CEN Neurological Emergencies

A 25-year-old female is brought to the emergency department with complaint of sudden onset right sided headache described as throbbing. Before the pain began, she complained of seeing flashing lights. She is now vomiting when she moves her head. It is likely that this patient is experiencing: a. Vascular migraine headache b. Temporal arteritis c. Tension headache d. Traumatic headache

A. A vascular migraine headache typically progresses through specific stages. In the prodromal phase, the patient may experience an aura. This aura may be visual disturbances including flashing lights or other disturbances. During the second phase, vasodilation causes the typical throbbing headache that usually begins on one side of the head. After the headache subsides, the patient may have a very tender head.

In a severe head injury, invasive monitoring devices may be used to manage increased ICP. Which of the following devices can be used to sample or drain CSF? a. Ventriculostomy b. Subarachnoid bolt c. Epidural sensor d. Intraparenchymal

A. A ventriculostomy or intraventricular catheter is inserted into the ventricles and allows CSF to be withdrawn for ICP control and culture collection. This type of catheter also allows contrast materials to be injected for radiological studies. Because of the invasive nature, there is a risk of hemorrhage and infection. This device is also more difficult to insert.

Which of the following would NOT be a treatment for meningitis? a. Administration of sedatives. b. Administration of antibiotics c. Administration of antipyretics d. Administration of anticonvulsants.

A. Administration of sedatives is not indicated for meningitis since continuing neurologic assessment is critical in order to identify if the level of consciousness decreases. Antibiotics for infection, antipyretics for fever, and anticonvulsants for possible seizures may all be indicated.

The National Institute of Neurological Disorders and Stokes (NINDS) has set the goal for initiation of fibrinolytic therapy in appropriate patients as: a. Within 1 hour of hospital arrival. b. Within 3 hours of hospital arrival. c. Within 4 hours of hospital arrival. d. Within 6 hours of hospital arrival.

A. NINDS recommends a goal for initiation of fibrinolytic therapy within 1 hour of arrival to the ED. NINDS also recommends a goal of door-to-admission time of 3 hours.

A 44-year-old man is brought to the emergency department by his wife with complaints of tingling in his hand and a metallic taste in his mouth. During assessment, he is alert and oriented but anxious. He is unaware of a repetitive chewing motion that he is making with his mouth. What is this patient likely experiencing? a. Partial or focal seizures b. Generalized absence seizures c. Grand mal seizures d. Status epilepticus

A. Partial or focal seizures are typified by focused motor activity and disturbances in vision, hearing, smell or taste. Numbness or tingling may be a symptom. In a simple partial seizure, the patient's mental status usually will not be affected. One of the most characteristic symptoms is the presence of some pattern of movement such as chewing, hand patting, grimacing, or lip smacking.

A 75-year-old female is brought to the emergency department after a witnessed fall by her family at the nursing home. On examination, she has bruising around both eyes and clear fluid draining from the left ear. What is the likely diagnosis? a. A basilar skull fracture b. Elder abuse c. Ruptured eardrum d. Nasal fracture

A. Periorbital ecchymoses (raccoon eyes) is a classic sign of basilar skull fracture. Clear drainage from the nose or ears should alert you to the fact that this might be CSF drainage due to the fracture. A simple test to determine if this drainage is CSF is to use the halo test for glucose (a normal finding in CSF). Put a drop of the clear fluid from the nose or ears on a piece of filter paper. If the fluid forms two distinct rings on the paper (the halo sign), this would indicate that the fluid is CSF.

To quickly evaluate a child's neurological status, all of the following standard evaluations can be used EXCEPT: a. The Epworth Scale. b. The AVPU scale. c. The Glasgow Coma Scale. d. Pupillary responses to light.

A. The Epworth Scale is a measure of sleepiness and is not part of the standard evaluation of a child's neurological exam. The AVPU and Glasgow Coma scales can be used to evaluate a child's neuro status. Pupillary size and response should also be checked.

An elderly man with a laceration on his elbow presents to the emergency department. He is obviously confused and appears to be frightened. His daughter is with him and explains that he has Stage 2 Alzheimer's disease and that she needs to stay with him. The correct response in this situation is: a. Allow the daughter to accompany the patient to his room. b. Ask the daughter to wait in the waiting room until after the exam is complete. c. Ask the daughter for a copy of the patient's Power of Attorney for Health Care. d. Ask the patient if he wants the woman to accompany him to the treatment room.

A. The patient with Alzheimer's disease is likely to be more cooperative and calmer if he is accompanied by a familiar face. The request for legal paperwork can occur at any point in the stay. An evaluation of whether or not the patient has been abused should be based on the physical exam since this patient is unlikely to be able to give you an accurate history.

A patient is brought to the emergency department after a car crash. The patient had a short period of unconsciousness. During the short transport, the patient awakened and was lucid.. During transport, he complained of a severe headache. After arrival in the ED, he lost consciousness and his left pupil became dilated. Which of the following should be suspected? a. Concussion b. Epidural hematoma c. Subdural hematoma d. Seizure disorder

B. A hallmark sign of an epidural hematoma is an injury resulting in loss of consciousness, followed by a period of lucidity with severe headache, and then followed by loss of consciousness again. A large epidural hematoma will usually require surgical intervention; a smaller epidural can sometimes be managed without surgery and just very close monitoring.

You are caring for a 30-year-old patient who has been diagnosed with Guillain-Barre syndrome. Which of the following is NOT an appropriate intervention? a. Prepare for emergency intubation. b. Prepare to administer succinylcholine. c. Prepare for possible plasmapheresis. d. Prepare to administer immunoglobulin.

B. Administration of succinylcholine is absolutely contraindicated in a patient with Guillain-Barre syndrome. This drug can cause lethal hyperkalemia in these patients.

Meningitis that is fatal in half of the infected patients is caused by a: a. Virus b. Bacteria c. Fungus d. Noninfectious agent

B. Bacterial meningitis is characterized by acute onset and is commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes and Neisseria meningitides. Bacterial meningitis commonly presents with the classic triad of symptoms: fever, stiff neck and diminished level of consciousness. Bacterial meningitis is fatal in approximately 50% of all cases.

Fibrinolytic therapy should be considered in hemorrhagic stroke. a. True b. False

B. Because of the bleeding risk, fibrinolytics and anticoagulants should not be used in hemorrhagic strokes, but should be the treatment considered first for ischemic stroke.

An 8-year-old boy is brought to the emergency department by his father who states that the child tends to "zone out" when he is stressed. The father states that the child tells him that he does not remember anything during those times. The father reports that the child tends to grimace during these periods but denies any pain after the episodes. Immediately after, the father says that the child is awake and alert. The father reports that his younger brother had similar episodes as a child. This child should be evaluated for which of the following? a. Partial or focal seizures b. Generalized absence seizures c. Grand mal seizures d. Status epilepticus

B. Generalized absence seizures occur primary in young children and are characterized by abrupt cessation of activity with occasional momentary loss of consciousness. Automatism such as chewing, hand patting, grimacing or lip smacking may be noted. These absence seizures may run in families. Typically, the child will appear to be normal after the seizure.

A 56-year-old woman is brought to the emergency department with a complaint of a severe, stabbing pain in her left temporal area. She reports that she has been experiencing night sweats, fever and aching joints. As you assess the patient, you notice red nodules over the left temporal area. It is likely this patient is experiencing: a. Vascular migraine headache b. Temporal arteritis c. Tension headache d. Traumatic headache

B. Temporal arteritis is most common in women over the age of 50. It is caused by inflammation of the branches of the carotid artery. Although headache is the most common symptom, the patient will often complain of sleep disturbances, night sweats, fever, weight loss, and the development of red nodules in the temporal region. Biopsy of the temporal artery will provide a definitive diagnosis of this condition.

The National Institute of Neurological Disorders and Stokes (NINDS) has set the goal for immediate general assessment by a stroke team or emergency physician as: a. Within 1 minute of arrival. b. Within 10 minutes of arrival. c. Within 30 minutes of arrival. d. Within 60 minutes of arrival.

B. The goal for general assessment by an ED or stroke team physician is within 10 minutes of arrival to the ED. Within the same 10 minutes, an urgent CT without contrast should also be ordered.

A late sign and symptom of increased intracranial pressure is: a. Headache b. Sluggish pupillary reaction c. Babinski reflex d. Blurred vision

C. A Babinski reflex (or extensor plantar reflex) is a normal finding in an infant but an abnormal reflex in an individual over two years of age. The Babinski is positive when the sole of the foot is stimulated and the great toe extends up to the top of the foot and the other toes flex down to the sole of the foot. The Babinski test is a diagnostic test that indicates central nervous system damage.

A 23-year-old patient is brought to the emergency department by EMS personnel. The paramedic reports a series of consecutive seizures that were reported by the patient's wife and that have continued during transport. The patient has not regained consciousness during transport. The patient's temperature is 100 degrees F, blood pressure is 152/100 and pulse is 120. The wife reports that the patient has a history of seizures but has never had an episode like this. Appropriate interventions include all of the following EXCEPT: a. Monitor the patient's airway and prepare for intubation if necessary. b. Prepare to give a sedative. c. Protect the patient from injury by restraining the patient's arms and legs. d. Prepare to give anticonvulsant medication.

C. Although the patient must be protected from injury, restraining the patient may cause injury and prevent the patient from being rolled to his side should he vomit. The stretcher should be in low position with side rails up. The side rails should be padded if possible.

A 15-year-old girl is brought to the emergency department after falling and striking her head during a soccer game. She states she feels fine and wonders what she is doing at the hospital. She has no memory of the event but recognizes her mother and is alert without nausea or vomiting. The response by her mother that would indicate she understands your discharge instructions is: a. I will keep her out of practice and games for the next two days. b. I will be sure her coach understands she should not return to full contact for the next week. c. We will follow up with a pediatric neurologist before she returns to practice. d. As long as she does not have any vomiting, she can return to practice immediately.

C. Concussion must be managed aggressively and any child who is suspected of having a concussion should be evaluated by a pediatric neurologist before being allowed to return to practice. A child with a concussion should return to play in a progressive fashion as dictated by symptoms. Coaches and teachers should be made aware of the concussion and should expect the child to need periods of rest during the day.

Which of the following may cause coup-contrecoup injuries? a. Rotational forces b. Deformation forces c. Deceleration forces d. Acceleration forces

C. Deceleration forces are those in which the head is moving and strikes a stationary object. Deceleration injuries can include skull fractures, contusions and hematomas, and coup-contrecoup injuries. In the coup-contrecoup injury, the brain is injured on opposite sides as the brain first hits against one side of the skull and then bounces back and hits the other side of the skull.

You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT: a. PT referral for development of a planned exercise program. b. Avoidance of prolonged sun exposure. c. Hot baths to promote muscle relaxation. d. Instructions to evaluate the home environment to ensure safety

C. Excessive heat from sun or hot baths should be avoided since this can cause acute exacerbations of symptoms. The MS patient should begin to evaluate the home environment to ensure a safe environment as symptoms progress.

A 17-year-old male is brought to the emergency department after a car crash. He was the unrestrained driver of the vehicle involved in a head-on collision. He is unconscious with fixed and dilated pupils bilaterally. What type of head injury does this patient likely have? a. Concussion b. Epidural hematoma c. Subdural hematoma d. Seizure disorder

C. Given the mechanism of injury and the fact that he is unconscious with fixed, dilated pupils are highly suggestive of acute subdural hematoma. In this case, surgery is required within 4 hours of injury to relieve the pressure. Subdural hematomas are the most common type of intracranial head injury and have the highest incidence of morbidity and mortality of any of the head injuries.

A 26-year-old woman presents with eye complaints including ptosis, diplopia and difficulty in keeping one eye closed. Pupils are equal and reactive to light and accommodation. She notes that she has had some difficulty swallowing recently, but denies any episodes of choking. What does this patient likely have? a. Increased ICP b. Muscular dystrophy c. Myasthenia gravis d. Multiple sclerosis

C. Myasthenia gravis occurs most frequently in women between the ages of 20 and 30. Ocular symptoms are the most common initial complaint and typically include ptosis, diplopia when looking in one direction for a sustained period of time, and difficulty closing one eye. Pupils are usually normal.

A young woman presents to the emergency department with a headache described as "the worst I've ever had". On arrival, she was alert and oriented with pupils equal and reactive. As she waits for a CT scan, she becomes confused. She continues to obey commands and continues to be awake and alert. Using the Glasgow Coma Scale, her GCS score is: a. 3 b. 10 c. 14 d. 15

C. The GCS ranges from 3 to 15. Since the patient has become confused, you can only award 4 points for Orientation; her other scores will continue to be normal. The GCS for this patient is 14. The ED physician must be made aware of this change and aggressive treatment must be started.

A 70-year-old man is brought to the emergency department after sustaining a closed head injury in a car crash in which he lost consciousness "maybe for a few minutes". Skull x-rays show a linear skull fracture. His initial GCS is 15. His medications include Coumadin and digoxin. What is this patient's risk for further problems with a brain injury? a. Low b. Medium c. High d. Unable to determine

C. This patient has several risk factors that make him at high risk for further problems with his head injury. Any patient above 60 or less than two years old should be considered high risk. The mechanism of injury and loss of consciousness are additional risk factors. The fact that he has a skull fracture is significant. Because he is anticoagulant therapy, he is at higher risk for bleeding into the skull.

When evaluating the 68-year-old stroke patient for fibrinolytic therapy, the relative contraindication to fibrinolytic therapy is: a. Stroke within the last three months. b. History of previous intracranial hemorrhage. c. Current use of an anticoagulant with an INR greater than 1.7. d. Myocardial infarction 2 months ago.

D. A myocardial infarction is a relative exclusion criterion if the MI occurred in the previous 3 months. The others are all exclusion criteria and should be reported to the ED physician.

Which of the following may alter the level of consciousness in a patient? a. Alcohol b. Electrolytes c. Infection d. All of the above may cause altered level of consciousness e. Both a and c only

D. An acronym that can be used to remember possible causes of decreased level of consciousness is AEIOU-TIPPS. These letters stand for Alcohol, Epilepsy or Electrolytes, Insulin (either hypo or hyperglycemia), Opiates, Uremia, Trauma, Infection, Poison, Psychosis, and Syncope.

A 24-year-old male is brought to the emergency department following a motorcycle crash. He reports that he does not think he had any loss of consciousness. He is awake and oriented with abrasions on his back, elbows and buttocks. There is a large scrape on the back of his helmet that was removed by EMS personnel. His c-spine has been immobilized. He was incontinent of urine at the scene of the accident. His blood pressure is 80 systolic and pulse rate is 60. There is no obvious sign of bleeding. Which of the following interventions would NOT be appropriate? a. Crystalloid fluid administration b. Vasoactive medications c. Methylprednisolone administration d. All of the above may be appropriate

D. Given the mechanism of injury and the chance of a spinal cord injury, the low blood pressure, urinary incontinence and bradycardia may indicate an injury at T6 or above. Since there is no indication of hypovolemia, the hypotension may be due to neurogenic shock due to spinal cord injury at T6 or above. Fluid administration is critical to ensure that fluid deficits are corrected, but the medications should also be considered for neurogenic shock.

Signs and symptoms of stroke may include all of following EXCEPT: a. Sudden weakness or numbness of the face, arm or leg. b. Sudden confusion. c. Sudden headache with no known cause. d. Hypotension.

D. Hypotension is typically not a sign of acute stroke. Hypertension, extremity weakness or numbness, confusion and sudden headache are all symptoms of stroke.

Methods to reduce increased intracranial pressure include all of the following EXCEPT: a. Administration of diuretics b. Administration of sedatives c. Keeping the head of the bed elevated d. Routine suctioning to maintain a patent airway.

D. Stimulation should be avoided in the patient with increased intracranial pressure. This will include minimizing suctioning except as absolutely necessary.

Increased ICP is caused by an increase in the volume of: a. Blood b. Brain tissue c. Cerebral spinal fluid d. Any of the above e. Both a and c only

D. There are three volumes in the skull: blood, brain and CSF. Because the skull is a closed box, an increase in any of these will increase the pressure within the skull. Normal ICP is 10 mm Hg or less. If one of the volumes increases in the head, cerebral blood flow can be affected unless one of the other volumes decreases to make room for the increased volume.

An infant with hydrocephalus is brought to the emergency department. She has a shunt that has been surgically inserted. Her mother reports that she has been sleeping more than normal and irritable when she is awake. During assessment, the child's fontanelle is full and tense. A nurse should prepare to: a. Administer antibiotics and discharge the child. b. Remove the shunt and send the child home with instructions to be seen by the neurosurgeon in two days. c. Discharge the child to home with instructions to her parents to return to the ED if the child becomes unresponsive or starts vomiting. d. Admit the child and prepare the parents for possible surgery for shunt revision.

D. This infant will usually be admitted, receive antibiotics, and go to surgery for shunt revision due to blockage. A shunt on a hydrocephalic will never be removed in the ED. Increased ICP due to shunt malfunction is an emergency that must be managed aggressively in the hospital.