Pre-Extern Tutorial, 12

July 17, 2017 | Author: Surat Tanprawate | Category: Stroke, Coma, Epilepsy, Neurology, Symptoms And Signs
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This lecture i gave a talk for extern in Maharaj Nakorn Chiang Mai hospital, preparing them for upcoming excited life......


Tutorial for Pre-Extern “Emergency Neurology” Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University

Friday, March 16, 2012

Friday, March 16, 2012

Neurology extern should know

• Medical coma Acute stroke • • Tonic-clonic seizure and status epilepticus

Friday, March 16, 2012


Friday, March 16, 2012

Wakefulness and ascending reticular activating system(ARAS)

>> level 2 weeks)

Anti-coagulant in acute ischemic stroke •

ยาที่ใช :  heparin  IV  drip  ,  LMWH  (enoxaparin)  SC

อาจพิจารณาให้ใน acute ischemic stroke กรณีต่อไปนี้

• • • • • Friday, March 16, 2012

Extracranial carotid or vertebral dissection Cerebral venous sinus thrombosis Unstable large vessel infarction Cardioembolic ที่พบ clot ในหัวใจ Arterial dissection

Brain herniation • • • • •

Friday, March 16, 2012

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

Herniation syndrome

Friday, March 16, 2012

Treatment IICP • •

ให้นอนยกศีรษะและส่วนบนของร่างกายสูง 20-30 องศา

พิจารณาให้ osmotherapy:

Friday, March 16, 2012

จัดท่าผู้ป่วยให้หลีกเลี่ยงการกดทับของหลอดเลือดดําที่คอ (Jugular vein)

Mannitol* 0.25-0.5 g/kg ทางหลอดเลือดดําใน 20 นาที 4-6 ครั้งต่อวัน

หรือ 10% Glycerol 250 ml ทางหลอดเลือดดําใน 30-60 นาที วันละ 4 ครั้ง

• •

หรือ 50% Glycerol 50 ml ทางปากวันละ 4 ครั้ง และ/หรือ Furosemide 1 mg/Kg ทางหลอดเลือดดํา

Treatment IICP

Friday, March 16, 2012

• •

หลีกเลี่ยงการให้ hypotonic solution

Hyperventilation เพื่อให้ Pco2 30-35 mmHg มีประโยชน์ในการลดความดันในสมองในช่วง สั้น ๆ ก่อนผ่าตัด

ไม่ควรให้ steroid

หลีกเลี่ยงภาวะขาดออกซิเจน พิจารณาใส่ท่อ ช่วยหายใจในกรณีที่มีการหายใจผิดปกติ

Hemicraniectomy in malignant middle cerebral artery infarction •

Malignant MCA infarction : การขาดเลือดของสมองบริเวณที่ เลี้ยงด้วย MCA เป็นบริเวณกว้าง จนอาจทําให้เกิดการกดเบียด ต่อเนื้อสมอง ทําให้มีbrain herniation ตามมา


• • • • • Friday, March 16, 2012

Contralateral weakness Eye deviate to ipsilateral lesion Global aphasia in dominant hemisphere Hemispatial neglect in nondominant hemisphere Signs of IICP, brain herniation

Hemicraniectomy in malignant MCA infarction

Friday, March 16, 2012

Keep in Externʼs mind Stroke 1. when the sudden neurological deficit occur; suspect stroke...every case 2. check time and onset (eligible for rt-PA??) and exclude mimicker cause (hypoglycemia, seizure) 3. if within 4.5 hours; call resident/neurologist “activate FAST TRACT” can request CT brain emergency 4. check v/s, assess severity, check and follow up neurological signs Friday, March 16, 2012

Tonic-clonic seizure and status epilepticus

Friday, March 16, 2012

Seizure and Epilepsy Seizure

the clinical manifestation of an abnormal and hypersynchronous discharge of a population of cortical neurones


a tendency toward recurrent seizures unprovoked by systemic or neurologic insults

least two unprovoked seizures at least 24 hours apart.

Acute symptomatic seizure

• Friday, March 16, 2012

a seizure occurring after identifiable cause (metabolic, stroke, traumatic brain injury or infection)

Seizure or Not seizure • Seizure mimicker • pseudo-seizure • convulsive syncope • movement disorder: myoclonus, chorea

• hipnic jerk Friday, March 16, 2012

Convulsive syncope • • •

Convulsive movements due to syncope Myoclonic, tonic, eye movement Very common,

normal blood donors (12-42%)

Not an epileptic seizure arising in an ischemic cortexcortex is silent

• •

Originates in brainstem-ischemic ʻdecorticationʼ

Friday, March 16, 2012

Does not require AEDs

Identify cause of seizure Acute processes

• • • • • • Friday, March 16, 2012

Stroke Metabolic disturbances CNS infection Trauma Drug Toxicity Hypoxia

Chronic processes

• • • •

Pre-existing epilepsy Ethanol abuse Old CVA Relatively longstanding tumors

What should we do? • Evaluate ABCD, and check basic lab,

intubation or oxygen therapy if indicate

• Clarify: is it seizure?? • If seizure is not stop; consider AEDs • Complete general, and neuro-exam • Brain imaging if indicate Friday, March 16, 2012

Friday, March 16, 2012

Status How to define status... Epilepticus •

1981, ILAE (International League against Epilepsy)

“a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur”

Premonitory status: increase in the usual frequency or severity of their seizures may precede status epilepticus ʻneed for emergency managementʼ

Friday, March 16, 2012

Friday, March 16, 2012

Compensated Friday, March 16, 2012


Friday, March 16, 2012

Premonitory tonic-clonic status epilepticus

• Buccal midazolam 10 mg(0.15-0.3 mg/kg in children)

• Rectal diazepam 10- 30 mg(0.2-0.3 mg/kg in children), repeated if necessary!

Up to 30 min!

Early tonic-clonic status epilepticus !  IV lorazepam, 4 mg bolus(0.07 mg/kg in children), repeated if necessary !  Basic life support airway intubation !  Monitoring : regular neurological observationECG, pulse oximetry !  Investigation: ABG, urea, elyte, glucose, liver enz, ca, mg, full blood count, AED level, blood sam ple for storage, ECG!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003) Friday, March 16, 2012

After 30 min!

Established tonic-clonic status epilepticus !  IV phenobarbitone, 20 mg/kg, 100 mg/min or !  IV PHT 10-15 mg/kg, 50 mg/ min or !  Phosphenytoin, 15mg phenytoin equivalent/ kg!

After 30-60 min!

Refractory tonic-clonic status epilepticus Get an anaesthetist !  Thiopentone 100-250 mg iv bolus, further 50 mg bolus every 2-3 minutes until seizure are controlled, then 3-5 mg/kg/hours to maintain a burst suppression pattern on the EEG or !  Propofol 2 mg/kg iv bolus, repeated if necessary, then 5-10, reducing to 1-3 mg/kg/hrs or !  midazolam., 0.1-0.2 mg/kg bolus to control seizure, repeated if necessary, then 0.05-0.5 mg/kg/hrs!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003) Friday, March 16, 2012

Keep in Externʼs Mind Seizure 1. Seizure or not seizure: history, neuro exam 2. Identify cause, ABCD management 3.Start AEDs if seizure tend to be recurrent 4. if seizure is going to be status; need to be quick, and follow up the status epilepticus guideline therapy

Friday, March 16, 2012

Friday, March 16, 2012

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Friday, March 16, 2012

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