Neurological Emergencies Burcu Ugurel, MD Phase III Department of Neurology

Neurological Neurological EmergenciesEmergencies

Burcu Ugurel, MDBurcu Ugurel, MDPhase IIIPhase III

Department of NeurologyDepartment of Neurology

Neurologic Emergency OutlineNeurologic Emergency Outline

• Change in Mental Status / ComaChange in Mental Status / Coma

• Stroke/TIA SyndromesStroke/TIA Syndromes

• Seizure & Status EpilepticusSeizure & Status Epilepticus

• Head Trauma Head Trauma

• InfectiousInfectious

• Vertigo/HeadachesVertigo/Headaches

• Peripheral NeuropathiesPeripheral Neuropathies

• MyasteniaMyastenia

• Acute myelopathiesAcute myelopathies

The Neurologic ExamThe Neurologic Exam

• Must do a complete thorough neuro exam to properly identify and diagnose any neurologic abnormality.

• Exam should include 5 parts:– Mental status, level of alertness (GCS)– Cranial nerve exam– Motor / Sensory exam– Reflexes– Cerebellar– Consider ; MMSE if Psych components

Change in Mental Status/ComaChange in Mental Status/Coma

• TemperatureTemperature– Hypothermia: causes coma when Temp<32.0 CHypothermia: causes coma when Temp<32.0 C– Hyperthermia: causes coma when Temp>42.0CHyperthermia: causes coma when Temp>42.0C

• InfectionInfection– Meningitis, Encephalitis, SepsisMeningitis, Encephalitis, Sepsis

• Endo/Exocrine, ElectrolyteEndo/Exocrine, Electrolyte– Hypo/HyperglycemiaHypo/Hyperglycemia– Hypo/hyperthyroidismHypo/hyperthyroidism– Hypo/hypernatremiaHypo/hypernatremia– Hepatic encephalopathyHepatic encephalopathy

• Opiods/ OD / AlcoholOpiods/ OD / Alcohol– Heroin, Psych Meds (TCA’s, SSRI’s)Heroin, Psych Meds (TCA’s, SSRI’s)

Mental Status/COMA Physical Mental Status/COMA Physical ExamExam

• Always attempt to get a complete history!!

• LOOK at your patient!– Smell the breath (ketones,alcohol,fetid)– Observe respiratory rate & patterns (Cheyne-Stokes)– Look for abnormal posturing.

• Decorticate (Flexion of UE with Extension of LE)

• Decerebrate (Extension of all Ext.)

– Look for needle marks, cyanosis, signs of trauma

• Obtain GCS Score! E4 V5 M 6– If less than 8, IMMEDIATE airway stabilization FIRST

priority!!

Glasgow COMA ScaleGlasgow COMA Scale

• Scores range from 3 (Worst) – 15 (Best)Scores range from 3 (Worst) – 15 (Best)

• Important for classifying degree of alteration Important for classifying degree of alteration • (Head Trauma)(Head Trauma)

• GCS < 8 = INTUBATE!!GCS < 8 = INTUBATE!!

Glasgow COMA ScaleGlasgow COMA Scale

• EYE Opening EYE Opening ResponseResponse– 4 = Spontaneous4 = Spontaneous– 3 = To Voice3 = To Voice– 2 = To Pain2 = To Pain– 1 = None1 = None

• Verbal ResponseVerbal Response– 5 = Oriented and converses5 = Oriented and converses– 4 = Confused but converses4 = Confused but converses– 3 = Inappropriate words3 = Inappropriate words– 2 = Inappropriate sounds2 = Inappropriate sounds– 1= None1= None

• MotorMotor– 6 = Obeys commands6 = Obeys commands– 5 = Localizes pain5 = Localizes pain– 4 = Withdraws to pain4 = Withdraws to pain– 3 = Decorticate (flexes 3 = Decorticate (flexes

to pain)to pain)– 2 = Decerebrate 2 = Decerebrate

(extends to pain)(extends to pain)– 1 = None1 = None

Ischemic Stroke SyndromesIschemic Stroke Syndromes

• Middle Cerebral Artery Occlusion Middle Cerebral Artery Occlusion (MCA)(MCA)

• Contralateral hemiplegia, hemianesthesia, and Contralateral hemiplegia, hemianesthesia, and homonymous hemianopsiahomonymous hemianopsia

• Upper extremity deficit > Lower extremityUpper extremity deficit > Lower extremity• Aphasia Aphasia (if dominant hemisphere involved)(if dominant hemisphere involved)

• Conjugate gaze impaired in the direction of the Conjugate gaze impaired in the direction of the lesionlesion


• Anterior Cerebral Artery Occlusion (ACA)Anterior Cerebral Artery Occlusion (ACA)– Contralateral leg, arm, paralysisContralateral leg, arm, paralysis– Lower Extremity deficit > Upper extremityLower Extremity deficit > Upper extremity– Loss of frontal lobe controlLoss of frontal lobe control

• IncontinenceIncontinence• Primitive grasp and suck reflexes enactedPrimitive grasp and suck reflexes enacted

• Posterior Cerebral Artery Occlusion (PCA)Posterior Cerebral Artery Occlusion (PCA)– Ipsilateral CN III palsy, visual lossIpsilateral CN III palsy, visual loss– Contralateral hemiparesis and hemisensory lossContralateral hemiparesis and hemisensory loss– Memory loss Memory loss


• Vertebrobasilar Artery Occlusion (VBA)Vertebrobasilar Artery Occlusion (VBA)

• Hallmark: Crossed Neurological DeficitsHallmark: Crossed Neurological Deficits• Contralateral hemiplegiaContralateral hemiplegia• Ipsilateral CN palsyIpsilateral CN palsy• Cerebellar findingsCerebellar findings

- Nausea/VomitingNausea/Vomiting- Vertigo, Nystagmus, Vertigo, Nystagmus, - Ataxia, DysarthiaAtaxia, Dysarthia- Tinnitus, deafnessTinnitus, deafness

CN and Cerebellar deficits that affect BOTH sides of the CN and Cerebellar deficits that affect BOTH sides of the bodybody

TIA TIA (Transient Ischemic Attacks)(Transient Ischemic Attacks)

• A temporary loss of neurologic function, that A temporary loss of neurologic function, that resolves completely <24 hresolves completely <24 h

• Main point: These patients at high risk for stroke Main point: These patients at high risk for stroke if:if:– >50>50– HT, DM, Smoker, Prior TIA in last monthHT, DM, Smoker, Prior TIA in last month

• Treat as CVA : Head CT (CVA protocol)Treat as CVA : Head CT (CVA protocol)• ASA 81-325mg poASA 81-325mg po• If cardiac arrythmia (atrial filbrillation) present, If cardiac arrythmia (atrial filbrillation) present,

consider Heparin ONLY after Head CT and Neuro consider Heparin ONLY after Head CT and Neuro consultationconsultation

Hemorrhagic Stroke SyndromesHemorrhagic Stroke Syndromes

• Hemorrhagic Strokes• Spontaneous rupture of berry aneurysm or AV

malformation (Subarachnoid hemorrhage). secondary to:• Hypertension• Congenital abnormality• Blood dyscrasia / Anticoagulant usage• Infection• Neoplasm

• Trauma (Epidural / Subdural Hematomas)• Hemorrhagic transformation of embolic stroke

Hemorrhagic Stroke SyndromesHemorrhagic Stroke Syndromes

• IntracerebralIntracerebral– Hypertensive intracerebral hemorrhage MOST Hypertensive intracerebral hemorrhage MOST

common causecommon cause– Traumatic, contusion, coup/contracoupTraumatic, contusion, coup/contracoup– Rupture of small blood vessels with bleeding Rupture of small blood vessels with bleeding

inside the brain parenchymainside the brain parenchyma• PutamenPutamen

• CerebellarCerebellar

• ThalamusThalamus

• Pontine ( 3 P’s – pinpoint pontine pupils)Pontine ( 3 P’s – pinpoint pontine pupils)

Intracerebral HemorrhageIntracerebral Hemorrhage

Treatment of StrokeTreatment of Stroke

• AS ALWAYS – ABC’s FIRST AS ALWAYS – ABC’s FIRST • What’s the Serum Glucose??What’s the Serum Glucose??

– Consider Thiamine 100mg IV, D 50 bolus if Consider Thiamine 100mg IV, D 50 bolus if hypoglycemic.hypoglycemic.

– Treat Hyperglycemia if Serum Glucose > 300mg/dlTreat Hyperglycemia if Serum Glucose > 300mg/dl• Protect the “Penumbra”Protect the “Penumbra”

– Keep SBP >90mm HgKeep SBP >90mm Hg– Goal keep CPP > 60mm Hg (CPP=MAP-ICP)Goal keep CPP > 60mm Hg (CPP=MAP-ICP)– Treat Fever ( Mild Hypothermia beneficial)Treat Fever ( Mild Hypothermia beneficial)

• Acetaminophen 650mg po or pr, cooling blanketAcetaminophen 650mg po or pr, cooling blanket– Oxygenate (Keep Sao2 >95%)Oxygenate (Keep Sao2 >95%)– Elevate head of bed 30 deg. (Clear c-spine)Elevate head of bed 30 deg. (Clear c-spine)

• Frequent repeat Neuro checks!! Reassess GCS!Frequent repeat Neuro checks!! Reassess GCS!

Thrombolytic Therapy for Acute Thrombolytic Therapy for Acute Ischemic Stroke ChecklistIschemic Stroke Checklist

• Answer to ALL must be Answer to ALL must be YESYES::– Age 18 or olderAge 18 or older– Clinical diagnosis of Acute Ischemic Stroke causing a Clinical diagnosis of Acute Ischemic Stroke causing a

measurable NON improving neurologic deficit.measurable NON improving neurologic deficit.– NO high clinical suspicion for SAHNO high clinical suspicion for SAH– Time of onset to treatment is <180 minutes.Time of onset to treatment is <180 minutes.

Thrombolytic Therapy for Acute Thrombolytic Therapy for Acute Ischemic Stroke ChecklistIschemic Stroke Checklist

• Answer to ALL MUST be NO:

– Evidence of hemorrhage on CT– Active internal bleeding (GI/GU) within last 21 days.– Known bleeding diasthesis:

• Platelets<100,000• Heparin within last 48 hours with elevated PTT• Warfarin use with PT > 15 seconds

– Within 3 months of IC injury, prior surgery or prior ischemic stroke.

– Within 14 days of serious trauma, major surgery– Recent AMI, arterial puncture/LP within 7 days– History of prior ICH, AVM, tumor,or aneurysm or seizure at

stroke– Systolic BP >185mmHg, or Diastolic BP >110Hg

Seizures & Status EpilepticusSeizures & Status Epilepticus

• Background:Background:– 1 – 2% of the general population has seizures1 – 2% of the general population has seizures– PrimaryPrimary

• Idiopathic epilepsy: onset ages 10-20Idiopathic epilepsy: onset ages 10-20

– SecondarySecondary• Precipitated by one of the following:Precipitated by one of the following:

• Intracranial pathologyIntracranial pathology– Trauma, Mass, Abscess, InfarctTrauma, Mass, Abscess, Infarct

• Extracranial PathologyExtracranial Pathology– Toxic, metabolic, hypertensive, eclampsiaToxic, metabolic, hypertensive, eclampsia

Approach for 1Approach for 1stst Seizure, New Seizure, New Seizure, or Substance/ Trauma Seizure, or Substance/ Trauma

Induced Seizure Induced Seizure • As always ABC’s First As always ABC’s First • IV, O2, MonitorIV, O2, Monitor

– Send blood for CBCSend blood for CBC– Anticonvulsant levelsAnticonvulsant levels– Prolactin levels / Lactate levelProlactin levels / Lactate level

• Head CTHead CT• Is patient actively seizing? Post ictal? Is patient actively seizing? Post ictal?

Pseudoseizure?Pseudoseizure?– Consider treatment optionsConsider treatment options

• Complete History and Physical ExamComplete History and Physical Exam– Including detailed Neuro ExamIncluding detailed Neuro Exam– Repeat Neuro evaluations a must!Repeat Neuro evaluations a must!

Approach to Breakthrough Approach to Breakthrough SeizureSeizure

• History, History, History!!History, History, History!!

• Main causes of Breakthrough Seizure:Main causes of Breakthrough Seizure:– Noncompliance with anticonvulsant regimenNoncompliance with anticonvulsant regimen– Start of new medication (level alteration)Start of new medication (level alteration)

• Antibiotics, OCP’sAntibiotics, OCP’s

– InfectionInfection• FeverFever

– Changes in body habitus, eating patternsChanges in body habitus, eating patterns– Supratherapeutic levelSupratherapeutic level

Status EpilepticusStatus Epilepticus

• Seizure lasting greater than 5 minutes OR Seizure lasting greater than 5 minutes OR two seizures between which there is two seizures between which there is incomplete recovery of consciousnessincomplete recovery of consciousness

• Treatment algorhythm:Treatment algorhythm:– As before ABC’sAs before ABC’s– IV, O2, MonitorIV, O2, Monitor– Consider ALL potential causesConsider ALL potential causes

• INH (pyridoxime/B-6 deficiency)INH (pyridoxime/B-6 deficiency)• EclampsiaEclampsia• Alcoholic (thiamine/B-1 deficiency)Alcoholic (thiamine/B-1 deficiency)• Other Tox ingestion (TCA’s, sulfonylurea OD)Other Tox ingestion (TCA’s, sulfonylurea OD)• TraumaTrauma

Status Epilepticus TreatmentStatus Epilepticus Treatment

• FIRST LINE TREATMENTFIRST LINE TREATMENT– Lorazepam (Ativan) 2mg/min IV up to 10 mg Lorazepam (Ativan) 2mg/min IV up to 10 mg

max. OR Diazepam(Valium) 5mg/min IV or PR up max. OR Diazepam(Valium) 5mg/min IV or PR up to 20mgto 20mg

• SECOND LINE TREATMENTSECOND LINE TREATMENT– Phenytoin or Fosphenytoin (Cerebyx):Phenytoin or Fosphenytoin (Cerebyx):

• 20mg/kg IV at rate of 50mg/min20mg/kg IV at rate of 50mg/min

• THIRD LINE TREATMENTTHIRD LINE TREATMENT– Get Ready to intubate at this point!!Get Ready to intubate at this point!!– Phenobarbitol 10-20mg/kg @ 60 mg/minPhenobarbitol 10-20mg/kg @ 60 mg/min

Status Epilepticus Adjunctive Status Epilepticus Adjunctive Treatment by HistoryTreatment by History

• Thiamine 100mg IV, 1-2 amps D 50Thiamine 100mg IV, 1-2 amps D 50– If suspect alcoholic, malnourished, hypoglycemiaIf suspect alcoholic, malnourished, hypoglycemia

• Magnesium Sulfate 20cc of 10% solutionMagnesium Sulfate 20cc of 10% solution– As above of if eclampsia (BP does NOT have to be As above of if eclampsia (BP does NOT have to be

200/120!!)200/120!!)

• Pyridoxine 5 gms IVPyridoxine 5 gms IV– INH or B-6 deficiencyINH or B-6 deficiency

Closed Head InjuryClosed Head Injury

• Concussion: Concussion: refers to a transient LOC following refers to a transient LOC following head injury. Often associated with retrograde head injury. Often associated with retrograde amnesia that also improvesamnesia that also improves– ““Coup” = injury beneath the site of traumaCoup” = injury beneath the site of trauma– ““Countrecoup” = injury to the side polar Countrecoup” = injury to the side polar

opposite to the traumatized areaopposite to the traumatized areaDiffuse Axonal Injury : Diffuse Axonal Injury : tearing and shearing of tearing and shearing of

nerve fibers at the time of impact secondary to nerve fibers at the time of impact secondary to rapid acceleration/deceleration forces. Causes rapid acceleration/deceleration forces. Causes prolonged coma, injury, with normal initial prolonged coma, injury, with normal initial head CT and poor outcomehead CT and poor outcome

Closed Head Injuries with Closed Head Injuries with HemorrhageHemorrhage

• Cerebral ContusionCerebral Contusion– Focal hemorrhage and edema under the site of Focal hemorrhage and edema under the site of

impactimpact– Susceptible areas are those in which the gyri Susceptible areas are those in which the gyri

are in close contact with the skullare in close contact with the skull• Frontal lobeFrontal lobe• Temporal lobesTemporal lobes

– Diagnostic Test of Choice: Head CTDiagnostic Test of Choice: Head CT– Treatment: Supportive with measures to keep Treatment: Supportive with measures to keep

ICP normal. Repeat Neuro checks. Repeat Head ICP normal. Repeat Neuro checks. Repeat Head Ct in 24 hours. Good prognosis.Ct in 24 hours. Good prognosis.

Cerebral ContusionCerebral Contusion

Management of Closed Head Management of Closed Head InjuriesInjuries

• As always ABC’s with C-Spine precautionsAs always ABC’s with C-Spine precautions• IV, O2, MonitorIV, O2, Monitor• Stabilize and resuscitateStabilize and resuscitate

– Sao2>95%Sao2>95%– SBP>90SBP>90– Treat FeverTreat Fever

• Head of Bed 30% (once C-Spine cleared)Head of Bed 30% (once C-Spine cleared)• Stat Head CT with Stat Neurosurgical Stat Head CT with Stat Neurosurgical

evaluation for surgical lesions.evaluation for surgical lesions.• Repeat Exams, looking for signs of Repeat Exams, looking for signs of

herniationherniation

Signs of Herniation / Increased Signs of Herniation / Increased ICPICP

• Headache, nausea, vomitingHeadache, nausea, vomiting• Decreasing LOCDecreasing LOC• Sixth nerve paresis (one or both eyes adducted)Sixth nerve paresis (one or both eyes adducted)• Decreased respiratory rateDecreased respiratory rate• Cushing reflex Cushing reflex

(hypertension/bradycardia/bradynpea)(hypertension/bradycardia/bradynpea)• PapilledemaPapilledema• Development of signs of herniationDevelopment of signs of herniation

– Fixed and dilated pupilFixed and dilated pupil– Contralateral hemiparesisContralateral hemiparesis– PosturingPosturing

Herniation SyndromesHerniation Syndromes

• CPP = MAP – ICP: Must keep CPP >60 mm CPP = MAP – ICP: Must keep CPP >60 mm HgHg

• Uncal Herniation:Uncal Herniation:– Occurs when unilateral mass pushes the uncus Occurs when unilateral mass pushes the uncus

(temporal lobe) through the tentorial incisa, (temporal lobe) through the tentorial incisa, presenting as:presenting as:• Ipsilateral pupil dilatationIpsilateral pupil dilatation

• Contralateral hemiparesisContralateral hemiparesis

• Deepening comaDeepening coma

• Decorticate posturingDecorticate posturing

• Apnea and deathApnea and death

Herniation SyndromesHerniation Syndromes

• Cerebellar HerniationCerebellar Herniation– Downward displacement of cerebellar tonsils Downward displacement of cerebellar tonsils

through the foramen magnum.through the foramen magnum.– Presents as :Presents as :

•Medullary compressionMedullary compression

•Pinpoint pupilsPinpoint pupils

•Flaccid quadriplegiaFlaccid quadriplegia

•Apnea and circulatory collapseApnea and circulatory collapse

Infectious EmergenciesInfectious Emergencies

Meningococcemia

Infectious Neurologic Infectious Neurologic EmergenciesEmergencies

• Meningitis: inflammation of the meningesMeningitis: inflammation of the meninges• History:History:

– Acute Bacterial Meningitis:Acute Bacterial Meningitis:• Rapid onset of symptoms <24 hoursRapid onset of symptoms <24 hours

– Fever, Headache, PhotophobiaFever, Headache, Photophobia– Stiff neck, ConfusionStiff neck, Confusion

• Etiology By Age:Etiology By Age:– 0-4 weeks: E. Coli, Group B Strep, Listeria0-4 weeks: E. Coli, Group B Strep, Listeria– 4-12 weeks: neotatal pathogens, S. pneumo, N. 4-12 weeks: neotatal pathogens, S. pneumo, N.

meningitides, H. flumeningitides, H. flu– 3mos – 18 years: S.pneumo, N. menin.,H. flu3mos – 18 years: S.pneumo, N. menin.,H. flu– >50/ alcholics: S. pneumo, Listeria, N. menin., Gram(-) >50/ alcholics: S. pneumo, Listeria, N. menin., Gram(-)

bacillibacilli

MeningitisMeningitis

• Physical Exam PearlsPhysical Exam Pearls– Infants and the elderly lack the usual signs and Infants and the elderly lack the usual signs and

symptoms, only clue may be AMS.symptoms, only clue may be AMS.– Look for papilledema, focal neurologic signs, Look for papilledema, focal neurologic signs,

ophthalmoplegia and rashesophthalmoplegia and rashes– As always full examAs always full exam

• Checking for aboveChecking for above• Brudzinski’s signBrudzinski’s sign• Kernigs signKernigs sign

– KEY POINT: If you suspect meningococcemia do KEY POINT: If you suspect meningococcemia do NOT delay antibiotic therapy, MUST start within NOT delay antibiotic therapy, MUST start within 20 minutes of arrival!!!!!20 minutes of arrival!!!!!


• Emergent CT Prior to LPEmergent CT Prior to LP– Those with profoundly depressed MSThose with profoundly depressed MS– SeizureSeizure– Head InjuryHead Injury– Focal Neurologic signsFocal Neurologic signs– Immunocompromised with CD4 count <500 Immunocompromised with CD4 count <500

• DO NOT DELAY ANTIBIOTIC THERAPY!!DO NOT DELAY ANTIBIOTIC THERAPY!!


• Lumbar Puncture ResultsLumbar Puncture Results

TEST NORMAL BACTERIAL VIRALTEST NORMAL BACTERIAL VIRAL

Pressure <170 >300 200Pressure <170 >300 200

Protein <50 >200 <200Protein <50 >200 <200

Glucose >40 <40 >40Glucose >40 <40 >40

WBC’s <5 >1000 <1000WBC’s <5 >1000 <1000

Cell type Monos >50% PMN’s MonosCell type Monos >50% PMN’s Monos

Gram Stain Neg Pos NegGram Stain Neg Pos Neg

Headache & VertigoHeadache & Vertigo

• Headache

• Types of Headache:– Migraine

• With aura

• Without aura

– Cluster Headache– Subarachnoid hemorrhage– Temporal arteritis

Headache managementHeadache management

• MigrainMigrain– Place patient in cool, quiet, dark environmentPlace patient in cool, quiet, dark environment– IV fluids if dehydratedIV fluids if dehydrated– Abortive therapy:Abortive therapy:

• Phenothiazines (antimigraine and antiemetic)Phenothiazines (antimigraine and antiemetic)• DHE (vaso/venoconstrictor) + antiemeticDHE (vaso/venoconstrictor) + antiemetic• Sumatriptan (5-HT agonist)Sumatriptan (5-HT agonist)• Opiods as LAST RESORT!!Opiods as LAST RESORT!!

• Cluster Headaches• TX: 100% O2 by N/C at 6-8 l/min• If no relief, Sumatriptan

VertigoVertigo

• History and PE exam again CRUCIAL!!History and PE exam again CRUCIAL!!– History:History:

• Truly a vertiginous complaint?Truly a vertiginous complaint?– r/o syncope / near syncope??r/o syncope / near syncope??

• Acute onset of severe symptoms or more gradual courseAcute onset of severe symptoms or more gradual course

VertigoVertigo

Peripheral Vertigo•History:

– Acute onset of severe dizziness, nausea, vomiting.– May be a positional worsening of symptoms– Recent history of URI or similar episodes in past which

resolved.•PE Pearls:•Horizontal nystagmus which fatigues•Normal Neuro exam with normal cerebellar function and gait•Reproduction of symptoms with Hallpike maneuver

VertigoVertigo

Central VertigoCentral Vertigo•Due to lesions of brainstem or cerebellumDue to lesions of brainstem or cerebellum•10 – 15% of cases10 – 15% of cases•Signs & Symptoms:Signs & Symptoms:

– Gradual onset of mild disequilibriumGradual onset of mild disequilibrium– Mild nausea and vomitingMild nausea and vomiting– Nonfatigable nystagmus (any direction)Nonfatigable nystagmus (any direction)– Associated neurological abnormalities:Associated neurological abnormalities:

• PtosisPtosis• Facial palsy, dysarthriaFacial palsy, dysarthria• Cerebellar findings, ataxiaCerebellar findings, ataxia

Emergent Peripheral Emergent Peripheral NeuropathiesNeuropathies

• Acute Toxic NeuropathiesAcute Toxic Neuropathies– Diptheria (Cornybacterium diptheriae)Diptheria (Cornybacterium diptheriae)

• Acutely ill patient with feverAcutely ill patient with fever

• Membranous pharyngitis that bleedsMembranous pharyngitis that bleeds

• Powerful exotoxin produces widespread organ damagePowerful exotoxin produces widespread organ damage– Myocarditis/AV Block,Nephritis, HepatitisMyocarditis/AV Block,Nephritis, Hepatitis– Neuritis with bulbar and peripheral paralysisNeuritis with bulbar and peripheral paralysis– (ptosis, strabismus, loss of DTR’s)(ptosis, strabismus, loss of DTR’s)

• TX: Parenteral PCN or ErythromycinTX: Parenteral PCN or Erythromycin– Horse Serum antitoxinHorse Serum antitoxin– Respiratory isolation and admission the ruleRespiratory isolation and admission the rule


– Botulism (Clostridium botulinum toxin)Botulism (Clostridium botulinum toxin)•Earliest finding(90%)= Blurred vision, diplopia, Earliest finding(90%)= Blurred vision, diplopia,

ophthalmoplegia, ptosisophthalmoplegia, ptosis•Neurologic abnormalities descend and will lastly Neurologic abnormalities descend and will lastly

involve the respiratory musculature and death involve the respiratory musculature and death with 6 hours if not treated!with 6 hours if not treated!

•Mentation and sensation are normalMentation and sensation are normal•Remember in infants with FTT (failure to thrive)Remember in infants with FTT (failure to thrive)

– Raw honey contains C. botulinumRaw honey contains C. botulinum•Tx: Aggressive airway stabilization!Tx: Aggressive airway stabilization!•Trivalent serum antitoxinTrivalent serum antitoxin•Lastly, there have been some recently reported Lastly, there have been some recently reported

cases of hypersensitivity to “Bo-tox”cases of hypersensitivity to “Bo-tox”


• TetanusTetanus– Symptoms 4 “T”’sSymptoms 4 “T”’s

• Trismus, Tetany, Twitching, TightnessTrismus, Tetany, Twitching, Tightness

• Risus sardonicus / opisthotonusRisus sardonicus / opisthotonus

• Signs of sympathetic overstimulationSigns of sympathetic overstimulation– Tachycardia, hyperpyrexia, diaphoresisTachycardia, hyperpyrexia, diaphoresis

– Management:Management:• Human Tetanus Immunoglobulin (HTIG)Human Tetanus Immunoglobulin (HTIG)

• dT ToxoiddT Toxoid

• MetronidazoleMetronidazole


• Guillain-Barre SyndromeGuillain-Barre Syndrome– Most common acute polyneuropathyMost common acute polyneuropathy– 2/3’s of patients will have preceeding URI or 2/3’s of patients will have preceeding URI or

gastroenteritis 1-3 weeks prior to onsetgastroenteritis 1-3 weeks prior to onset– Presents as: paresthesias followed by Presents as: paresthesias followed by

ascending paralysis starting in legs and moving ascending paralysis starting in legs and moving upwardsupwards• Remember Miller-Fischer variant: has minimal Remember Miller-Fischer variant: has minimal

weakness and presents with ataxia, arreflexia, and weakness and presents with ataxia, arreflexia, and ophthalmoplegia.ophthalmoplegia.

– DX: LP will show cytochemical dissociationDX: LP will show cytochemical dissociation• Normal cells with HIGH protein.Normal cells with HIGH protein.

– TX: Self limiting, Early and aggressive airway TX: Self limiting, Early and aggressive airway stabilization, IvIgstabilization, IvIg

Emergent myopathIesEmergent myopathIes

• Myasthenia GravisMyasthenia Gravis– Most common disorder of neuromuscular Most common disorder of neuromuscular

transmissiontransmission– An autoimmune disease that destroys An autoimmune disease that destroys

acetylcholine receptors (AchR) which leads to poor acetylcholine receptors (AchR) which leads to poor neurotransmission and weakness neurotransmission and weakness

– Proximal >> Distal muscle weaknessProximal >> Distal muscle weakness– Commonly will present as:Commonly will present as:

• Muscle weakness exacerbated by activity, and is relieved by Muscle weakness exacerbated by activity, and is relieved by restrest

– Clinically: ptosis, diplopia and blurred vision are Clinically: ptosis, diplopia and blurred vision are the most common complaints. Pupil is spared!the most common complaints. Pupil is spared!

Emergent myopathIesEmergent myopathIes

• Myasthenia GravisMyasthenia Gravis– Myasthenic crisis = A true emergency!!Myasthenic crisis = A true emergency!!– Occurs in undiagnosed or untreated patientsOccurs in undiagnosed or untreated patients

•Due to relative Ach (acetylcholine) deficiencyDue to relative Ach (acetylcholine) deficiency•Patients present with profound weakness and Patients present with profound weakness and

impending respiratory failureimpending respiratory failure– TX: Stabilize and manage airwayTX: Stabilize and manage airway

•Consider edrophonium 1 -2 mg IVConsider edrophonium 1 -2 mg IV (AchE inhibitor)(AchE inhibitor)

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Neurological Emergencies Burcu Ugurel, MD Phase III Department of Neurology