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Tutorial for Pre-Extern “Emergency Neurology”

Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University

Friday, March 16, 2012

Friday, March 16, 2012

Friday, March 16, 2012

Neurology extern should know

Medical coma

Acute stroke

Tonic-clonic seizure and status epilepticus

Friday, March 16, 2012

COMA

and

ACUTE CONFUSIONAL STATE

Friday, March 16, 2012

Wakefulness and ascending reticular activating system(ARAS)

>> level <<

drowsiness

stuporous

semi-coma

coma

Friday, March 16, 2012

reticular activating system(ARAS) >> level << drowsiness stuporous semi-coma coma Friday, March 16, 2012

VARIOUS STATE OF CONSCIOUSNESS

VARIOUS STATE OF CONSCIOUSNESS 2 component of consciousness: arousal and awareness coma, vegetative state, minimally

2 component of consciousness: arousal and awareness

coma, vegetative state, minimally conscious state, and locked-in syndrome.

Friday, March 16, 2012

Practical approach

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 examination

evaluate location and cause

Friday, March 16, 2012

evaluate severity

and cause Friday, March 16, 2012 • evaluate severity “GCS” “CPOMR” clinical classification coma with
and cause Friday, March 16, 2012 • evaluate severity “GCS” “CPOMR” clinical classification coma with

“GCS”

“CPOMR”

clinical classification

coma with localizing sign

coma without localizing sign but with meningeal sign

coma without both localizing and meningeal sign

ARAS is located mainly at the brainstem, and both hemisphere

“CPOMR” can help us to localize the lesion

hemisphere “CPOMR” can help us to localize the lesion • Conscious: drowsy, stupor, semi-coma, coma •

Conscious: drowsy, stupor, semi-coma, coma

Pupil: dilate, constrict, response to light, uni-bilateral abnormality

Ocular movement: doll ʼ s eye, eye deviation, nystagmus

Respiratory pattern:

Friday, March 16, 2012

The pupil

The pupil Parasympathetic control Friday, March 16, 2012 Sympathetic control

Parasympathetic control

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The pupil Parasympathetic control Friday, March 16, 2012 Sympathetic control

Sympathetic control

Pupillary pattern

Pupillary pattern Friday, March 16, 2012

Friday, March 16, 2012

“Doll ʼ s eye” “Oculocephalic reflex” Friday, March 16, 2012

“Doll ʼ s eye” “Oculocephalic reflex”

“Doll ʼ s eye” “Oculocephalic reflex” Friday, March 16, 2012
“Doll ʼ s eye” “Oculocephalic reflex” Friday, March 16, 2012

Friday, March 16, 2012

Motor response and Posture in coma

Motor response and Posture in coma Decerebrate rigidity bilateral upper and lower limb extensor posture, usually

Decerebrate rigidity bilateral upper and lower limb extensor posture, usually the consequence of bilateral mid-brain lesions

Decorticate posture bilateral flexion of the upper limbs and extension of the lower limbs, usually the consequence of an diencephalic lesion (late)

Friday, March 16, 2012

the Respiratory pattern

the Respiratory pattern Cheyne-Srokes Central neurogenic hyperventilation Apneusis Clustering breathing Ataxic breathing

Cheyne-Srokes

Central neurogenic hyperventilation

Apneusis

Clustering breathing

Ataxic breathing

Friday, March 16, 2012

Where is it?

Where is it? Friday, March 16, 2012

Friday, March 16, 2012

COMA

Localizing sign-no Meningeal sign-yes

Severe meningitis

or

sign- no Meningeal sign- yes Severe meningitis or CT with CM in bacterial meningitis Meningitis with

CT with CM in bacterial meningitis

Meningitis with complication; hydrocephalus, vasculitis, infarct

with complication; hydrocephalus, vasculitis, infarct CT without CM in SAH Encephalitis Subarachnoid hemorrhage

CT without CM in SAH

Encephalitis

Subarachnoid

hemorrhage

!"CT"Brain"with"

contrast

!"Lumbar"

puncture

contrast !"Lumbar" puncture MRI Brain in viral encephalitis Friday, March 16, 2012

MRI Brain in viral encephalitis

Friday, March 16, 2012

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

These causes are reversible; if no localizing sign; lab screen first Glucose, CBC with Plt, BUN, Cr, Elyte, Ca, Mg, PO, Oxygen sat

Friday, March 16, 2012

Keep in Extern ʼ s Mind

Alter mental state 1. Ask history; if obvious history suggest cause, treat immediately (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, SAH, brain stem stroke, stroke with brain herniation -) if coma with meningeal sign; do CT brain emergency -) if coma with focal sign; do CT brain emergency

Friday, March 16, 2012

Acute stroke

Friday, March 16, 2012

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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Stroke can be

Ischemic 75%

Hemorrhagic

(25%);

subarachnoid,

intracerebral

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

Friday, March 16, 2012

TOAST classification

Large-artery atherosclerosis(emboli/ thrombosis)

Cardioembolism(high-risk/medium-

risk)

Small-vessel occlusion(lacune)

Stroke of other determine etiology

Stroke of undetermined etiology

TOAST, Trial of Org 10172 in Acute Stroke Treatment.

Features of TOAST Classification of Subtypes of Ischemic Stroke

of TOAST Classification of Subtypes of Ischemic Stroke Friday, March 16, 2012 HP Adams, Jr, BH

Friday, March 16, 2012

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

Anterior vs Posterior circulation

Anterior vs Posterior circulation Friday, March 16, 2012

Friday, March 16, 2012

Lacunar stroke syndrome

Pure motor stroke/hemiparesis Ataxic hemiparesis

Dysarthria/clumsy hand syndrome

Pure sensory stroke

Mixed sensorimotor stroke

Friday, March 16, 2012

Condition that mimic stroke

miscellaneous SAH TGA vertigo MS syncope/presyncope 3.1% dementia psychogenic migraine confusional state 3.6%
miscellaneous
SAH
TGA
vertigo
MS
syncope/presyncope
3.1%
dementia
psychogenic
migraine
confusional state
3.6%
SDH
tumour
PN palsy
toxic/metabolic
18.2%
seizures
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%

Friday, March 16, 2012

% of all stroke mimics (n=670)

“Acute brain attack”

ABCD, Neuro sign w/u stroke mimicker; specially hypoglycemia in DM, post- seizure EKG IV NSS, Lab (CBC plt, PT, PTT, INR, BUN/Cr/elyte

seizure EKG IV NSS, Lab (CBC plt, PT, PTT, INR, BUN/Cr/elyte CT Brain non-contrast emergency clinical

CT Brain non-contrast emergency

clinical stroke within 2-3.5 hours

Activate Fast tract for rt-PA

stroke within 2-3.5 hours Activate Fast tract for rt-PA Friday, March 16, 2012 CT Brain normal

Friday, March 16, 2012

CT Brain normal or evidence of acute ischemic stroke

IV rtPA if indicated

Friday, March 16, 2012

Friday, March 16, 2012

CT brain, non-contrast

สามารถทําได้รวดเร็ว ใช้เวลาน้อย

วินิจฉัยภาวะเลือดออกในสมอง เฉียบพลันได้โดยมีsensitivity เกือบ

100%

Minor or subtle signs : loss of lentiform nucleus, loss of insular ribbon, loss of gray-white differentiation and sulcal effacement

Friday, March 16, 2012

ribbon, loss of gray-white differentiation and sulcal effacement Friday, March 16, 2012 Hemorrhagic stroke Ischemic stroke

Hemorrhagic stroke

ribbon, loss of gray-white differentiation and sulcal effacement Friday, March 16, 2012 Hemorrhagic stroke Ischemic stroke

Ischemic stroke

Problems of clinical diagnosis within 6 hours of onset

Do you need a neurologist?

Approximately 75% of conditions mimicking stroke are neurological

How many of these can be identified by CT?

~15% of non-stroke disorders (e.g. subdural) found by CT

rest diagnosed clinically/with other tests

CT < 6hrs of ischemic stroke often normal

If CT is normal

Often need stroke specialist or neurologist to confirm clinical diagnosis of stroke before thrombolysis:

avoid thrombolysis for migraine, focal epilepsy, ʻ functional weakness ʼ , ischemic deficit after subarachnoid hemorrhage!

Friday, March 16, 2012

Standard treatment in acute ischemic stroke

IV rtPA within 3 hrs : NNT=10 (now 3-4.5 hrs)

Stroke unit : NNT = 30-40

ASA within 48 hrs : NNT 140

Early decompressive surgery for malignant MCA infarction : NNT =2 for death prevent

Friday, March 16, 2012

ข้อบ่งชี้ในการให้ยาละลายลิ่ม

เลือด

อาการเข้าได้กับโรคหลอดเลือดสมอง

ขาดเลือด

อาการทางระบบประสาทไม่ได้หายเอง

อาการทางระบบประสาทไม่น้อยเกินไป เช่น มีอาการชาอย่างเดียว

สามารถให้การรักษาได้ทันภายในเวลา 3-4.5 ชั่วโมง

Friday, March 16, 2012

3-4.5 ชั่วโมง Friday, March 16, 2012

Anti-platelet in acute ischemic stroke

Aspirin 160-325 mg ภายใน 48 ชั่วโมง ( หลังได้rtPA 24 ชั่วโมง ขึ้นไป)

Every 1000 patients treated

13 more patients alive/independent

7 less recurrent ischemic stroke

2 increase symptomatic ICH

ในช่วง acute phase ยังไม่แนะนําตัวอื่นยกเว้นแพ้aspirin หรือ กรณีsecondary prevention ( > 2 weeks)

Friday, March 16, 2012

Anti-coagulant in acute ischemic stroke

ยาที่ใช:"heparin"IV"drip","LMWH"(enoxaparin)"SC

อาจพิจารณาให้ใน acute ischemic stroke กรณีต่อไปนี้

Extracranial carotid or vertebral dissection

Cerebral venous sinus thrombosis

Unstable large vessel infarction

Cardioembolic ที่พบ clot ในหัวใจ

Arterial dissection

Friday, March 16, 2012

Brain herniation

Brain herniation Friday, March 16, 2012 • Subfalcine (A) • Uncal (B) • Central (C) •

Friday, March 16, 2012

Subfalcine (A)

Uncal (B)

Central (C)

Extradural (D)

Tonsillar (E)

Herniation syndrome

Friday, March 16, 2012

Herniation syndrome Friday, March 16, 2012
Herniation syndrome Friday, March 16, 2012
Herniation syndrome Friday, March 16, 2012
Herniation syndrome Friday, March 16, 2012

Treatment IICP

ให้นอนยกศีรษะและส่วนบนของร่างกายสูง 20-30 องศา

จัดท่าผู้ป่วยให้หลีกเลี่ยงการกดทับของหลอดเลือดดําที่คอ (Jugular vein)

พิจารณาให้osmotherapy:

Mannitol* 0.25-0.5 g/kg ทางหลอดเลือดดําใน 20 นาที 4-6 ครั้งต่อวัน

หรือ 10% Glycerol 250 ml ทางหลอดเลือดดําใน 30-60 นาทีวันละ 4 ครั้ง

หรือ 50% Glycerol 50 ml ทางปากวันละ 4 ครั้ง

และ /หรือ Furosemide 1 mg/Kg ทางหลอดเลือดดํา

Friday, March 16, 2012

Treatment IICP

หลีกเลี่ยงการให้hypotonic solution

หลีกเลี่ยงภาวะขาดออกซิเจน พิจารณาใส่ท่อ ช่วยหายใจในกรณีที่มีการหายใจผิดปกติ

Hyperventilation เพื่อให้Pco2 30-35 mmHg มีประโยชน์ในการลดความดันในสมองในช่วง สั้น ๆ ก่อนผ่าตัด

ไม่ควรให้steroid

Friday, March 16, 2012

Hemicraniectomy in malignant middle cerebral artery infarction

Malignant MCA infarction : การขาดเลือดของสมองบริเวณที่ เลี้ยงด้วย MCA เป็นบริเวณกว้าง จนอาจทําให้เกิดการกดเบียด ต่อเนื้อสมอง ทําให้มีbrain herniation ตามมา

Signs

Contralateral weakness

Eye deviate to ipsilateral lesion

Global aphasia in dominant hemisphere

Hemispatial neglect in nondominant hemisphere

Signs of IICP, brain herniation

Friday, March 16, 2012

Hemicraniectomy in malignant MCA infarction

Hemicraniectomy in malignant MCA infarction Friday, March 16, 2012
Hemicraniectomy in malignant MCA infarction Friday, March 16, 2012
Hemicraniectomy in malignant MCA infarction Friday, March 16, 2012
Hemicraniectomy in malignant MCA infarction Friday, March 16, 2012
Hemicraniectomy in malignant MCA infarction Friday, March 16, 2012

Friday, March 16, 2012

Keep in Extern ʼ s mind

Stroke

1. when the sudden neurological deficit occur;

suspect stroke

every

case

2. check time and onset (eligible for rt-PA??) and

exclude mimicker cause (hypoglycemia, seizure)

3. if within 4.5 hours; call resident/neurologist

“activate FAST TRACT” can request CT brain emergency

4. check v/s, assess severity, check and follow up

neurological signs

Friday, March 16, 2012

Tonic-clonic seizure and status epilepticus

Friday, March 16, 2012

Seizure and Epilepsy

Seizure

the clinical manifestation of an abnormal and hypersynchronous discharge of a population of cortical neurones

Epilepsy

a tendency toward recurrent seizures unprovoked by systemic or neurologic insults

least two unprovoked seizures at least 24 hours apart.

Acute symptomatic seizure

a seizure occurring after identifiable cause (metabolic, stroke, traumatic brain injury or infection)

Friday, March 16, 2012

Seizure or Not seizure

Seizure mimicker

pseudo-seizure

convulsive syncope

movement disorder: myoclonus, chorea

hipnic jerk

Friday, March 16, 2012

Convulsive syncope

Convulsive movements due to syncope

Myoclonic, tonic, eye movement

Very common,

normal blood donors (12-42%)

Not an epileptic seizure arising in an ischemic cortex- cortex is silent

Originates in brainstem-ischemic ʻ decortication ʼ

Does not require AEDs

Friday, March 16, 2012

Identify cause of seizure

Acute processes

Stroke

Metabolic

disturbances

CNS infection

Trauma

Drug Toxicity

Hypoxia

Friday, March 16, 2012

Chronic processes

Pre-existing epilepsy

Ethanol abuse

Old CVA

Relatively long- standing tumors

What should we do?

Evaluate ABCD, and check basic lab, intubation or oxygen therapy if indicate

Clarify: is it seizure??

If seizure is not stop; consider AEDs

Complete general, and neuro-exam

Brain imaging if indicate

Friday, March 16, 2012

Friday, March 16, 2012

Friday, March 16, 2012

Status

Epilepticus

How to define status

1981, ILAE (International League against Epilepsy)

“a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur”

Premonitory status: increase in the usual frequency or severity of their seizures may precede status epilepticus ʻ need for emergency managementʼ

Friday, March 16, 2012

Friday, March 16, 2012

Friday, March 16, 2012

Friday, March 16, 2012 Compensated Decompensated

Friday, March 16, 2012

Compensated

Decompensated

Friday, March 16, 2012

Friday, March 16, 2012

Premonitory tonic-clonic status epilepticus •  Buccal midazolam 10 mg(0.15-0.3 mg/kg in children) •  Rectal
Premonitory tonic-clonic status
epilepticus
•  Buccal midazolam 10 mg(0.15-0.3 mg/kg in
children)
•  Rectal diazepam 10- 30 mg(0.2-0.3 mg/kg in
children), repeated if necessary!
Up to 30 min!
Up to 30 min!

Friday, March 16, 2012

repeated if necessary! Up to 30 min! Friday, March 16, 2012 Early tonic-clonic status epilepticus ! 
Early tonic-clonic status epilepticus !  IV lorazepam, 4 mg bolus(0.07 mg/kg in children), repeated if
Early tonic-clonic status epilepticus
!  IV lorazepam, 4 mg bolus(0.07 mg/kg in children), repeated if
necessary
!  Basic life support airway intubation
!  Monitoring : regular neurological observationECG, pulse
oximetry
!  Investigation: ABG, urea, elyte, glucose, liver enz, ca, mg, full
blood count, AED level, blood sam ple for storage, ECG!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003)

30-60 min! After 30 min!After

30-60 min ! After 30 min ! After Friday, March 16, 2012 Established tonic-clonic status epilepticus
30-60 min ! After 30 min ! After Friday, March 16, 2012 Established tonic-clonic status epilepticus

Friday, March 16, 2012

Established tonic-clonic status epilepticus !  IV phenobarbitone, 20 mg/kg, 100 mg/min or !  IV PHT
Established tonic-clonic status epilepticus
!  IV phenobarbitone, 20 mg/kg, 100 mg/min
or
!  IV PHT 10-15 mg/kg, 50 mg/ min
or
!  Phosphenytoin, 15mg phenytoin equivalent/
kg!
min or !  Phosphenytoin, 15mg phenytoin equivalent/ kg! Refractory tonic-clonic status epilepticus Get an
Refractory tonic-clonic status epilepticus Get an anaesthetist !  Thiopentone 100-250 mg iv bolus, further 50
Refractory tonic-clonic status epilepticus Get an anaesthetist
!  Thiopentone 100-250 mg iv bolus, further 50 mg bolus every 2-3
minutes until seizure are controlled, then 3-5 mg/kg/hours to
maintain a burst suppression pattern on the EEG
or
!  Propofol 2 mg/kg iv bolus, repeated if necessary, then 5-10
mg.kg/hrs, reducing to 1-3 mg/kg/hrs
or
!  midazolam., 0.1-0.2 mg/kg bolus to control seizure, repeated if
necessary, then 0.05-0.5 mg/kg/hrs!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003)

Keep in Extern ʼ s Mind

Seizure 1. Seizure or not seizure: history, neuro exam

2. Identify cause, ABCD management

3.Start AEDs if seizure tend to be recurrent

4. if seizure is going to be status; need to be quick, and follow up the status epilepticus guideline therapy

Friday, March 16, 2012

Friday, March 16, 2012

Friday, March 16, 2012

download slide at openneurons Friday, March 16, 2012

download slide at

openneurons

Friday, March 16, 2012

download slide at openneurons Friday, March 16, 2012