Neurologic Emergencies

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Brenda Shelton, who will be talking with us about any and all questions you have regarding neurologic emergencies. Welcome Brenda!

 sheltbr 

Hi all- thanks for joining. Bring on the questions!

 Laurl at ONS 

To get the ball rolling, what is PRES and who gets it?

 sheltbr 

PRES is posterior reversible encephalopathy syndrome that is characterized by acute severe neurologic syndromes. It is common in leukemia, transplant, with tacrolimus and cyclosporine.

 mgrue 

Is this very common

 sheltbr 

This is noted as rare, but we have seen it a few times- it was finally detected when all else ruled out and a MRI showed parietal- occipital changes. Maybe some of you have questions about more common disorders?

 sheltbr 

We have seen more PRES, or maybe we are just better at detection now. It can also be a manifestation with labile hypertension as we see in our patients. It is also more common in children.

 Laurl at ONS 

What is vertebroplasty and how is it used to treat spinal cord compression?

 sheltbr 

This is a new technique to repair vertebral collapse that has been extremely helpful in management of spinal cord compression. It allows for repair without hardware.

 sheltbr 

Have any of you on line had patients treated with vertebroplasty?

 mgrue 

Is there evidence to show how long the vertebroplasty will last?

 smallnurse 

Not as far as I know...

 sheltbr 

I don't know how long this procedure is effective. In non-oncology patients it has been for 5+ years. I guess it may depend upon bone health.

 mgrue 

the company that sells the product does a really nice inservice. We have had them present at our hospital.

 sheltbr 

Good idea. This helps clarify best candidates so nurses can be aware when this option is suitable.

 sheltbr 

We have had some recent particularly challenging cases of lymphatomatous meningitis that were difficult to diagnose. Is this something some of you have encountered?

 sheltbr 

In the three cases we had, it took several LP's to diagnose the disorder.

 sheltbr 

The real challenge in each case was the severity of illness and understanding whether the patient had a reversible illness or something unfixable. Two of the three did well with chemotherapy for a short time.

 sheltbr 

OK- about lymphomatous meningitis- though really can be any cancer spread to meninges....

 sheltbr 

Cancer spread to meninges looks a lot like infectious meningitis and the tricky part is that it can't be ruled out until 3-5 LPs are negative. Since this may be the only site of relapse it makes treatment decisions difficult.

 Laurl at ONS 

Brenda,  can you give me the signs and symptoms, including subtle ones, that the beside nurse should know re: how to identify an intracranial bleed? And what to do?

 sheltbr 

Re: bleeds: Suspicion, suspicion......more to come

 sheltbr 

Re: bleeds: First always assess the acuity of symptoms. One key is that sxms are minutes to hours in onset.

 sheltbr 

Second, the patient is likely to have unequal neurologic changes- pupils, movement, etc.

 sheltbr 

Another key sxm is the worst headache ever.

 sheltbr 

We just had a young patient with histiocytic sarcoma get slightly agitated, moan, and STOP breathing last week. Pinpoint equal pupils- she bled into her pons.

 sheltbr 

The key thing to realize as a bedside nurse is to establish an airway and hyperventilate (ambu bag). It is quite likely your hospital has a stroke team and they should be called immediately.

 sheltbr 

When neuro arrives, they should bring with them a med that nurses never give anywhere but neuro ICU- 23% saline. It is pushed and causes the brain to shrink, buying time to decide next action and surgical candidacy.

 sheltbr 

This is handy to know in case someone asks for it- it is not available on floors- but should be in the Emergency dept if no neuro ICU.

 sheltbr 

We have had lots of new joinees- have you any questions about neurologic emergencies?

 gigi225 

its all new to me, I read everything I can on adverse reactions.

 sheltbr 

I think neuro scares people- thanks for speaking up. Let's talk about neuro reactions- e.g. ifosphamide neuro reactions?

 smallnurse 

We have quite a few patients receiving Ifex currently as an outpatient, Is there anything in particular that we should we be looking 4?

 stemcell 

I have heard ifosphamide induced seizures but never seen it. I guess because it is infused slowly with mixed fluid.

 sheltbr 

Ifosphamide can cause an acute neurologic syndrome that can manifest as seizures or acute manic psychosis.

 sheltbr 

I am not aware that it is blood level related, but does seem to occur more often in later doses. The interesting thing is the very unproven treatment- infusion of methylene blue.

 stemcell 

Isn't it related to infusion rate?

 sheltbr 

When toxicity is suspected we give methylene blue two three times a day (yep- green urine) and watch for changes. You  must check met hemoglobin levels on them. I think it is more common in CI, but not always true.

 sheltbr 

CI- continuous infusion. I have also seen once with bolus but once you get the syndrome you don't usually get rechallenged, so not sure if you know when to give slower.

 sheltbr 

Any experienced nurses- have you seen less severe and more manageable spinal cord compression with universal treatment with bisphosphonates?

 dianebrown 

Recently a patient received Neupogen injection and 20 minutes later had a reaction and became unconscious. Have you heard of Neupogen having this reaction?

 smallnurse 

I work in outpt setting, but interesting with the SCC and bisphos. What are they doing??

 sheltbr 

I feel like I have heard this situation but I do not know of this happening or a reason for it. In almost anyone with allergic reactions, they can have respiratory or neuro sudden changes that present with unconsciousness.

 sheltbr 

Re- bisphosphonates. We now treat most patients with bone mets with a bisphosphonate to reduce risk of bone breakdown. They inhibit osteoclasts ( which break down bone) and I feel like we have seen less vertebral collapse and cord compression.

 dianebrown 

The patient was hospitalized for 3 days and was told by a neurologist that the reaction was related to the Neupogen. However, I haven't heard of this happening.

 stemcell 

i guess the pt has hypersensitivity in e-coli.

 sheltbr 

That is a good theory though now I will look this up.

 sheltbr 

Have any of you seen "ministrokes" with patients getting chemo related hypertension?

 sheltbr 

I have found some oncologists are reluctant to treat hypertension until severe, but these "lacunar" strokes are vasoconstrictive spastic cerebral vessel activity that leads to short-term stroke symptoms with clean carotids (usual cause of TIA/stroke)

 sguthrie 

This is my first time using the Chat Rm. No burning question....Just wanted to see how it works. I work in Radiation Oncology so our emergencies are primarily SVC and Spinal Cord compressions

 Laurl at ONS 

Sguthrie, you might want to check out this transcript tomorrow when its posted to the Hot topics website, we talked about SCC some earlier in the chat.

 sguthrie 

Thanks, will definitely check it out.

 sheltbr 

I am concerned that we don't have a good standard of when to treat hypertension. Do any of you have thresholds to treat or to hold some of anti-angiogenic drugs?

 sheltbr 

The JNC definition of hypertension is > 140/90. I am seeing patients go as high as 180/100 and it makes me nervous. What is your practice?

 sheltbr 

There is no wrong answer here. Do some of you wait to see proteinuria WITH the hypertension?

 sheltbr 

Here is a thought. If patients go about 140/90, evaluate for other symptoms. Anyone with visual changes, headaches, proteinuria should get treatment. Best first treatment is an ACE inhibitor. This can be challenging because patients can't always come in. There are lots of places patients can get free BP checks.

 sheltbr 

Oops- go above 140/90 not about. Also any changes in orientation or wakefulness should be checked out as they may indicate these TIAs

 Laurl at ONS 

We have about 5 more minutes -please continue to ask your questions! Also, at the end of today’s chat, please take a moment to cut and paste this URL into your browser and take our very brief survey = we’d love to hear what you think of these chats! The URL is: http://research.zarca.com/k/RsTUTRsRYVsVXVSVsPsP . Thank you!

 sheltbr 

Is there any specific info you would like me to share in these last few minutes?

 Laurl at ONS 

Hi Kcrone, we are just about out of time, but if you have a specific question we'd love to hear it!

 sheltbr 

If this is an area you would like to work on we are planning a session at next year's APN conference on advanced neuro assessment

 kcrone 

Shoot! Not a specific question... I'll have to read the chat later.

 sheltbr 

Please do. Perhaps you can join one of the others.

 kcrone 

others?

 Laurl at ONS 

no problem, the transcript will be posted tomorrow! Please be sure to also come to the next chat, this Friday at 6pm EASTERN. ( that's the "others"!) It is on Heme Onc emergencies.

 kcrone 

great!

 Laurl at ONS 

OK, we are out of time for today - many thanks for joining us. Please do take a look at the other topics coming up - next chat is Friday. Thanks for attending!

 stemcell 

thanks

 sheltbr 

Thanks to all for coming today. Hope you will join us for one of the other Oncologic emeregency chats