Category: Neurology

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History

• Sudden and maximal in onset
• Compared to previous headaches
• Family history of aneurysm
• Associated Symptoms
  • Photophobia
  • Visual Changes
  • Neck Stiffness

Exam

• Full neuro examination
  • Cranial nerves
  • Visual fields
  • Speech
  • Cerebellar (finger-nose)
  • Motor
  • Sensation
  • Gait

Testing Plan

• Non-contrast head CT
  • Excellent sensitivity <6 hours from onset
• Lumbar puncture
  • >100 RBCs in tube 4
    • Can be difficult to interpret after a traumatic lumbar puncture
  • Xanthochromia

Treatment Plan

• Prevent rebleeding
  • Keep SBP <140
    • Nicardipine
  • Reverse any anticoagulants
    • Vitamin K
    • Prothrombin complex concentrate
    • Fresh frozen plasma
• Prevent vasospasm
  • Nimodipine PO
• Prevent delayed ischemia
  • Avoid hyperthermia
  • Avoid hyper/hypoglycemia
• Prevent seizures
  • Levetiracetam (aka Keppra)

Additional Reading

• Ottawa Subarachnoid Hemorrhage (MDCalc)

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My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.

Introduction

Contraindications to tPA

• Objective contraindications
  • Hypoglycemia
  • Blood pressure (>185/110)
  • Hemorrhagic CVA seen on head CT
• Other common contraindications
  • Mnemonic: ABCDE
    • A– History of Aneurysm, AVMs (or other intracranial structural problems)
    • B– Actively Bleeding
    • C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months
    • D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)
    • E– Endocarditis
• Relative Contraindications (Discuss with neurology)
  • Minimal or resolving symptoms
  • Recent surgery or major trauma
  • Seizure
  • Recent lumbar puncture
  • Pregnancy
  • Active pericarditis
• 3-4.5 Hour Contraindication Addons
  • A- Age >80
  • B- Bad Stroke (NIH >25)
  • C- CT shows multilobar stroke
  • D- Bleeding diasthesis (even if coagulation studies normal)
  • E- Ever had old stroke or diabetes

Additional Reading

• tPA Contraindications for Ischemic Stoke (MDCalc)
• 2018 Stroke Management Guidelines (AHA/ASA)

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Introduction

• Simple seizure
  • Seizure ends in <5 minutes AND
  • Patient wakes up before next seizure
    • No meds required
• Status epilepticus
  • Seizure lasts >5 minutes OR
  • Patient has a 2nd seizure before waking up from 1st
    • Initiate status epilepticus pathway

Approach to Status Epilepticus

• Step 1: Give a benzodiazepine
  • Lorazepam (IV)
  • Diazepam (IV or PR)
  • Midazolam (IV or IM)
• Step 2: Give an anti epileptic
  • Levetiracetam (Keppra)
  • Fosphenytoin
  • Valproic Acid
• Step 3: Continue attempting agents for 30 minutes
  • If seizure continues, you must move onto step 4…
• Step 4: Sedate and intubate the patient
  • Propofol
  • Phenobarbital
• Step 5: Start patient on continuous EEG
  • Detects non-convulsive status epilepticus
  • Usually started once patient is in ICU

Additional Reading

• Round 9 – Seizure (EM Clerkship)
• Emergency Management of Status Epilepticus (EM Cases)

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Basic Approach

• Step 1: Describe the seizure
  • Did patient have an aura?
  • Was there loss of consciousness?
  • What did the movements look like?
  • Did they have postictal phase?
  • Did they have a trauma as well?
• Step 2: Ask about TIME (mnemonic)
  • Tongue biting
    • Usually occurs on the lateral sides of tongue
  • Incontinence
  • Medication changes/adjustments
  • Ethanol use
• Step 3: Do a FULL neurologic examination
  • Mental Status
  • Cranial nerves
  • Visual fields
  • Speech
  • Cerebellar (finger-nose)
  • Motor
  • Sensation
  • Reflexes
  • Gait
• Step 4: Testing plan
  • Glucose
  • Pregnancy Test
  • CBC
  • Electrolyte panel
  • Urine drug screen
  • Drug levels of anti-epileptic agents
• Step 5: Simple seizures (<5 minutes) do not require immediate treatment
  • Roll them on side
  • Suction

Additional Reading

• Approach to Status Epilepticus (EM Clerkship)

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Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses

• Aortic Dissection and Abdominal Aortic Aneurysm (AAA)
  • Age >50
  • Hypertension
  • “Ripping” or “Tearing” pain
  • Absent pulses in lower extremities
• Spinal Infections
  • Fever
  • Immunocompromized
    • HIV
    • Diabetes mellitus
    • Transplant patients
• Spinal cord compression (especially cauda equina)
  • Urinary retention
    • Consider obtaining post-void residual
  • Saddle anesthesia
  • Fecal incontinence/decreased rectal tone
• Fracture
  • Recent trauma
  • Advanced age
• Cancer
  • History of cancer
  • Night sweats
  • Weight loss

Step 2: Testing Plan (If Patient Has Red Flags)

• X-ray or CT scan if concerned for fracture
• MRI if concerned for infection, cord compression, or cancer

Step 3: Symptom Management

• NSAIDS
  • Naproxen
  • Ibuprofen
• “Muscle relaxants”
  • Cyclobenzaprine
• Other agents
  • Opiates
  • Topical therapy
  • Lidocaine patches

Step 4: Counseling

• Remain active
• Avoid heavy lifting
• Red flags = immediate return to ED

Additional Reading

• Round 6 – Back Pain (EM Clerkship)
• Back Pain Red Flags (WikEM)

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Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?

Step 1: How Does Patient Describe the Vertigo?

• Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)
• Central vertigo
  • Mild
  • Vague
• Peripheral vertigo
  • Severe
  • Sudden

Step 2: What Are the Associated Symptoms?

• Central vertigo frequently associated with “The Dangerous D’s”
  • Diplopia (double vision)
  • Dysphagia (difficulty swallowing)
  • Dysmetria (uncoordinated movement)
  • Dysarthria (difficulty speaking)

Step 3: Does this Patient Have Risk Factors for Central Vertigo?

• History of stroke
• Atrial fibrillation
• Diabetes
• Recent trauma

Step 4: Do a Neuro Exam

• Important exam findings for central vertigo
  • Abnormal gait
  • Abnormal finger-to-nose
  • Nystagmus
• Important exam findings for peripheral vertigo
  • Dix-Hallpike

Step 5: Plan

• If concerned for CENTAL vertigo
  • MRI head/neck
• If concerned for PERIPHERAL vertigo
  • Treat with meclizine

Additional Reading

• Posterior Circulation Strokes and Dizziness (emDOCs)

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Get your attending!

Step 1: Obtain Last Known Well

• Stroke treatments including tPA and thrombectomy both require last known well
  • <3-4.5 hours for tPA
  • <24 hours mechanical thrombectomy

Step 2: Finger Stick Blood Glucose

• Hypoglycemia is classic mimic of CVA
• Results can be obtained immediately

Step 3: STAT Head CT Without Contrast

• Poor sensitivity for ischemic stroke
  • Primary use is identification of hemorrhagic stroke
  • Required prior to administration of tPA!

Step 4: Perform NIHSS

• Use calculator (MDCalc)

Step 5: Give tPA (If No Contraindications)

• Follow department protocol and contraindications
  • Frequently being updated

Additional Reading

• tPA Basics (EM Clerkship)
• 2013 AHA Stroke Guidelines (AHA)
• NIH Stroke Scale/Score (MDCalc)

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Mnemonic: AEIOU-TIPS

Step 1: Evaluate the Airway

• General principles
  • “If they can’t speak, they can’t control their airway”
  • “If GCS is <8, intubate”
• In the real world, it’s a clinical judgement call
  • Postictal patients?
  • Intoxicated patients?

Step 2: Point of Care Labs

• Finger stick blood glucose
• EKG
  • Dysrhythmia?
  • Ischemia?
  • Abnormal intervals?
• Pregnancy test

Step 3: Consider Naloxone

• Classic dose – 0.4 to 2mg IV/IM
  • Many start with lower doses to lower chance of severe withdrawal
• Can also be given intranasal (2-4mg)

Step 4: Consider Differential Diagnosis

• Mnemonic: AEIOU-TIPS
  • *Note: You don’t need to order all of these tests on every patient with altered mental status!!!
• Alcohol
  • Blood alcohol level
  • Thiamine
• Endocrine/Electrolytes
  • Includes
    • Hypoglycemia
    • Hepatic encephalopathy
    • Myxedema coma
    • Hyponatremia
  • Obtain
    • Electrolyte panel
    • Hepatic panel
    • TSH
    • Ammonia
• Ischemia (Cardiac)
  • EKG
  • Troponin
• Opiates
• Uremia
• Trauma
  • CT head without contrast
  • CT cervical spine without contrast
• Infection
  • Urinalysis
  • Chest x-ray
  • Lumbar puncture
  • CBC
  • Lactic acid
  • Blood cultures
• Poisoning
• Stroke
  • CT head without contrast
  • Neuro exam for focal deficits

Additional Reading

• Round 1 – Altered Mental Status (EM Clerkship)
• Approach to Altered Mental Status (SAEM)

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With this complaint, it’s ALL about doing a good history and exam.

Step 1: Write Out Your Differential Diagnosis

• The KING
  • Subarachnoid hemorrhage
• The QUEEN
  • Meningitis
• 3 Killers in the BRAIN
  • Stroke
  • Hematomas
  • Elevated ICP/Tumors
• 3 Killers in the VESSELS
  • Arterial dissection
  • Brain DVT (Dural Venous Sinus Thrombosis)
  • Giant cell/temporal arteritis
• 3 MISCELLANEOUS killers
  • Preeclampsia
  • Carbon monoxide toxicity
  • Glaucoma

Step 2: How Does This Compare to Previous Headaches?

• Finding the answer to this question is not always easy!

Step 3: Do a FULL Neuro Exam

• Mental status
• Neck stiffness
• Extra-ocular movements
• Visual fields
• Cranial nerves
• Speech
• Motor
• Sensation
• Finger to Nose
• Gait

Step 4: Order Tests As Necessary

• CT head without contrast
• MRI brain
• Lumbar puncture
• ESR
• Carbon monoxide level

Step 5: Give “Headache Cocktail”

• Mix and match based on personal and patient preferences
  • IV Dopamine antagonist
  • IV Antihistamine
  • IV Steroid
  • IV NSAIDS
  • IV Fluids
  • Tylenol
• Triptans and opiates rarely indicated

Additional Reading

• Round 7 – Headache (EM Clerkship)
• Round 11 – Headache (EM Clerkship)
• Approach to Headache (SAEM)