Professional Documents
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Survival Neurology
Surat Tanprawate, MD, MSc(London), FRCP(T)
Division of Neurology, Chiang Mai University
Neurology extern should know
Headache
Acute stroke
Acute treatment
Prophylactic treatment
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Pharmacotherapy of acute
migraine attack
Non-specic
Acetaminophen,
NSAIDs
caffeine
opioids
neuroleptic
Specic
Ergotamine(Cafergot)
Triptan
Ergotamine tartrate+ Caffeine
Ibuprofen (400)/
Naproxen (250),
Diclofenac(25)
1 tab prn headache
Cafergot
1 tab prn headache
(moderate to severe)
Recommended
medication for
migraine prevention
EFNS guideline
2009
Evers, S et al.
European Journal of Neurology 2009, 16: 968981
Started when high
headache frequency,
high severity
Duration 3-6 months
TTH diagnostic criteria
Featureless headache
Non-pharmacologic intervention
COMA
and
ACUTE CONFUSIONAL
STATE
Alter mental status
Coma/alter level of
consciousness
Other: delirium,
aphasia, psychiatric
problem
Hx taking/physical
exam
clinical classication
1. coma with localizing sign
2. coma without localizing sign but with meningeal sign
3. coma without both localizing and meningeal sign
4. coma with seizure
2 component of consciousness: arousal and awareness
coma, vegetative state, minimally conscious state, and locked-in syndrome.
VARIOUS STATE OF CONSCIOUSNESS
Delirium
Acute confusional
state
Practical approach
History taking
as the patient can not talk, then ask their relative or witness
Physical exam
Repeat PE, further lab, radiologic studies if cause not yet identied
! Antipsychotic Dosing in Elderly
!
Use clinical judgment depending on severity of symptoms for
starting dose:
!
Haloperidol
!
0.5mg mild
!
1mg moderate
!
2mg severe
Acute stroke
when we suspect stroke
weak, numb
cerebellar sign
cortical sign
Large-artery atherosclerosis(emboli/
thrombosis)
Cardioembolism(high-risk/medium-
risk)
Small-vessel occlusion(lacune)
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Brain herniation
Subfalcine (A)
Uncal (B)
Central (C)
Extradural (D)
Tonsillar (E)
Herniation syndrome
Treatment IICP
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Keep in Externs mind
Stroke
1. when the sudden neurological decit 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
Seizure and status
epilepticus
Patient come with clinically
suspected seizure
Known case
epilepsy with
recurrent seizure
First diagnosed
seizure
Status
epilepticus
Seizure
mimicker
Cause?
Treatment options
Treatment cause
AED?
Seizure or Not seizure
Seizure mimicker
pseudo-seizure
convulsive syncope
hypnic jerk
Seizure vs Syncope
Bhidayasiri R. et al. Neurological differential diagnosis 2005
Identify cause of seizure
(symptomatic seizure)
Acute symptomatic
seizure
Stroke
Metabolic
disturbances
CNS infection
Trauma
Drug Toxicity
Hypoxia
Remote symptomatic
seizure
Pre-existing epilepsy
Ethanol abuse
Old CVA
Relatively long-
standing tumors
What should we do?
SE > 10 minutes
Lowenstein DH (1999)
SE > 5 minutes
Complication of SE
Acidosis
Cerebral edema
Hypoglycemia
Topiramate(feed)
drug use depend on stage of status
stage of status AED treatment
Premonitory (0-5 min) Diazepam (i.v. bolus)
Early (5-30 min)
Diazepam (i.v. bolus) followed by
phenytoin (iv load) or sodium valproate
(i.v. loading) or levetiracetam (i.v.)
Established (30-60 min)
half dose i.v. load of previous drug, if
seizure dont stop, load another drug
Refractory ( > 60 min)
Propofol (i.v.), or midazolam (i.v.), or
thiopental (i.v.) or phenobarbital (i.v.) or
topiramate (feed)
Diazepam
diazepam 10 mg (2-5mg/min)
e.g. weight 50 kg
e.g. weight 50 kg
e.g. weight 50 kg
e.g. weight 50 kg
Vial: 10 mg/ml
5% Dextrose/w
e.g. weight 50 kg
Vial: 1 g/vial
5% Dextose