Neuro Call

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Neuro Call
2011-07-05 15:24:19

On Call Survival Guide
Show Answers:

  1. On Call Basics
    Why we are usually called
    ¤ED calls
    -Vertebrobasilar insufficiency à vertigo
    -Weird neuro stuff (walking probs, Guillian Barre, headaches)
    -Altered Mental Status
    -BS police à call us for conversion d/o type stuff

    -Usually strokes or concern for status epilepticus
    -Random weird cases
  2. On Call Basics 2

    ¤Any change in neurological exam requires a patient to be seen immediately by you or your senior.

    ¤This is important for our in-patients, consult patients, or patients we have already been consulted on.
  3. Approach to Neuro Dx
    3 steps

    ¤1st: Is this neurological? Can a non-neurological diagnosis explain this problem?

    ¤2nd: What is the time course?

    ¤3rd: Where does it localize? CNS or PNS or multi-focal?
  4. Onset | FOCAL | DIFFUSE

    Acute |Vascular |Toxic/Metabolic

    Subacute |Inflammatory|Inflammatory

    Chronic |Neoplastic |Neuro-

    Acute: seconds to hours
    Subacute: days to weeks
    Chronic: months to years
  5. Time Course
    Main point:
    ¤Any acute neurological deficit that occurs suddenly is a stroke until proven otherwise

    ¤Once stroke is ruled out, other considerations include seizure (post-ictal phenomenon i.e. Todd’s paralysis) or complicated migraines
  6. Neuro Diagnosis Approach: Localization

    Lower Motor Neuron signs:
    ¤Fasiculations (observable muscle quivering)Decreased Tone

    Upper Motor Neuron Signs
    ¤Less Atrophy
    ¤Increased tone
    ¤Babinskis and primitive frontal release signs
    ¤Arm extensor pattern, Leg flexor pattern
  7. Stroke Basics
    Who, What, Where, When, Why, and How?

    -Risk factors for stroke: HTN, HLD, DM, obese, old age, tobacco
    -If young and have stroke: then think trauma (vertebral dissection), autoimmune disease, hypercoaguable state, or congenital heart disease

    ¤What to ask?
    -Ask about blood pressure, if its low (then they may still have a stroke but need to consider hemodynamic deficit)
    -Ask about last time normal (time when they didn’t have any neurological deficits)
    -Ask about what deficiencies they are having (speech issues, weakness, numbness)
  8. Stroke Basics 2
    Where to be admitted?
    ¤If tPA, then NSICU
    ¤If TIA with complete resolution, then floor unless BP is crazy (then NSICU)

    Where is their stroke (localizing basics)?
    ¤Cortical findings: gaze preference, seizure, expressive or receptive aphasia (not dysarthria), neglect of one side of their body, bilateral visual field deficits

    ¤Brainstem findings: crossed sensory findings (i.e. L face, R body), eye movement issues, asymmetric pupils, ataxia, vertigo, nausea (will be mild), or weakness in all 4 extremities
  9. Stroke Basics 3
    Post tPA pearls:
    ¤Keep systolic BP <180 (use drip if necessary)
    ¤No anti-platelet therapy or subq Heparin for 24h
    ¤Reorder brain imaging 24h post tPA administration
    ¤If change in neuro exam, take this very seriously (check BP and get stat head CT)
    ¤If nauseated, then go see (could be head bleed)
    ¤If hypotensive, then give IV fluids and go evaluate
  10. Seizure Basics
    Who has seizures?
    ¤Risk factors to ask: head injury with loss of consciousness, family hx of seizures, childhood history of seizures or febrile seizures, and hx of meningitis/encephalitis

    ¤Remember you need to have a cortical lesion to seize.
    -Subcortical disease does not cause seizures
  11. Seizure Basics 2
    What kinds of seizures are there?
    -Occur from a specific side (one side) of the brain
    -Simple partial: these are auras only (completely normal cognitively)
    -Complex partial: altered level of consciousness (but they don’t have to completely lose consciousness); may stare, make weird sounds, do repetitive motions

    -In adults with no prior history, are usually from withdrawal of a substance or metabolic.
    -Usually full body rhythmic jerking. Ask about incontinence and tongue biting
    -Can evolve from a partial seizure which then generalizes to involve both hemispheres resulting in a loss of consciousness
    -Remember withdrawal seizures are always generalized seizures.
  12. Seizure Basics 3
    What should I ask the patient or family?
    ¤Seizure risk factors
    ¤Are these events stereotyped (the same every time)?
    -Do you they have a warning prior to their event?
    -Focality, such as head turning or eye deviation each time?
    ¤How long do they last?
    ¤How are they afterwards? Confused, tired, body aches?
    ¤Tongue biting, urinary incontinence?
    ¤Are they taking their seizure medication?
    ¤Any recent infection? Any recent head trauma? Sleeping well or poorly? Stress level?
  13. Seizure Basics 4
    Where to examine if someone calls you concerned about status and the patient is too altered to talk to you?
    ¤Pinch them at all 4 extremities via nailbed pressure and also try sternal rub.

    ¤If no movement, then my concern for status epilepticus is higher à consider continuous EEG (if you can’t explain their altered level of consciousness another way).
    -For intubated patients: ask them to take them off of sedation for at least 5-10 minutes prior to your arrival.
    -“Asking a neurologist to perform a neuro exam with sedation on is like asking an ophthalmologist to look at someone’s eyes with them covered up” – Dr. Kanter
  14. Seizure Basics 5
    Why do people have seizures?
    ¤Previously mentioned seizure risk factors
    ¤Note, however in about 50% of cases a cause is never found

    ¤Pneumonic: AEIOU TIPS
    A: alcohol, anoxia
    E: endocrine, electrolytes, encephalitis, epilepsy
    I: infection
    O: overdose
    U: uremia

    T: tumor, trauma, toxic
    I: insulin (hypoglycemia)
    P: psychiatric disease (pseudo-seizures)
    S: stroke, sub-dural hematoma, sub-arrachnoid hemorrhage
  15. Seizure Basics 6
    How do I workup new onset seizures?
    ¤MRI brain w and w/out contrast

    ¤Routine EEG (remember a normal or abnormal EEG does not necessarily rule in or out seizures)
    -EEG tells us whether the brain is primed to seize (epileptiform discharges are what are concerning on EEG, not slowing)

    ¤Labs: order renal, liver, urine drug screen, and seizure medication level (if on Dilantin or Tegretol)
  16. Seizure Basics 7
    How to treat seizures?
    ¤Acute: give them Ativan 2mg, if they seize again, then give another 2mg. Remember 4mg of Ativan in 5-10 minutes can be a recipe for intubation (get drowsy)

    ¤Status basics:
    -If Ativan fails, then give a Fosphenytoin load (20 mg/kg IV x 1). Maintence Fosphenytoin is given 5mg/kg divided bid or tid.

    Dilantin level management (7-11 rule)
    -If <7, then increase TOTAL dose by 100mg
    -If between 7-11, then increase TOTAL dose by 50mg
    -If greater than 11, then increase TOTAL dose by 30mg
  17. On Call Basics
    Remember should you have any concerns, then call or find your senior.

    And again:
    ¤Any change in neurological exam requires a patient to be seen immediately by you and/or your senior.