Pre-Extern Tutorial, 14

8/12/2019 Pre-Extern Tutorial, 14

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Neurology extern should know

Headache Medical coma and confusional state Acute stroke

Tonic-clonic seizure and status

epilepticus


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Patient presents with

complaint of a headache

Critical first step:Hx taking, physicalexam

Red flag signs or

alarming signs

Meets criteria for

primary headache

disorder?

Migraineheadache

Tension-typeheadache

Clusterheadacheand other

TACs

Red flag signs

Investigation

Secondaryheadachedisorder

Other (rare)headachedisorder

(+)(-)

(+)


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Headache: Key

1. Identify serious causeRed flag sign?

2. Know common primary headache Feature of migraine, TTH,

trigeminal neuralgia3. Consult specialist :

secondary headachenon responder

no idea


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Normal neurological

examination

Abnormal neurologicalexamination

Focal neurologic s/s

other than typical

visual or sensory aura

Papilledema

Temporalprofile

Concurrentevent

Provokingactivity

Age

Age> 50

Sudden onset-SAH, ICH, masslesion (posteriorfossa)

Worseningheadache-Mass lesion, SDH,MOH

Pregnancy, postpartum-Cerebral veinthrombosis, carotiddissection, pituitaryapoplexy

Headache withcancer, HIV,systemic illness(fever, arteritis,collagen vasculardisease)

Neck stiffness

Triggered bycough, exertion orValsava-SAH, mass lesion

Worse in the

morning-IICPWorse onawakening-Low CSFpressure


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!"#$%&'(")*$+,-.,/0(123

4&536678Tension type

headache

Migraine Clusterheadache


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Unilateral Throbbing

Nausea

Blur vision with zig zag line

Sensitive to light


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Treatment

Life style modification

Acute treatment

Prophylactic treatment


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!"#$%&'()*+,-.%&+(trigger factors)

/0%01

%0&+/+

/020&


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!"#$%&'()*+,-.%&+

(trigger factors)

./&012

3!$4*5.!01$%6"#+&78.297+


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Pharmacotherapy of acute

migraine attack

Non-specific Acetaminophen,

NSAIDs caffeine opioids neuroleptic

Specific Ergotamine(Cafergot) Triptan

Ergotamine tartrate+ Caffeine

Ibuprofen (400)/

Naproxen (250),

Diclofenac(25)

1 tab prn headache

Cafergot1 tab prn headache

(moderate to severe)


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Recommendedmedication for

migraine preventionEFNS guideline

2009

Evers, S et al.

European Journal of Neurology 2009, 16: 968981

Started when high

headache frequency,

high severity

Duration 3-6 months


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TTH diagnostic criteria

Featureless headache

Headache with bilateral location,pressing/tightening character, noother associated symptoms

Common triggered by stress


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Treatment of TTH

Life style modification: stress

Acute medication: simple analgesic,NSAIDs, muscle relaxant

Prophylactic medication: TCAs,Depakine

Non-pharmacologic intervention


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COMAand

ACUTE CONFUSIONALSTATE


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Alter mental status

Coma/alter level ofconsciousness Other: delirium,

aphasia, psychiatricproblem

Hx taking/physical

exam

clinical classification1. coma with localizing sign2. coma without localizing sign but with meningeal sign3. coma without both localizing and meningeal sign

4. coma with seizure


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2 component of consciousness: arousal and awarenesscoma, vegetative state, minimally conscious state, and locked-in syndrome.

VARIOUS STATE OF CONSCIOUSNESSDelirium

Acute confusional

state


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Practical a roach

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 exam CPOMR (conscious level, pupil, ocular movement, motorresponse, respiration) Meningeal sign, seizure, other neurological symptoms?


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clinical classification1. coma with localizing sign2. coma without localizing sign

but with meningeal sign3. coma without both localizing

and meningeal sign

4. coma with seizure


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COMALocalizing sign-noMeningeal sign-yes

Severe meningitisorMeningitis with complication;hydrocephalus, vasculitis, infarct

Encephalitis

Subarachnoid

hemorrhage

- CT Brain

with contrast- Lumbarpuncture

CT with CM in bacterialmeningitis

CT without CM in SAH

MRI Brain in viral encephalitis


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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

Thesecausesarereversible;ifnolocalizingsign;labscreenfirstGlucose,CBCwithPlt,BUN,Cr,Elyte,Ca,Mg,PO,Oxygensat


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Keep in Externs Mind

Alter mental state

1. Ask history; if obvious history suggest cause, treatimmediately (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-) if coma with meningeal sign; do CT brain emergency-) if coma with focal sign; do CT brain emergency-) if coma with sign suggesting to seizure: start AED


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Delirium, Acute confusional state

- good wakefulness- impair orientation- fluctuation of consciousness(usually occur at night)- broader cause than coma


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Etiologies - I WATCH DEATH

! I = Infection

! W = Withdrawal

! A = Acute Metabolic

! T = Trauma

! C = CNS Pathology

! H = Hypoxia

! D = Deficiencies(especially vitamin)

! E = Endocrinopathies

! A = Acute Vascular

! T = Toxins

! H = Heavy metals

D li i t


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Delirium management

Monitor VS and I/O

Ensure good oxygenation

D/C nonessential medications

Minimize opioids, Benzodiazepine, etc

Repeat PE, further lab, radiologic studies if cause not yet identified

! Antipsychotic Dosing in Elderly

! Use clinical judgment depending on severity of symptoms for

starting dose:

! Haloperidol

! 0.5mg mild

! 1mg moderate

! 2mg severe


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Acute stroke


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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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3.1%

3.6%

18.2%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

seizures

toxic/metabolic

PN palsy

tumour

SDH

confusional state

migraine

psychogenic

dementia

syncope/presyncope

MS

vertigo

TGA

SAH

miscellaneous

% of all stroke mimics (n=670)

Condition that mimic stroke


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Stroke can be...

Ischemic 75%

Hemorrhagic(25%);

subarachnoid,intracerebral

Large-artery atherosclerosis(emboli/thrombosis)

Cardioembolism(high-risk/medium-risk)

Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology

TOAST,TrialofOrg10172inAcuteStrokeTreatment.HP Adams, Jr, BH Bendixen,Stroke 1993;24;35-41

TOAST classification


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Anterior vs Posteriorcirculation


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Standard treatment in acute

ischemic stroke

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

Stroke unit : NNT = 30-40 ASA within 48 hrs : NNT 140

Early decompressive surgery for malignant

MCA infarction : NNT =2 for death prevent


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D1E


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Brain herniation

Subfalcine (A) Uncal (B) Central (C) Extradural (D) Tonsillar (E)


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Herniation syndrome


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Treatment IICP

-G;1;2:Y$V8Z/8[);>;L1


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Treatment IICP

Kc:+d2


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Keep in Externs mind

Stroke

1. when the sudden neurological deficit occur;

suspect stroke...every case2. check time and onset (eligible for rt-PA??) and

exclude mimicker cause (hypoglycemia, seizure)3. if within 4.5 hours; call resident/neurologistactivate FAST TRACT can request CT brain

emergency4. check v/s, assess severity, check and follow up

neurological signs


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Seizure and statusepilepticus

P ti t ith li i ll


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Patient come with clinicallysuspected seizure

Known caseepilepsy with

recurrent seizure

First diagnosed

seizure

Statusepilepticus

Seizuremimicker

Cause? Treatment optionsTreatment cause

AED?


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Seizure or Not seizure

Seizure mimicker pseudo-seizure convulsive syncope movement disorder: myoclonus,

chorea, paroxysmal dyskinesia hypnic jerk


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Seizure vs Syncope

Bhidayasiri R. et al. Neurological differential diagnosis 2005


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Identify cause of seizure

(symptomatic seizure)

Acute symptomatic

seizure Stroke Metabolic

disturbances CNS infection Trauma Drug Toxicity Hypoxia

Remote symptomatic

seizure Pre-existing epilepsy Ethanol abuse Old CVA Relatively long-

standing tumors


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New proposed

definition of SE Status Epilepticus Cooperative Study

group (1998) SE > 10 minutes

Lowenstein DH (1999) SE > 5 minutes


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Management of SE


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Key

treat early as possible

step up AED is depended on stage of

SE add on therapy is needed

monitor EEG regularly, even if noobvious seizure

D fi t f th


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Define stage of the

status epilepticus

Pre-monitory status(0-5 min)

Early status(5-30 min) Established status(30-60 min) Refractory status(>60 min)


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Drug used

diazepam, phenytoin(Dilantin), valproicacid(Depakine), levetirazetam(Keppra)

Phenobarbital, propofol, midazolam,thiopental

Topiramate(feed)


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drug use depend on stage of status


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Diazepam

diazepam 10 mg (2-5mg/min) max 10 mg per dose can be repeated 2 doses


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Phenytoin

Vial: 250 mg/5 ml/vial 0.9% NaCl (dont use infusion pump)

starting dose: 20 mg/kg (rate < 1 mg/kg/min)

maintenance: 5-8 mg/kg/day e.g. weight 50 kg

Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20min. then Dilantin 100 mg+0.9%NSS 100 cc ivdrip in 15 min


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Valproic acid

Vial: 400 mg/4 ml/vial 0.9% NaCl or 5% Dextrose

starting dose: 20-30 mg/kg (rate < 50 mg/min) maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day) e.g. weight 50 kg

Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30min. then Depakine 100 mg/hr (10 cc/hr)

warning: hepatotoxicity


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Midazolam

Vial: 1 mg/ml/vial, 5 mg/ml/vial, 15mg/ 3ml 0.9% NaCl or 5% Dextrose/w

starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min) maintenance: 0.05-0.4 mg/kg/hr e.g. weight 50 kg

Midazolam 5 mg iv bolus then + Midazolam (1:1)ivdrip 5 cc/hr (0.1 mg/kg/hr)


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Levetiracetam

(Keppra) Vial: 500 mg/5 ml 0.9% NaCl or 5% Dextrose/w 100 ml starting dose: 2,000-4,000 mg/kg in 15 min maintenance: 10-30 mg/12 hr e.g. weight 50 kg

Keppra 2000 mg iv in 15 min then 1000 mg iv q 12hour


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Propofol

Vial: 10 mg/ml 5% Dextrose/w

starting dose: 2 mg/kg bolus

maintenance: 5-10 mg/kg/hr e.g. weight 50 kg

Propofol (2:1) iv 100 mg then 250 mg/hr

Consult *#2"is required


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Thiopentone

Vial: 1 g/vial

starting dose: 100-250 mg in 20 min then 50 mg q2-3 min until seizure stop

maintenance: 3-5 mg/kg/hr

Consult *#2"is required


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Phenobarbital

Vial: 200 mg/4 ml in sterile water 10 ml 5% Dextose

starting dose: 20 mg/kg (rate < 100 mg/min) maintenance: 1-4 mg/kg/day


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Topiramate

for SE

Clinical trial: 500 mg every 12 hoursnoso/orogastric feed for 2 days then150 mg-750 mg every 12 hours

Effective dose: 300-1600 mg/day


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Monitoring

Tapering off AED seizure stop > 24 hours Burst suppression on EEG > 24

hours Slow tapering off AED if seizure recur, increase AED dose

enough to control seizure

Keep in Externs Mind


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Keep in Extern s Mind

Seizure1. Seizure or not seizure: history, neuro exam2. Identify cause, ABCD management3.Start AEDs if seizure tend to be recurrent4. if seizure is going to be status; need to be

quick, and follow up the status epilepticusguideline therapy


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