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Advanced Neurological Emergencies Flashcards

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  1. A flight crew is transporting a 45-year-old male who was involved in a high-speed motor vehicle collision. The patient presents with a GCS of 6, an ipsilateral dilated and non-reactive pupil, and contralateral hemiparesis. These findings are most indicative of which neurological emergency?

    Answer: Uncal herniation

    The classic triad of an ipsilateral dilated pupil (due to compression of the oculomotor nerve), contralateral hemiparesis (due to compression of the cerebral peduncle), and a decreased level of consciousness is the hallmark of uncal herniation. [1, 5] This is a life-threatening condition where the uncus of the temporal lobe is displaced inferiorly through the tentorial notch.

  2. A patient with a traumatic brain injury begins to exhibit Cushing's triad. Which of the following sets of vital signs correctly represents this phenomenon?

    Answer: Hypertension, bradycardia, and irregular respirations

    Cushing's triad is a physiological nervous system response to increased intracranial pressure (ICP). It consists of hypertension (often with a widening pulse pressure), bradycardia, and irregular respirations (such as Cheyne-Stokes or ataxic breathing). [4, 9, 11] It is a late and ominous sign of brainstem compression and impending herniation. [6]

  3. A flight paramedic is managing a patient in status epilepticus who has been seizing for over 10 minutes. IV access is not yet established. According to current guidelines, what is the most appropriate initial intervention?

    Answer: Administer 10 mg midazolam intramuscularly

    For prehospital management of status epilepticus without established IV access, the American Epilepsy Society guidelines recommend the administration of 10 mg of midazolam via the intramuscular route. [22, 24, 25] This allows for rapid drug administration and absorption to terminate seizure activity, which is the primary goal. Intramuscular midazolam has been shown to be as effective as intravenous lorazepam in this setting. [28]

  4. You are transporting a patient who was stabbed in the right side of his neck. He is experiencing ipsilateral (right-sided) loss of motor function, proprioception, and vibration sense, with contralateral (left-sided) loss of pain and temperature sensation below the level of the injury. This specific pattern of neurological deficit is known as:

    Answer: Brown-Séquard Syndrome

    Brown-Séquard syndrome results from hemisection of the spinal cord. It is characterized by the ipsilateral loss of motor function (corticospinal tract) and proprioception/vibration sense (dorsal columns), and contralateral loss of pain and temperature sensation (spinothalamic tract), which crosses over at the level of the spinal cord. [7, 13]

  5. During the management of a patient with a suspected aneurysmal subarachnoid hemorrhage (SAH), which of the following is a primary goal to prevent re-bleeding?

    Answer: Strict blood pressure control, typically targeting a systolic BP < 160 mmHg

    In a patient with a suspected or confirmed aneurysmal subarachnoid hemorrhage, strict blood pressure control is crucial to prevent re-bleeding, which is a major cause of mortality. [18, 35] Guidelines recommend maintaining a systolic blood pressure below 160 mmHg until the aneurysm is secured. [18, 30] Hypotension must also be avoided to maintain adequate cerebral perfusion pressure.

  6. A 68-year-old female presents with acute onset of left-sided facial droop and right arm weakness that began exactly 2 hours ago. Her blood glucose is 110 mg/dL and a non-contrast CT scan shows no hemorrhage. Which of the following is an absolute contraindication for the administration of intravenous alteplase (tPA) in this patient?

    Answer: The patient's blood pressure is 190/115 mmHg

    According to the American Heart Association/American Stroke Association guidelines, a sustained blood pressure of systolic > 185 mmHg or diastolic > 110 mmHg is an absolute contraindication for IV alteplase. [23, 27] Blood pressure must be lowered and maintained below this threshold before tPA can be administered safely. The other options are not absolute contraindications in this specific scenario.