Neurological emergencies Sarah Ramsay Dept of Anaesthesia and ICU Are you in a coma or only sleeping?? Approach to the unconscious patient Specific conditions Simultaneous… Assessment AND treatment Avoid secondary injury Purpose of assessment • To document the level of consciousness and other brain functions so that the patient's progress can be followed • To localize pathology and narrow the differential diagnosis Not sleeping… • General examination • Neurological examination – GCS – Brain stem function (pupils, gag etc) – Other cranial nerves – Peripheral nervous system (motor & sensory) GLASGOW COMA SCALE • Verbal • Motor • Eyes GLASGOW COMA SCALE • Verbal • Motor • Eyes Verbal • • • • • • Orientated Confused Inappropriate Incomprehensible Nil (T=intubated) Motor • • • • • • Obeys commands Localizes to pain Flexion to pain (withdrawal) Abnormal flexion Extensor response Nil Eyes • • • • Spontaneous To speech To pain Nil • Status epilepticus • Acute CVA • Head injury Status epilepticus • Risk of brain damage: local & 2o injury • “Recurrent seizures with failure to recover from one seizure before next seizure begins” • “continuous clinical or electrical seizure activity for >30 mins; regardless of conscious level” Known epileptic or de novo case – Tumour – Cerebrovascular disease – Head injury – Infection – Hypoxic encephalopathy – Drug abuse / overdose / withdrawal – Metabolic – Primary epilepsy – Pseudoepilepsy SE: Why so bad? • • • • • • Hypoxia Lactic acidosis Hypercarbia Rhabdomyolysis Hyperpyrexia Hypoglycaemia • • • • • • Hypertension (early) Arrhythmias Neurogenic APO Hypotension (late) Aspiration Injury, burns etc SE: Treatment • ABC & oxygen & IV access • Glucose if indicated or unsure (50mls/D50%; paeds 2ml/kg D25%) (100mg thiamine first for adults) • Diazepam (0.2mg/kg) or lorazepam (0.1mg/kg) IV (or PR) • Phenytoin load 15mg/kg at ≤ 50mg/min (to terminate SE or prevent further fits) • Monitor ECG and BP SE: Treatment • Investigate & monitor (EEG) • Persistent: > further phenytoin (5mg/kg x doses) > phenobarbitone (20mg/kg) > thiopentone (3-5mg/kg) or propofol (3mk/kg) then infusion SE: outcome Depends on • Aetiology • Age • Duration of status • Systemic complications (anoxia) • Treatment given Mortality: – 35% Acute CVA • Infarction: 160 per 100,000 • Intracerebral haem: 52 per 100,000 • Subarachnoid haem: 16 per 100,000 Per year: 3500 deaths; 16000 new strokes in HK Ischaemic stroke • • Most will not get ICU care Supportive therapy: – oxygen, avoid aspiration – maintain cerebral perfusion (HR & BP control – labetolol) – Aspirin (& ? Warfarin) • Stroke units • Thrombolysis Ischaemic stroke Thrombolytic therapy (rt-PA): lower mortality & 30% improved morbidity       onset of 185 diastolic > 100 History of warfarin therapy or PT >15 seconds Platelet count 75, GCS < without hydrocephalus or intracerebral haematoma unlikely to benefit from aggressive treatment [...]... Cerebral Cerebral Cerebral tumour haemorrhage infarct abscess Subdural Extradural Infection Toxins and drugs • • • • • • Sedatives Narcotics Alcohol Poisons Psychotropic drugs Carbon monoxide Overdose (deliberate & accidental) Withdrawal states • Status epilepticus • Acute CVA • Head injury Status epilepticus • Risk of brain damage: local & 2o injury • “Recurrent seizures with failure to recover from one seizure... Ischaemic stroke • • Most will not get ICU care Supportive therapy: – oxygen, avoid aspiration – maintain cerebral perfusion (HR & BP control – labetolol) – Aspirin (& ? Warfarin) • Stroke units • Thrombolysis Ischaemic stroke Thrombolytic therapy (rt-PA): lower mortality & 30% improved morbidity       onset of further phenytoin (5mg/kg x 2 doses) > phenobarbitone (20mg/kg) > thiopentone (3-5mg/kg) or propofol (3mk/kg) then infusion SE: outcome Depends on • Aetiology • Age • Duration of status • Systemic complications (anoxia) • Treatment given Mortality: 3 – 35%... • Make a diagnosis • Specific treatment • On-going assessment • Optimize outcome (good nursing care; nutrition) Causes… • Coma due to injury or compression of the reticular activating system = STRUCTURAL COMA • Coma due to generalized impairment of cerebral cortex (+/- the brainstem) = METABOLIC COMA Structural coma more urgent than metabolic Non-traumatic coma - no focal or lateralising signs With...Assessment • General examination • Neurological examination – GCS – Brain stem function (pupils, gag etc) – Other cranial nerves – Peripheral nervous system (motor & sensory) History • Known systemic disease & medication • Previous neurology • Circumstances of onset (?trauma, ? drugs) After assessment… ? Non-traumatic coma ? No focal or lateralising... brain damage: local & 2o injury • “Recurrent seizures with failure to recover from one seizure before next seizure begins” • “continuous clinical or electrical seizure activity for >30 mins; regardless of conscious level” Known epileptic or de novo case – Tumour – Cerebrovascular disease – Head injury – Infection – Hypoxic encephalopathy – Drug abuse / overdose / withdrawal – Metabolic – Primary epilepsy... morbidity       onset of 185 diastolic > 100 History of warfarin therapy or PT >15 seconds Platelet count ... Treatment • Resuscitation = ABC (2o injury; c-spine) • Emergency treatment (glucose; thiamine; ?drug antagonists) • Make a diagnosis • Specific treatment • On-going assessment • Optimize outcome... impairment of cerebral cortex (+/- the brainstem) = METABOLIC COMA Structural coma more urgent than metabolic Non-traumatic coma - no focal or lateralising signs With meningism • SAH • Meningitis... unconscious patient Specific conditions Simultaneous… Assessment AND treatment Avoid secondary injury Purpose of assessment • To document the level of consciousness and other brain functions so