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Approach to Neurologic Emergencies

Approach to Neurologic Emergencies . Indiana University School of Medicine Emergency Medicine Clerkship. Objectives. From the IU EM Didactic Learning Objectives: 13. Discuss the differential diagnosis of patients presenting to the Emergency Department with altered mental status.

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Approach to Neurologic Emergencies

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  1. Approach to Neurologic Emergencies Indiana University School of Medicine Emergency Medicine Clerkship

  2. Objectives • From the IU EM Didactic Learning Objectives: • 13. Discuss the differential diagnosis of patients presenting to the Emergency Department with altered mental status. • 14. Identify the appropriate candidate for thrombolytic therapy in the Emergency Department. • 36. Discuss the approach to the actively seizing patient, new onset seizure patient, chronic seizure patient, and the febrile seizure patient in the Emergency Department. • NB: Febrile seizures not covered in this lecture; covered in Peds lecture

  3. Case #1 • You are working a late evening shift and receive an EMS call • 94 year old female; unknown PMH • Normally A&O x3 at baseline; lives independently • Daughter called to “check in this evening” and had no response • EMS found patient lying on floor, confused

  4. Case #1 • EMS glucose—146 • The medic tells you that the patient’s pupils were slightly sluggish, so he gave a dose of Narcan without any response

  5. Coma Cocktail • Not routinely given, but considered • Glucose • Check early and administer D50 if low • Consider empiric D50 if no meter available • Naloxone (Narcan) • Reverses the effects of narcotics that may be affecting mentation and or breathing • Use if patient apneic or suspect narcotic toxicity • May precipitate withdrawal in chronic users • Thiamine • Consider in alcoholics

  6. Does our patient have dementia or delirium?

  7. Altered Mental Status-Differential Dx • A-Alcohol • E-Endocrine • I-Insulin- Diabetes • O-Oxygen and opiates • U-Uremia, hypertensive encephalopathy • T-trauma, temperature • I-infection • P-Psychiatric • S-Space occupying lesion, stroke, subarachnoid hemorrhage, shock

  8. Altered Mental Status-Differential Dx • Not all conditions listed on previous slide need a test to rule them out • Use information obtained from history, physical examination, family to narrow differential diagnosis and guide approach

  9. Case #1 • On arrival, the patient is awake and alert, making moaning noises and not following commands well • VS: P 86 BP 124/84 RR 24 T 100.8 Biox-84% on RA • Exam • Pupils 2 mm and reactive; no focal neurologic weakness • Left lower lung rales

  10. Vital Signs • Often provide clue to underlying etiology • Hypoxia- either as a cause of confusion or as a result of hypoventilation because of neurologic insult • Needs to be rapidly recognized and treated

  11. Vital Signs-continued • Hypotensive-shock • May see tachycardia as well • Hypertensive- consider intracranial hemorrhage • Fever • Moves infectious etiologies higher on the list • Although some septic patients may be afebrile or hypothermic

  12. Altered Mental Status-Workup • Focus based on history and exam as possible • Can be difficult especially when limited information present in H&P • For our patient • CBC, BMP, ECG, U/A, CXR

  13. Case #1 • WBC 8,000 • BMP WNL • ECG sinus tachycardia without ischemic change • CXR next slide

  14. Case #1

  15. Case #1 Diagnosis • Community Acquired Pneumonia • Causing hypoxia and resulting mental status changes • Patient admitted for IV ATBx and oxygen therapy

  16. Case #2 • 75 year old male • Fell off ladder two days ago • Has been increasingly confused at home

  17. Case #2 • Vitals T 98.4 F BP 178/104 HR 72 RR 14 Biox 97% • Patient lying on the stretcher • Eyes closed, responds to voice • Speech confused • Moves all extremities spontaneously, follows commands slowly

  18. GCS • What’s his GCS score?

  19. GCS Glasgow Coma Scale Minimum score = 3 Maximum score = 15 Assess eye opening, motor response, verbal response

  20. GCS-Mnemonic • Helps with maximum score in each category • Eyes- “Hey four eyes” (4) • Motor- “Six cylinder motor” (6) • Verbal- “Jackson Five” (5)

  21. GCS-Eye Opening • 4-Spontaneously • 3-To Verbal • 2-To pain • 1-None

  22. GCS-Best Verbal Response • 5- Oriented, converses • 4-Disoriented, confused • 3-Inappropriate words • 2-Incomprehensible sounds • 1-None

  23. GCS-Best Motor Response • 6-Obeys commands • 5-Localizes pain • 4-withdraws to pain • 3-decorticate posturing • 2-decerebrate posturing • 1-none

  24. Obtaining a History • In the altered patient, important to contact family members, nursing staff at ECF, caregivers • Review the EMR, look in wallet for alerts/medication lists • They will often be the only potential history source and can provide crucial information

  25. History-Altered Mental Status • Focus upon trying to find out their baseline • Recent illnesses? • New medications? • Ingestions/Polypharmacy?

  26. Pupils-Altered Mental Status Generally preserved in metabolic causes • Unilateral dilated pupil in unresponsive patient • Think uncal herniation secondary to bleed/space occupying lesion

  27. Pupils-Altered Mental Status • Bilaterally fixed dilated pupils= anoxic injury • Pinpoint, nonreactive without systemic response to Naloxone= pontine injury

  28. Physical Exam-Altered Mental Status • Look for pallor (anemia), needle tracks (IVDU), cyanosis (hypoxia) • Breath-smell for ETOH or ketones (fruity) • Head-look for abrasions, contusions, craniotomy scars, shunts • Eyes-icterus, fundoscopic, gaze preference

  29. Physical Exam-Altered Mental Status • Mouth-look for tongue lacerations (on the sides) suggesting seizure • Neck-evaluate for meningismus; remember to have a low threshold to immobilize the cervical spine if there is any question of trauma • Lungs-wheezing or abnormal breath sounds; suggesting COPD leading to hypercarbia

  30. Physical Exam-Altered Mental Status • Abdomen-ascites, stigmata of liver failure that might tip you off to hepatic encephalopathy

  31. Case #2 • Concern for traumatic intracranial hemorrhage given history of fall and new onset altered mental status • CT obtained

  32. Case #2

  33. Case #2 • Neurosurgery consulted • Patient admitted to NSICU

  34. Case 3 • 67 yo male brought in by ambulance with 2 hour history of right sided weakness and facial droop • PMH: HTN, DM • VS: T: 36.3 BP: 130/80, HR: 90, SpO2: 99% on RA

  35. Case 3-Exam • Gen-awake, alert, GCS 15 • PERRLA, EOMI, no nystagmus • Right facial droop; some slurring noted on spontaneous speech • 4/5 strength RUE/RLE; remainder nonfocal • Follows commands well

  36. Acute Stroke • #1 priority—is this patient a candidate for thrombolytics? • Safe, effective administration of thrombolytics is time and criteria dependent • Failure to follow time/criteria guidelines increases the risk of iatrogenic intracranial bleed

  37. Acute Stroke-Initial Priorities • Is this patient in the time window? • 3-4.5 hours from symptom onset depending on institution (discussion to follow) • Patients who went to bed normal and awoke with deficit-disqualified from consideration • Priority-get patient quickly to CT to rule out ICH and remain within time window

  38. Acute Stroke-Initial Priorities • Rule out other causes of neurologic findings • ICH-Get head CT • Hypoglycemia-get finger stick glucose • Aortic dissection-assess for chest pain, abdominal pain occurring with the neurologic symptoms • Obtain EKG to assess rhythm

  39. Thrombolytics • Must weigh risks and benefits • Benefit: potential return of neurologic function • Risk: ICH, non CNS hemorrhage death, poor functional outcome • Essential to discuss with patient, family, and document this discussion • MUST apply current evidence and carefully apply inclusion/exclusion criteria

  40. Thrombolytics-Inclusion Criteria • Inclusion Criteria • Age 18 or over • Clinical diagnosis of acute ischemic stroke causing a measurable neurologic defect • Time of symptom onset well established to be less than 180 minutes before treatment would begin • This excludes many patients as duration is frequently longer than 3 hrs, includes time to obtain and read head CT

  41. Thrombolytics-The evidence • Controversial • study done by NINDS in 1995 • NNT=9 for increase in normal function at 3 months • Significant Intracranial Hemorrhage rate about 6% • NNH=15 • Most with worse deficits than stroke • About half of ICH fatal • Not reproduced outside of NINDS • Until ECASS 3 published in 2008 NINDS study group 1995

  42. Thrombolytics-ECASS 3 • Prospective, randomized, double blind trial to assess safety and efficacy of thrombolysis up to 4.5 hours from symptom onset • Higher rate of favorable outcome in treatment group versus placebo (52% versus 45%) • Higher rate of ICH in treatment group (27% versus 17%) Hacke et al 2008

  43. Thrombolytics-ECASS 3 • Thrombolytics less efficacious from 3-4.5 hours than from 0-3 hours • Odds ratio for favorable outcome • 2.80 for 0-90 minutes • Only 1.40 for 3-4.5 hours Hacke et al 2008

  44. Thrombolytics-ECASS 3 • ICH rate reported in study higher than original NINDS trial • Bottom line: From 3-4.5 hours, modest increase in improved functional outcome. Increase in intracranial hemorrhage risk Hacke et al 2008

  45. Case 3 • Patient’s blood sugar normal, EKG is NSR, labs drawn and patient sent for urgent head CT. • On return from head CT patients symptoms have resolved • Normal motor function bilaterally on exam • Head CT neg but defer on TPA as patients symptoms have resolved spontaneously. • What is your next step?

  46. Case 3-Diagnosis/Workup • TIA-transient ischemic attack • Patient needs Neurology consult • Evaluation for reversible cause or stroke and risk factor modification • Carotid us, MRI/MRA, Cardiac Echo • Frequently done as inpatient • TIA patients at increased risk of stroke especially in the days after a TIA • Can be done as outpatient if patients deficits have resolved and expedient workup can be arranged

  47. TIA-Short Term Outcomes • JAMA study (2000) • 1707 TIA patients • Observed for rate of stroke, recurrent TIA, cardiovascular events, death in 90 days after initial ED evaluation for diagnosis of TIA Johnston et al 2000

  48. TIA-Short Term Outcomes • 180 (10.5%) patients returned to ED with CVA • 91 of the CVAs occurred in the first 2 days • Risk factors associated with risk of returning with CVA: • Age >60 (odds ratio: 1.8) • Diabetes mellitus (OR: 2.0) • Symptom duration >10 minutes (OR: 2.3) • Weakness (OR: 1.9) • Speech disturbance (OR: 1.5) Johnston et al 2000

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