內科加護病房常見之神經科問題

神經內科林俊豪

何時緊急找 Neurologist ?

Mental change Weakness of limbs Fever with headache Convulsion

何時緊急找 Neurologist ?

Unilateral limbs weakness +/- facial asymmetry or slurred speech ,easy choking stroke, brain tumor….

Weakness of bilateral legs or four limbs without cranial nerve dysfunction spinal cord lesion, AIDP, myopathy

Fever with headache or mental change CNS infection

意識改變的原因

造成意識改變的原因有許多都不是先從腦部疾病造成的

例如藥物中毒 , 缺氧 , 肝昏迷 , 內分泌如血糖過高或過低 , 酸鹼不平衡 , 敗血症 , 高血壓腦病變…

其他腦部疾病包括腦出血，腦梗塞，腦脫疝，腦膜炎或腦炎

呼吸現象評估

兩側大腦深部，天幕上巨大病灶，代謝性腦病變

中腦或上橋腦

下橋腦病變

呼吸現象評估

橋腦尾部及延腦上方

延腦

瞳孔反應

簡單來說 光刺激由第二對視神經傳入 瞳孔收縮由第三對動眼神經執行 瞳孔擴張經由交感神經路徑控制

瞳孔反應

眼位與身體姿勢及無力

意識不清，單側肢體無力又兩眼偏移：極有可能是腦部問題

眼球偏向無力側—對側橋腦 眼球偏離無力側 --- 大腦病灶，位在無力肢體

對側---> 記住一點，通常腦部病灶在無力肢體對側 癲癇也會造成眼球偏移

角膜反射

使用棉花尖端碰觸角膜，經第五對三叉神經傳入，在橋腦及延腦間傳遞，再經由兩側顏面神經傳出而眨眼

stroke

Infarction Hemorrhage—

SAH

ICH Headache, vomiting, seizure, coma---

hemorrhage is more likely TIA – transient ischemic attack

Stroke Management

Diagnostic tests

brain CT— 如懷疑 brain stem infarction, focus posterior fossa

ECG

clinical chemistry--- complete blood count and platelet count, PT,INR, PTT

serum electrolytes, blood glucose, ABG,

Hepatic and renal chemical analysis

Thrombolytic treatment – rt-PA rt-PA : 0.9 mg/kg,10% bolus in one minutes Time window : 3 hours 切記 NIH stroke scale 6-25 Exclusion:

age <18 y/o or >80 y/o 非絕對 bleeding tendency or other active bleeding

BP : SBP > 185 or DBP >110mmHg

blood sugar : < 50 or > 400 mg/dL

Stroke Management

The European Stroke Initiative Executive Committee and the EUSI Writing Committee Update 2003

General stroke treatment

Vital signs Glasgow coma scale NIH stroke scale Pupil size and light reflex ( large infarction or

brain stem infarction in evolution)

Pulmonary function and airway protection oxygen supply at low flow rates ：沒有證據

在 human brain infarction 有幫助 Little evidence that stroke patients benefit fro

m hyperbaric oxygen therapy Intubation : unconscious patient (GCS<8 ?) a

t high risk for aspiration

Blood pressure management

Many patients with acute stroke have elevated BP

Cerebral blood flow autoregulation may be defective in an area of evolving infarction

ischemic penumbra is passively dependnet on the mean arterial pressure

abrupt drops in blood pressure must be avoided

Blood pressure management

Prior hypertension:

180/100-105 mmHg Other cases:

160-180/90-100 mmHg SBP over 220-230 mmHg

DBP over 120-130 mmHg

indication for early but cautious drug therapy

Blood pressure management

Treatment may be appropriate in the setting of concomitant:

acute myocardial infarction

cardiac insufficiency

acute renal failure

aortic arch dissection Thrombolysis or heparin administration Large infarct area with brain edema?

Blood pressure management--drugs Avoid sublingual nifedipine !!!

possible ischemic steal

Captopril Labetalol Sodium nitroprusside

Glucose metabolism

An increase in serum glucose level at hospital admission may be frequently found.

High glucose levels are harmful in stroke. Temporary insulin treatment may become

necessary.

Body temperature

Hyperthermia increases infarct size. Although there are no prospective data,one

may consider to treat fever as early as the temperature reaches 37.5 °C.

Acetaminophen

Fluid and electrolyte management Some degree of dehydration on admission is

frequent and may be related to bad outcome. Presence of brain oedema a slightly negati

ve fluid balance Hypotonic solution (NaCl 0.45% or glucose 5

%) are contra-indicated due to the risk of brain oedema increase.

Aspirin

Aspirin given within 48 hors after stroke : reduce mortality and rate of recurrent stroke minimally, but statistically significantly

Dose :160- 300 mg

anticoagulation

Heparin : not a standard therapy for all stroke subtypes

Contraindication:

large infarcts

uncontrollable arterial hypertension

advanced microvascular change In the brain

Special treatment

Haemodilution : failed to demonstrate a decline in mortality or disability

Neuroprotection : no evidence

Seizure: post-stroke epilepsy may develop in 3-4% of cases

Prophylactic anticonvulsant: no evidence

Brain oedema and elevated ICP CPP=MAP-ICP, should be kept > 70 mmHg Management

head position :elevation 30°

pain relief

appropriate oxygenation supply

Mannitol : 25-50 g every 3-6 h

Glycerol : 250 ml q6h

Hypertonic saline (3% NaCl)

Brain oedema and elevated ICP Hyperventilation

PCO2 25-30 mmHg Hypothermia:32-33 °C

Status epilepticus

Seizures last longer than 10 minutes or if two or more seizures occur in close succession without recovery of consciousness

Convulsive or non-convulsive

Status epilepticus

Ativan 4mg iv in 2 min, max 8 mg Valium 10 mg iv in 2 min ,max 20 mg 以上需注意呼吸抑制 Phenytoin 20 mg/kg, bolus 5mg/kg 可兩次 60 kg patient 4-5 支 iv drip , < 50 mg/min

(fosphenytoin, 150 mg/min, minimal irritaton)

Status epilepticus

Valproic acid IV form

2 支 loading then 1.5 支 q8h 較少 allergy, 可能對 myoclonic seizure 或一

開始就是 generalized seizure 有用，可快速達到理想濃度

但需考慮和其他藥物交互作用，以及肝指數及Ammonia 濃度上升

Status epilepticus

Phenobarbital : 20 mg/kg i.v., 5 mg/kg bolus

( 本院無 IV form) Midazolam (Dormicum) : 15mg/3mL

例 60 kg 病人 , 4 vial in 48 ml N/S1mg/mL

0.2mg/kg bolus then 0.1-2.0 mg/kg/hr

1 vial loading ,then run 6-120 c.c./hr

Status epilepticus

Propofol : 1-5 mg/kg bolus then 2-4 mg/kg/hr

60 kg 病患 , 1 amp 200mg/20 mL

6-30 c.c bolus then run 12-24 c.c./hr Gabapentin (Neurontin) Topiramate (Topamax) Rivotril

Spinal cord lesion

Disc herniation Tumor Myelitis Hemorrhage Infarction Epidural abscess

Spinal cord lesion

Paraplegia Tetraplegia Hemiplegia with contra-lateral sensation loss Urine or stool retention ： AIDP 少見 Sensory level + ： myopathy 不會有 DTR increase

Spinal cord lesion

Neurologic emergency

Once paralysis, forever paralysis Image study : MRI, as soon as possible Treatment: steroid

Solu-Medrol 1000 mg /qd IV drip for 3 days

Decadron 5-10mg q8h-q6h IV

CNS infection

Meningitis Brain abscess: 未必需施行 lumbar puncture Encephalitis :CSF 未必異常 Diagnosis

brain CT

lumbar puncture :IICP is not contraindication

Lumbar puncture

Normal pressure : 100-180 mmH2O Cells: less than 5 lymphocyte Protein : less than 45 mg/dL Glucose: 0.6-0.7 of serum concentration Traumatic tapping: 500-1000 RBC / 1 WBC

Lumbar puncture

檢體需速件處理 最好於飯後兩小時左右施行 記得 check serum glucose 如 ICP 太高（約 300 mmH2O 以上），先給

予 Mannitol