emergancy med #3

what is a primary HA

when the HA is the disorder itself like migrraine, tension type HA, cluster HA

secondary causes of HA

• vascular

• infectious

• increase in ICP

• toxic metabolic

• ocular

what vascular problems can cause HA

SAH, omtracranial hem, cervical dissection, gaint cell artertis

toxins that can cause HA

carbon monoxide, any hypoxia

what is in a focus neuro assesment

§Pupils and cranial nerves

§Motor and sensory function

§Speech

§Coordination

§Gait, if appropriate

what are the HA red flags

primary HA

Prior similar headaches

No meaningful change in frequency, quality, or severity

No SNNOOP10 red flags

Normal neurologic examination

No concerning fundoscopic findings

No high-risk clinical context

treatment for primary HA

Symptomatic treatment (analgesics/abortive therapy, antiemetic or IVF if needed)

Reassess after treatment

Discharge when improved and clinically stable

Appropriate outpatient follow-up

when should you get an LP for HA

• mengitis

• SIH

• idopathic intracranial HTN

what must you consider neuroimaging prior to LP

• alterned mental status

• focal neuro deficit

• papiledema

• new onset seizure

• known CNS lesion

• immunocompromised

do all pt need CT before LP

no

why LP in mengitis

glucose/protein count and to gram stain and pcr

LP for idopathic intracranial HTN for what putpose

to get opening pressure andk CSF compostion

when to ct angiogram of head and neck in HA

suspected aneurysm/ SAH or cervical artery dissection

when to get MRI in HA

when you think mass, infection, or cant tell from CT

the primary HA and their locations

the feature of a tension HA

headband like tightness

not disabeling

may radiate from neck to shoulder or back to cranium

not worsend by physical activity

no naysea or vommiting

May have photophobia OR phonophobia, but not both (fear ro specific sounds)

common triggers of tension HA

stress/ anxiety

sleep distrubances or fatigue

prolonged muscle tension/posture

tension HA tx

§NSAID — e.g., ibuprofen, naproxen, ketorolac

§Acetaminophen

§Combination acetaminophen/NSAID may be considered if needed

§Reassess after treatment

§Discharge if symptoms improve and evaluation is reassuring

§Outpatient follow-up for frequent/recurrent headaches

what med to aviopd in tension HA

opiod

how does a migraine present

duration 4-72 hours

u/l pain that can be throbbing or pulsating

with ot w/o aura

worsened by physical activity

nausea or vommiting

photophobia and phonophobia are common

trigger of migraine

stress

sleep disturbances

certain foods and alc

hormonal changes

certain foods and alc

weather and envirnmental changes

trigger that favor migrain over tension

certain foods and alc

hormonal changes

certain foods and alc

weather and envirnmental changes

sx that favor migraine over tension

photobobia + phonophobia

nausea and vommitting

dibiliating

worsened by physical activity

u/l pain

treatment for migraine

NSAID – e.g., IV ketorolac

Antidopaminergic antiemetic

• IV prochlorperazine or metoclopramide

  • Treat both headache and N/V

Triptan 

• e.g., sumatriptan, rizatriptan

• Most effective early (within 1-2 hours) in the attack; appropriately selected patients

Dexamethasone - may reduce HA recurrence but not acute pain

Avoid opioids - not recommended for routine migraine treatment

Reassess after treatment

Discharge if symptoms improve and evaluation is reassuring

Outpatient follow-up for frequent, recurrent, or poorly controlled migraines

what migraine med can treat HA and N/V

IV prochloperazine or metoclopramide

what migraine med is best given early 1-2 hr

sumatriptan and tiztriptam they are both triptans

what migrain med can reduce the reccurance but not acute pain

dexamethasone

cluster HA pain location

is in and around one eye

cluster HA presentation

sudden onset 15-180 min’

strictly u/l around eye

severe to excruciating

often occrus the same time of day

associated with ipsilateral autonomic

what is the timing of a cluster HA

occurs 1 every other day to 8 times a day in a cluster period

usually occurs the same time of day mostly at night

common triggers during a cluster period

alc

hot weather or heat exposure

nitro

fisrt line tx for sluster HA

100% O₂ via nonrebreather mask at 12-15 L/min for 15–20 min

Sumatriptan 6 mg SC – has a rapid onset for acute attacks

alternative med for cluster HA

Zolmitriptan intranasally

what to aviod in cluster ha

oral medications for acute attacks cause oral has slow onset

opiods

features of SAH

• thundercalp HA

• photophobia

• neck pain or stiffness

• focal deficit

• may have syncope or altered mental

• nausea and vomitting

what are thr isk factoirs of SAH

HTN, smoking, polycstic disease, kidney disease, family history of aneurysm

what can r/o SAH

NEGATIVE ct WITHIN 6 HOURS OF ONSET AND normal neurological exam

what to do if CT is negative but sx started greater than 6 hrs ago

LP or CTA to confirkm

LP findings in SAH

xanthochromia, persistent RBCs in CSF

CTA in sah

identifies and characterizes an aneurysm when SAH is diagnosed or strongly suspected

what is the target BP in SAH

SBP less than 160

what meds to use if BP is greater than 160 in SAH

labetalol or nicardipine

definitive treatment for SAH

• urgent neurosurgical intervention

• endovascular coling or surgical clipping

triad of mengitis

fever, HA, neck stiffness

other sx mengitis can have

altered mental

nausea, vomiting

photophobia

neuro deficits

petechal or purple rash with menigococcal disease

test for menigitis

kernig

brudzinkis

abscnce does not exlclude disease

CSF findings in bacterial v viral

bacterial mengitis tx

§Ceftriaxone + vancomycin

§Add ampicillin if age >50 or immunocompromised

Dexamethasone immediately before or with first antibiotic dose when bacterial meningitis is strongly suspected

viral menigits/ encephalitis tx

§Supportive care for most viral meningitis

§IV acyclovir if HSV/VZV CNS infection is suspected

can you discharge mengitis

if uncomplicated viral meningitis may discharge with reliable follow up

encephalitis

inflammation of the brain parenchyma most commonly due to viral infection

what helps distinguish encephalitis from uncomplicated mengitis

alterted mental or evidence of brain dysfunction

features of encepslitis

Fever

Headache

Altered mental status or change in behavior/personality 

Seizures

Focal neurologic deficits

May have movement abnormalities

encephalitis dx

lumbar puncture is the most useful

increase lymphocytes, increase proteins and normal glucose

when to do a CT for encephalitis

before LP if concerned for increase ICP, or new focal deficits

tx for encephalitis

support+ emperic IV acylovir cause you presume HSV until excluded and always admit

temporal arteritis aka gain cell

inflammatory vasculitis of medium and large arteries that typically involve branches of the carotid artery an can cause irreversible vision loss

temporal arteritis presents

• new HA in pt greater than 50

• temporal/ scalp tenderness

• jaw claudication

• VA symptoms

• consitutional sx

• temporal artery many be thickened

  • polymaalgia rheumatica

temporal artheritis is more common in

women older than 30

dx of temporal arteritis

temporal artery ultrasound or biopsy can confirm diagnosis

tx of gaint cell

start steriods DO NOT DELAY FO CONFIRMATION

pred if no vision

IV methypred if vision plus consult optho

idopathic intracranial HTN

HA, transient visual obscuration, blurred vision or dioplopia, pustatile tinnitus, CN 6 palsy

idopathic intracrnial HTN occurs iin

women of childbearing age with obesity

dx intracranial HTN

neuroimaging and lumbar puncture that shows increase opening pressure

what is an opening pressure consistant with intracrnial HTN

above 25

tx of intracrnial HTN

• acetazolamide: decreases CSF production

• optho eval

dx for a brain tumor

noncontrast CT then MRI with contrast

tx of brain tumor

neurosurgey

when to admit for brain tumor

neurological defect, seizure, increase ICP, mass affects

brain tumor with cerebral edema causing neuro sx tx

dexamethosone`

does COHb level indicate the severity

no

CO toxin tx

100 % oxygen via nonrebreather

consider hyperbaric o2

observe until sx resolve

the diagnostic criteria for epilepsy

• 2 or more unproved seizures occurin 25 hrs a part

• 1 unproved seizure with high risk of recurrence

status epilepticus

5 or more min seizure or multiple not returning to baseline

slide 38 for what causes seiaures

what makes a febrile seizure complex

• focal features

• longer than 15 min

• recurs within 24hrs

what lab to get in seizure right away

point of care glucose

when to get noncontrast CT for seizure

Fever

Headache

Altered mental status or change in behavior/personality 

Seizures

Focal neurologic deficits

May have movement abnormalities

These are all sighns of intracranial cause

when to discharge a seizure that last less than 5 min

Returned to neurologic baseline

Normal neurologic examination

No serious provoking cause identified

No concerning findings requiring admission

Reliable follow-up available

Arrange prompt neurology follow-up

Outpatient EEG ± MRI

when to admit seizure

Status epilepticus or recurrent seizures

Failure to return to neurologic baseline

New/persistent focal neurologic deficit

Serious underlying cause requiring treatment

Significant abnormality on diagnostic evaluation

Unable to ensure safe discharge or follow-up

tx in first five min of seizure

ABCs; protect patient

Monitor

IV/IO access

Point-of-care glucose → treat hypoglycemia

first line for status epilepticus

•Lorazepam IV OR

•May repeat once if seizure continues

•No IV access → midazolam IM

secound line

Levetiracetam IV

Fosphenytoin IV

Valproate IV

when you everyone second choice you get a Very Lonley Feeling

what is a first line med you can use if patient has no IV acess

•No IV access → midazolam IM

persitant seizure after benzo and secound line drug

Refractory status epilepticus

Airway management/intubation as needed

Continuous IV anesthetic (e.g., propofol or midazolam)

Continuous EEG

Neurology + ICU admission

tx status epilepticus

tx alc withdraw seizure

Benzodiazepines (lorazepam or diazepam) are first-line

Phenobarbital if persistent symptoms after adequate benzodiazepine treatment

Treat concurrent alcohol withdrawal

Routine antiseizure medications are not indicated

Eclampsia tx

•New-onset, generalized, tonic-clonic seizures or coma in a patient with preeclampsia

•Treatment: Magnesium sulfate

Hyponatremia seizure tx

3% hypertonic saline

isoniazed toxcty seizure tx

pyridoxine (vitamin B6) + benzodiazepine

what ethnicity higher risk for stroke

highern death rates for non-hispanic black and pacific islander adults

what has helped stroke death rates decrease

• stroke units

• thrombolysis

• mechanical clot retrival

• expanding tx time window

stroke ischemic occurs

any disease that causes interruption of blood flow to the brain

what are the different types os ichemic strokes

thrombotic

embolic

hypoperfusion

what are the types of hemorrhagic strokes

intracerebral

nontraumatic subarachnoid hemorrhage

basiliar supplies blood to

THALAMUS

veryebral supplies blood to

brainstem

what are the risk factors for thrombotic stroke

age, HTN. DM, CAD, smoking

risk factors for embolics strokes

A FIB

VAVLE replacement

recent MI