42 y/o woman with unwitnessed episode of loss of consciousness and urinary incontinence

Transcription

1 Top Five Neurological Emergencies: When To Refer February 23, 2011 Jinny Tavee, MD Associate Professor Neurological Institute Cleveland Clinic Foundation 1 CASE 1 42 y/o woman with unwitnessed episode of loss of consciousness and urinary incontinence 2 1

2 Seizure: New Onset ABCs Determine if it s really a seizure & check glucose If actively seizing > 2min: First line: Lorazepam 2mg IV up to 0.1mg/kg. Second line: Fosphenytoin 1000mgPE IV no faster than 150mg/min [Level desired (10-20) x Vd (.8) x pt s weight (kg)= dose in mg PE of fosphenytoin] Third Line: Propofol IV (be ready to intubate) Alternatives: Midazolam, Valproic acid and Levetiracetam IV 3 Seizure: In The Orders Check Dilantin level in 1 hr after loading Check labs, esp Na and Mg (give 1-2gm MgS04 to get level > 2) Seizure precautions CT head stat: r/o bleed Frequent neuro checks MRI w/ and w/o gadolinium, temporal lobe protocol vs. stroke protocol If level ok, start maintenance dose (PHT 300) 4 2

3 CASE 2 48y/o right handed man with history of atrial fibrillation with sudden onset left face and arm weakness 5 Acute Stroke ABC s apply O2 to keep sats 94% Avoid hypotension Other vitals: temperature, heart rate and rhythm Time LAST SEEN NORMAL Risk Factors: prior strokes/tias, CAD, arrhythmias, valvular disease, HTN, DM, lipids, tobacco history Concurrent chest pain, palpitations, SOB Screening neuro exam Blood glucose, platelets, PT/PTT, cardiac enzymes, EKG STAT head CT w/o contrast, rule out bleed 6 3

4 Acute Stroke: IV-tPA Check inclusion & exclusion criteria Time window now extended to 4.5 hrs SBP < 185 and DBP < 110 Permissible to give 10mg labetolol x 2 Discuss risks/benefits with patient and family efficiently IV t-pa 0.9mg/kg total or maximum 90mg Give 10% bolus over 1 minute, then Remaining 90% infusion over 60 minutes Admit to ICU 7 CASE 3 72 y/o man with history of prostate CA now complains of back pain and bilateral lower extremity weakness 8 4

5 Spinal Cord Injury: Compression Presents w/ back pain at level of compression, band like sensation sometimes progressive gait/sensory/bowel and bladder disturbance etiologies: tumor, mets, herniated disk, epidural abscess, hematoma, and AVM exam: DO RECTAL, get sensory level, check tone and extensor plantar response GET NEUROSURGERY INVOLVED STAT 9 Cord Compression: in the orders MRI complete spine ASAP Get plain films while waiting for MRI look for mets,osteomyelitis,diskitis,fracture,, or dislocation Decadron 4-100mg IV bolus, then 4mg q 6h Rad Onc for emergent radiation tx if tumor GI prophylaxis with PPI and H2 blocker Accuchecks and sliding scale insulin Foley to gravity and bowel regimen PAS/Heparin SQ 10 5

6 CASE 4 50 year old man with 3-4 month history of fluctuating double vision and droopy eyelids now presents with progressive generalized weakness and shortness of breath over the last 2 days 11 Diagnosis Tensilon test Establish observable measure of weakness Have atropine at bedside 10mg edrophonium EMG-single nerve fiber and repetitive nerve conduction studies Ach Receptor Antibody 90% positive in generalized form <50% if only ocular muscles involved MuSK Ab CT scan to evaluate thymus (antistriated muscle Ab) Check for other endocrine and autoimmune abnormalities:tsh, DM, ANA panel 12 6

7 Myasthenia Gravis Mestinon (watch side effects) Steroids Other immune modulating maintenance therapy Mycophenylate mofetil (cellcept) Azathioprine (imuran) Cyclosporine (neoral) Plasmapheresis IVIg Thymectomy For myasthenics in crisis: stop anticholinisterase inhib prior to intub DO NOT START STEROIDS IN VIRGIN PATIENT unless intubated VC<15cc/kg or NIF -20 Oropharyngeal weakness (inability to clear secretions) or clinical signs of resp failure 13 Case 5 36-year-old woman with ascending paresthesias in the feet and hands, difficulty walking, and back pain 2 weeks after an episode of viral gastroenteritis 14 7

8 Guillain Barre Syndrome ABCs Frequent NIF, vital capacity Watch for autonomic involvement Minimal sensory findings on exam, but areflexic Diagnosis with nerve conduction studies (needle EMG 3 weeks) and lumbar puncture to evaluate for elevated protein MRI brain if facial involvement, cervical spine if arms Immune modulating therapy: IVIG vs pheresis NOT BOTH No steroids