status epilepticus tx

ABORT seizure before neuronal injury occurs

Benzodiazepines FIRST


THEN 2nd or 3rd line drugs (Dilantin, Phenobarb, etc)

these people are often intubated because they are not breathing

19

concerns with paralyzing someone

need to for intubation but can't tell if your pt is still seizing

20

Most common cause of seizures in EDMost common cause of seizures in ED

Out of meds? Most common cause of seizures in ED

21

Hx of a seizure

have you ever had this before
if you have epilepsy is the pattern changing?

Trauma Hx?
people that see fall with abandon

Substances used?

recent illness?

LMP?

Country of origin

22

seizure after trauma

concern for internal bleeding in the brian

23

why are we worried about substance abuse with seizing

lack of alcohol can cause seizing

if you are too sick to get alcohol you need to know

24

why are we asking lmp in a female pt

do not want to miss pre eclampsia

25

PE with seizure

Post-ictal or still seizing?

ABCDE’s first

VS should improve with recovery

Tongue trauma, urinary incontinence


AND head to toe exam

26

what is the head to toe exam in a pt with a seizure

• Trauma

• Neuro deficit

• Infection

• Evidence other Dz

• Stigmata of EtOH

• Toxidrome

27

Red flags in a seizure

First seizure: Why??

Head trauma: Bleed, ICP

VS not resolving: Why??

Alcohol withdrawal (these folks are SICK – ICU admit)

Fever, infection: Need LP? Shock?

Rash: Meningitis?

Vomiting: Airway disaster, aspiration risk

Electrolytes: Which ones? Mg,

Stimulants: Bleed? CVA?

Prolonged post-ictal state: Why?

Focal neuro deficit: CVA, bleed?

Travel/Endemic area?

Neurocystercercosis

Malignancy: Mets to brain? – Often present with a first time seizure

Renal/liver Dz: Uremic or encephalopathic??

HIV: Toxo-, histo-, infection

Coumadin/Plavix: Bleed?

Pregnancy: Eclampsia

28

Head trauma with seizure concerns

: Bleed, ICP

29

Fever, infection:

LP
meningitis

30

if vomiting we are worried about

airway

31

Travel/Endemic area couplex with first seizure worry about

• Neurocystercercosis

32

1. If history of seizures workup labs

a. D-stick on all, upreg

b. Observe, reassess

c. Safety: bedrails, etc

d. Measure drug levels

e. Alcohol, tox screen

f. Chem for electrolytes

ii. Sz causes lactic acidosis

Creatinine Kinase (CK) if prolonged down-time --> looking for rhabdomyolysis

33

Chem for electrolytes in a seizure where the pt has a history of seizure

If cause not obvious

34

2. If first seizure

D-stick on all, upreg

If sz stops, pt now normal, and there is no obvious cause:

Chem panel

Magnesium, phosphorus if EtOH

EtOH, U tox

Coumadin? PT/INR

HIV test

Consider Head CT non-con

Add lumbar puncture only if fever, suspect SAH, encephalitis, etc

EEG: on admission or as outpt

35

what drug levels would we measure in a pt with a hx of a seizures

Dilantin, Carbamazepine, Valproic acid, Phenobarb
ii. Not: Keppra, Lamictal, etc

36

when would you be worried about rhabdomyolosis

why?

what would you order?

Creatinine Kinase (CK) if prolonged down-time

37

what would you do for a actively seizing pt

Protect pt, abort the seizure with meds

order lorazepam diazepam

When stop: suction oral blood/secretions, O2, time the event

Recheck d-stick, re-examine, cardiac monitor

38

what is the abortive treatment

Abortive Tx 1st line: Benzodiazepines – know 3

Lorazepam (2mg IM/IV)

Midazolam (2-5mg IM/IV),
Diazepam (5mg IV)

39

New Sz, now well and no Red Flags?

New Sz, now well and no Red Flags? Neurology consult to initiate EEG, tx and follow up.

40

etiology of febrile seizures

Rapid rise in temperature, not the number itself

Risks: hx same, family hx

41

want this on all children with a febrile seizure

D stick

42

• Search for source of fever or occult infection in children would involve getting a

CBC, Chem, UA, CXR

Blood and +/- stool culture

43

when would you get a CT or a LP in a kid with a seizure

No CT.
No LP if dx clear and kid looks great


44

When would you get a LP on a kid with seizures

when would you get a LP on a adult with seizures

recent anbx use -->LP
you're missing whatever bug it is

kid look sick


Add lumbar puncture only if fever, suspect SAH, encephalitis, etc

if RBC are in CSF--> SAH

45

febrile seizure tx

for the most part febrile seizure are partial or generalized?

NOT MEDS

**
they are generalized

46

5 essential questions for syncope

1. Ever had this before? What was the Dx?

2. Really lose consciousness? Fall? Hurt yourself?

3. What were you doing? Last thing you remember?

4. Sick lately? Upset? EtOH, drugs?

5. PMHx, Meds, Fam Hx, Soc Hx

47

Pseudoseizure

Psych, emotional distress
• Atypical movements
• Brief post-ictal period
this is where you can tell
• Good Soc Hx
• Refer to psych, EEG outpt


say "it's a little inconsistent with a generalized seizure post ictal"

48

over the age of __ we are worried about syncope

>50yrs

49

how does syncope look like seizure

brief clonic activity is a thing

50

syncope and cardiac issues might be suspected if

Syncope w/ exertion (critical aortic stenosis) or when supine – think cardiac

51

Red flag hx with syncope (7)

before/after event

a. Chest pain

b. Palpitations

c. Headache

d. SOB

e. Abd pain

f. Back pain (aortic dissection)

g. Bleeding (coumadin)

have you been recently hospitalized

melena

pace maker?

52

important recent social/family hx as it pertains to syncope

Recent hospitalization, surgery, procedure

Fam Hx of sudden death (Thoracic aortic Dissection, PE, cardiac arrhythmias)

53

abnormal sxs after syncope that are of concern

Abnormal VS
• Hypotension
• Tachy-, bradycardia
• Fever

Diaphoresis
• Confusion, focal deficit
• Cardiac murmur
• Rales, wheeze, edema
• Melena (GI bleed)
• Head trauma
• Pregnancy
• Pacemaker (issue with it itself)

54

main categories for the syncope ddx

cardiac
intracerberal
aorta
GIB/anemia
ectopic pregnancy
pulm embolism

55

cardiac -three big causes of syncope

i. Arrhythmia
ii. Aortic stenosis
iii. Hypertrophic, other cardiomyopathies

56

intracerberal

i. Hemorrhage, SAH
ii. Ischemic stroke: rarely

57

common reasons people faint

a. Volume depletion – dehydration or are you bleeding from somewhere?

i. Dehydration, n/v/d

b. Medication effect

c. Drug/EtOH effect

d. Vasomotor (vasovagal)

e. Emotional event/reaction

f. Mimic – unwitnessed seizure

g. Hypoglycemia**

58

what are you worried about with the aorta that can cause syncope

Dissection, aneurysm, aortic stenosis

59

Syncope in young, healthy, completely recovered person

All get:

EKG

consider D-stick (although you really wouldn't come back if you were hypoglycemic)

Hct +/- depending on history

60

Syncope in young, healthy, completely recovered person- female

All females (12-55yrs) get Upreg

61

what is not routine for syncope in young healthy person

CT, CBC, Chem, troponin, etc; not routine part of w/u

unless you have red flags

62

Other diagnostics driven by age, Hx, PE

IV hydration, O2, monitor, labs, troponin

CXR, +/-CT. Echocardiogram, Holter Monitor

c. >50yo – higher risk, more extensive work up

63

Young, healthy, completely recovered, stable?-syncope

Young, healthy, completely recovered, stable?

Likely benign cause. Home if stable w/ return precautions

EKG and UPT

Close follow-up, PO hydration, avoid risks
>50yo – bigger work up, home if w/u all neg, no risks

64

Vertigo

Sensation of motion, room spinning

is the room spinning or are you spinning inside the room

65

what are the two types of vertigo

Major question for us = Central or Peripheral?

3. Peripheral is usually benign
4. Central causes usually serious – red flag!

66

Hx of vertigo

1. Describe what you feel
2. OPQRST the sx to death
3. Trauma, recent illness?
4. Hearing changes, tinnitus?
5. Headache, weakness?
6. Associated sx’s – fever, bleeding, etc…

67

can you describe peripheral vertigo

onset

nystagmus is

worse with

associated sxs?

neuro deficits ?

sudden onset, intense, paroxysmal, w/ movement;
nystagmus is horizontal/torsional, fatigable; tinnitus, n/v,
+/- normal TM,

NO FOCAL NEURO deficit

68

BPPV -what is the cause

MOST common cause

Otolyth in the semicircular canal

Vertigo lasts seconds, positional

69

inflammation, after viral infection can cause this type of vertgio-ear sxs

labrynthitis

70

labrynthitis story

• Vertigo for days, ear/hearing sx’s

Movement exacerbates, post viral

71

Vestibular Neuritis:

inflammation
• Vertigo for days, no ear sx’s
• Movement worse, post viral

72

Story behind Meniere’s, what does it look like and what age do we see it most commonly present

40-70s

Episodic, chronic, incurable

SN hearing loss, tinnitus

73

central causes of vertigo


Cerebellar CVA, hemorrhage

Vertebrobasilar vascular insufficiency/CVA

Basilar artery migraine

Multiple sclerosis

Temporal lobe seizure

74

vertigo caused by drugs will be seen with

Drugs cause peripheral sx’s – ear sx’s predominate

75

nystagmus in central vertigo

Nystagmus present in all: type, direction, duration matter

76

peripheral vertigo presents with this type of nystagmus

horizontal and fatiguable

(bppv can be nonfatiguable_

77

Ptosis? w/ vertigo what are you worried about (4)

Botulism, MG, CVA, CN

78

what are you looking for in the ears with vertigo

Vesicles, cholesteatoma -tumor behind the eardrum, perforated TM?

79

Head impulse with peripheral vertigo

Abnormal (saccade) suggests peripheral

80

Head impulse w/ central vertigo

Normal in central causes

81

peripheral vertigo nystagmus

one direction: horizontal/torsional – never vertical, fast phase away from affected ear, intensity decreases w/ fixation, fatigues on repeat

82

what type of peripheral vertigo would NOT fatigue

BPPV may not fatigue

83

nystagmus beats towards or away from affected ear with peripheral vertigo

away

(beats towards opposite eye)

84

nystagmus with central vertigo

any direction (vertical, rotary), fast toward lesion, little effect with fixation/gaze direction change, does not fatigue

85

Test of Skew

Cover one eye, uncover, repeat. Eye position deviation when uncover, corrects.

86

positive test of skew indicated

b. Positive suggests central cause

87

Peripheral Motor Weakness differs from central how?

i. Not central nervous system
1. CVA/TIA is sudden onset, unilateral
1. Slower onset, progressive, bilateral
2. Neuromuscular junction vs. muscles
3. Respiratory compromise concerns

88

PE of peripheral motor weakness

1. Strength testing
2. DTR’s: +2 is normal
3. Cranial nerves
4. Sensation testing
5. Cerebellar testing

89

Most common cause of
acute
bilateral
flaccid paralysis

v. Guillain-Barre

90

story of Guillain-Barre

Autoimmune, demyelinating, progressive, symmetrical

91

paralysis with guillain barre starts with

Ascending pattern – legs first

loss of DTR

92

grade 1 strength

a trace of contraction is noted in the muscle by palpating the muscle while attempting to contract

93

the pt may move muscles against gravity but not resistance form the examinar with the grade of strength

grade 3

94

the patient is able to actively move the muscle when gravity is eliminated

grade 2

95

the patient may move the muscle agains some resistance

grade 4

96

tx of guillaine barre

immunoglobulins, plasmapheresis

97

who gets guillane barre

5. 2/3 have preceding viral illness (also Zika, etc)

a. 1/6 GB cases after Flu shot

98

what sxs do you see with GB

Hand paresthesia, muscle pain, may involve CN’s

99

what are we concerned about with GB

Dx is clinical; worry about respiratory issues, dysautonomia

Neurology consult. Admit.

100

Most common disorder of neuromuscular transmission

MG

101

MG is seen most commonly in the population

Bimodal peak: 30’s (female predominant), 80’s (male)

102

SXS of MG

Eye, facial, swallowing, speech muscle sx’s predominate

Bilateral or unilateral ptosis, diplopia, vision changes

Peek sign: close eyes --> can’t maintain, can see sclera

Flat expression, “lost their smile”

Gets “tired” talking, chewing fatigue, difficulty swallowing

Generalized weakness, fatigue, can’t climb stairs

103

DTR w/ MG

intact

104

botulism pt looks like

IVDU with eye sxs, facial sxs, weakness

105

what is the key to MG

Key: sx’s get worse with use, better with rest

Descending, DTR’s intact

ED Dx:
Tensilon (Enlon)/ edrophonium test, ice pack test (their strength comes back but when their eyes warm up their deficit comes back).
Neuro consult, Admit.

106

sx of botulism

Sudden, severe, symmetric, bilateral weakness – eyes, face, neck first; extremities last

Mental status, sensory intact

Infants: floppy, lethargic

107

tx of botulism

These pt’s are sick: recognition is key, respiratory concerns

Tx: Antitoxin, supportive care. Neuro consult. Admit

108

Young, female > male, autoimmune?

MS

look for monocular vision changes

need labs LP and mRI

Episodic weakness, paresthesias, disequilibrium – atypical pattern

109

Abrupt, progressive, bilat, proximal muscle weakness – legs usually before arms

2. Can’t rise from chair, brush hair, lift, etc

May have dysphagia

Polymyositis

110

Must consider this Dx in anyone w/ low back pain!

Cauda Equina Syndrome
Transverse Myelitis
Spinal epidural abscess

111

Cauda Equina Syndrome sxs

Symptoms: Unilateral or bilateral radicular back pain with:

True leg weakness, bilat or unilateral

Bladder incontinence or retention, hesitancy

Stool incontinence, loss of anal tone

Numbness in the “saddle” and perineal distribution; genitals

Loss of or reduced lower extremity DTR’s

. Charting should reflect all of above in low back pain pt’s

"SENSORY IS INTACT in the b/l lower extremities INCLUDING the saddle region"

112

cause of Cauda Equina Syndrome

2. Cause: mechanical compression on “horse’s tail”

a. Disc, fracture, infection, tumor

113

IVDU with fever + back pain, radicular sx’s


need to think about

Spinal epidural abscess

114

picture of transverse myelitis

Bilateral motor and sensory loss w/ radicular back pain, B/B dysfunction/incontinence, sensory changes

rapidly progressively

115

Low K+, Fam Hx, meds (diuretics)

Weakness local or generalized

Descending, DTR’s diminished

Hypokalemic Periodic Paralysis

116

Hypokalemic Periodic Paralysis triggers

Triggers: carbs, cold, exercise

117

Tick Paralysis looks like

1. Suggestive Hx
2. Ascending, DTR’s diminished
3. Remove tick – resolves 24-48hrs

118

“Saturday Night Palsy” can't do what

stop in the name of love

119

tx of “Saturday Night Palsy”

vi. Splint with wrist in extension
1. Resolves weeks to months
vii. Consider occult Fx
viii. Referral to PMD, neurologist

120

CN VII mononeuropathy

b. Bell’s Palsy

121

how do you know bells from stokre

persons forehead is involved in bells

in CVA the forehead is spared

122

Bell’s Palsy need a

ear exam

123

Diplopia can be caused by

cranial nerve palsy III, IV, VI

124

who gets diplopia

Idiopathic, traumatic; central: tumor, etc vs. peripheral: vascular (DM, vascullitis), cavernous sinus thrombosis

125

what do you need to do with pt w suspected palsy

need to isolate what is wrong (look at the chart)

3 and 6 is the most common

1. Monocular or binocular? Evoke the diplopia
2. Do the eyes line up on EOM’s/cover test?
3. Ptosis? Pupils?

126

1. Ptosis, “down and out” gaze, non-reactive, dilated pupil

iv. CN III – occulomotor – DM, temporal arteritis

127

1. “head-tilt” to opposite shoulder to avoid diplopia, eye “down and away”

v. CN IV – trochlear – rare, idopathic, kids

128

1. Lose lateral gaze, horizontal diplopia, cover affected eye – diplopia resolves

vi. CN VI – abducens – DM, increased ICP

129

what should you consider with palsy

: Lupus, Lyme’s, Botulism, Wenicke’s, Syphilis, Thyroid, Vit B Deficiency too
ix. Labs, CT head/face

130

most common location of a focal impaired awareness seizure

temporal lobe

131

Drug induced causes of vertigo will most likely present with

ear sxs predominate

132

very rare tumor that can be the cause of vertigo

cerebellar pontine angle tumor

133

vertigo tx

labs no necessary for peripheral

antiemetics
antihistamines
benzodiazepine

safety return precautions

epley in ED
semont at home
ENT refereal if reoccurent or hearing loss findings

134

central vertigo tx

w/u is necessary

MRI

135

UMN findings

hyper-reflexia
muscle tone: increased spastic
no fasiculations
no atrophu

babinski present

136

LMN findings

hyporeflexive

decreased or flaccid muscle tone
fasiculations
severe atrophy
and absent babinski

137

RF for transverse myelitis

Risks:
Herpes
MS
vasculitis
Lyme dz
TB
IVDU
IMZ

138

polymyositis

abrupt
progressive
bilat
proximal muscle weakness

USUALLY legs before arms

139

polymyositis common lab finding

increase CK
increase aldalase
Anti-JO1 antibody

DYSPHAGIA
HYSPHONIA
Proximal abrupt and progressive b/l weakness

legs usually before arms
cna't prush hair

140

dermatomyositis sxs

similar to polymyositis but with race to face chest and upper back in a shawl pattern

141

Tx for guillane Barre

immunoglobulins and plasmapharesis

142

age of MG pts

bimoda;
30s and 80s

143

what motor weakness syndromes would lead to a loss of DTRs

guillan barre- ascending
tick paralysis ascending (diminished)
hypo kalmeic paralysis (diminished) -descending
cauda equina (diminished

144

what would be an essential hx question to ask in a pt suspected of hypokalemic periodic paralysis

usually on diuretics

triggered by cold or carbs or exercise