neurologic emergencies

  1. stroke define
    rapidly developing disturbance of cerebral fx lasting longer than 24 h
  2. define TIA
    acute episodes of focal loss of cerebral fx lasting <24 h
  3. 2 most common pathologic processes that result in stroke
    • 1. occlusive
    • large vessel
    • small vessel
    • emblic
    • inadequate blood flow

    • 2. hemorrhagic
    • hypertensive
    • SAH
    • AVM
    • henorrhagic metastises
    • venous infarction
    • arteritis
    • bleeding diastheses
  4. risk factors for stroke
    • age
    • hypertension
    • diabetes
    • smoking
    • afib/cardiomyopathy/valve dz
    • cad/hyperlipidemia
    • obesity/inactivity
    • OCP use
  5. history in suspected stroke
    o- when did it start

    p- what was pt doing

    q- what sxs developed


    s- symptoms associated, headache, chest pain, palpitations, vision changes, weakness, numbness, swollowing or speech problems, involuntary movements, loc, incontinence


    • pmh- recent surgeries, trauma, infections
    • meds
    • drug use
  6. physical exam in suspected stroke
    • vs- often occur in setting of hypotensiona nd hypertension
    • heent- temporal artery tenderness may be present in elderly w temporal arteritis
    • neck- nuchal rigidity, caritid bruit
    • heart- arrhythmia, murmur
    • lung-
    • extremities- stigmata of endocarditis(splinter hemorrhages,janeway lesions, osler nodes), hemorrhagic diasthesis, and/or vasculitis
    • neuro-
    • MS-level of consciousness, orientation, memory, naming, speech, understanding, reading, writing, copying
    • CN- including fundiscopic and visual field impairment
    • Motor- strength and pronator drift
    • DTR-initially hypoactive then hyperactive, babinski
    • sensory- pain, temp, light touch, sharp, proprioception(rhomberg)
    • cerebellar-balance, heel to shin, finger to nose and gait
  7. useful tests in strokes
    blood glucose

    cbc, lytes, pt/ptt,


    cxr- eval for infiltrates, cardiomegaly, signs of malignancy

    EKG- arrhythmia,cardiomegaly, ischemia, (both SAH and ischemic stroke can cause peaked t waves, st segment changes, qt interval changes)

    NonContrast CT- primarily to r/o hemorrhage or mass effect. ischemia will not usually show up for 24-48 hours. repeat imaging in 7-10 days may furhter define. sensitivity for SAH is 95% if in doubt do LP.

    MRI-perferred over CT for brain stem stroke, subacute hematoma, demyelinating diseases, AVMs.

    • optional tests
    • ESR-manditory in those > 50 w HA or transient vision loss
    • LP-if meningitis or SAH suspected
    • carotiod doppler
    • echocardiography
    • angiography
    • MRA
    • RPR,LYME,toxicology, antithrombinIII, protein c, protein s, anticardiolipin antibody, blood cultures(endocarditis)
  8. stroke differential dx
  9. goals to stroke therapy
  10. treatment of TIA
  11. Treatment of Acute Stroke
    ABC- oxygen, IV, Monitor

    do not lower bp unless >220 systolic in hemorrhagic stroke or >120 diastolic in in occlusive stroke. >180 systolic in SAH.

    get neurology/neurosurgery consult/transfer early

    do frequent neuro checks
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neurologic emergencies