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Global Objectives

How to Complete a Clinically Relevant & Directed Neurologic Exam in ED CVA Patients Edward Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL. Global Objectives. Improve pt outcome in stroke

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Global Objectives

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  1. How to Complete a Clinically Relevant & Directed Neurologic Exam in ED CVA PatientsEdward Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

  2. Global Objectives • Improve pt outcome in stroke • Make consistent and reliable neuro Dx • Provide rationale ED therapies • Maximize ongoing learning • Be comfortable with our clinical skills • Minimize any unnecessary work

  3. Session Objectives • Present clinical case history • Consider acute stroke for a directed exam • Ask clinically relevant questions • Conduct a directed ED H&P • Examine the NIH Stroke Scale (NIHSS) • Review optimal ED documentation

  4. “Real” Session Objectives • State the bare minimum that must be done in order to get the job done. • Allow you to forget about doing the rest.

  5. Why Do This Exercise? • How to proceed is unclear for many. • A uniformly applied minimal standard is better than a non-uniform approach. • Once achieved, a minimal standard can be enhanced. • This is a standard of care issue.

  6. Some Perspective • Stroke is a common ED problem. • Outcome from stroke can be devastating. • Use of tPA in stroke is an important issue. • Guidelines are being developed at the local and national level regarding CVA pts. • The cornerstone of this activity remains the front line Emergency Physician.

  7. A Disclaimer. • Although I have listened to many lectures on the neurologic exam, I am not fully comfortable with this part of my practice. • What I do in clinical practice may fall below the standard of care. • Others also may fall short of a reasonable standard in doing a stroke neuro exam.

  8. A Pledge. • I will not simply create controversy. • I will attempt to clarify what are the important clinical questions. • I will attempt to state which physical and neuro exam elements are useful and why. • I will demonstrate a way in which the physical exam findings can be recorded in order to facilitate patient care.

  9. A Clinical History A 62 year old female acutely developed aphasia and right sided weakness while in the grocery store. The store clerk immediately called 911, with the arrival of CFD paramedics within 9 minutes, at 6:43 pm. She arrived at the ED at 7:05 pm, completed her head CT at 7:25 pm, and obtained a neuro consult at 7:35 pm, approximately one hour after the onset of her symptoms. What are the next Rx steps?

  10. ED Presentation What parts of the history and physical exam really matter? Why? In what way will the neurologic exam direct the ED diagnosis and therapy? What must be documented? Why?

  11. Acute Neurologic Exam Questions • What general exam should be done? • What neuro exam should be done? • What exam findings guide therapy? • What exam findings predict outcome? • What is the NIH stroke scale? • How can documentation be optimized?

  12. Acute Ischemic Stroke:Etiology • Thrombotic, embolic, hypoperfusion • Majority are vessel thrombosis • Clot formation on diseased vessel • 20% are embolic, from heart, great vessels • Hypoperfusion with cardiogenic shock

  13. Acute Ischemic Stroke: Syndromes • Anterior cerebral • Middle cerebral • Posterior cerebral • Vertebrobasilar • Basilar artery occlusion • Cerebellar • Lacunar • Arterial dissection

  14. Acute Ischemic Stroke H & P:Some Practical Questions • Does the neuro exam tell us anything the CT scan does not? • Do we need to localize the CVA clinically? • Isn’t a large ICH evident most often based on the pt’s mental status and overall appearance? • Who checks for proprioception or a positive Rhomberg in a pt with a CVA?

  15. Acute Ischemic Stroke H & P:Rationale for Exam Findings • To make the correct diagnosis • To identify a stroke syndrome • To identify CVA precipitants/etiology • To determine further diagnostic tests • To determine ED therapies • To allow for proper documentation

  16. Rationale for a Directed Neuro Exam:To Make the Correct Diagnosis • A complete neuro exam helps when Sx are vague, mild or confusing • TIA, seizure or migraine variant setting • Exam puts a name on non-persistent Sx • Most acute stroke pts have obvious Sx • What else causes L sided paralysis acutely? • Doesn’t the constellation of Sx make the Dx? • Which Dx must be immediately excluded?

  17. To Make the Correct Diagnosis: A Stroke Differential Diagnosis • Hypertensive encephalopathy • Subdural, epidural hematoma • Meningitis, encephalitis, abcess, labarynthitis • Seizure, SE, Todd’s paralysis • Neoplasm • Hypoglycemia, metabolic • Migraine • Peripheral nerve, Bell’s palsy • Multiple sclerosis

  18. Rationale for a Directed Neuro Exam:To Identify a Stroke Syndrome • The neurologic exam must establish: • anterior or posterior circulation location. • if the Dx is cerebellar hemorrhage. • if the lesion is in the brain stem. • if the lesion is in the spinal cord. • There is no other requirement with regards to the acute Dx of the stroke pt.

  19. To Identify a Stroke Syndrome:Anterior vs. Posterior Circulation • Markedly different presentations. • Anterior circulation: • Sx (motor, sensory) on the same body side • Sx contralateral to the side of the CVA • Visual field deficits, gaze abnormalities • Aphasia, dysarthria, apraxia

  20. To Identify a Stroke Syndrome:Anterior vs. Posterior Circulation • Posterior circulation: • Minimal (transient) motor abnormality • Marked sensory (LT, pinprick) abnormality • Visual abn, oculomotor palsy • Ataxia, hemiballism • Vertebrobasilar system: • CN, body motor deficits on alternating sides • Hemiparesis, hemiplegia, dizziness, dim vision, dysarthria, dysphagia, vomiting

  21. Rationale for a Directed Neuro Exam:Cerebellar Hemorrhage • A specific clinical presentation: • Nausea, vomiting, central vertigo • Headache, nuchal rigidity • Syncope, ataxia, inability to ambulate • AMS when brainstem is compressed • Pathologic respiratory pattern • A true surgical emergency (evacuation). • Often difficult to detect on CT.

  22. Rationale for a Directed Neuro Exam:Brain Stem Lesion • A specific clinical presentation: • Markedly abnormal vital signs • Altered mental status, often coma • Pupillary abnormalities • Abnormal respirations • Often with the need for immediate intubation • A picture of critical illness

  23. Rationale for a Directed Neuro Exam:Spinal Cord Lesion • Injury with unilateral or bilateral findings • Complete spinal cord injury • Partial syndromes • Central, anterior, Brown-Sequard • Cauda equina • Tumor, abcess, epidural hematoma • Disc disease/acute herniation • No Hx, Px findings that suggest a CVA

  24. Rationale for a Directed Neuro Exam:To ID Stroke Precipitant/Etiology • What is the etiology of the stroke? • What findings suggest the need for a specific Rx or further Dx testing? • Four stroke etiologies are noted: • Thrombotic (atherosclerosis) • Embolic • Hemorrhage • Subarachnoid hemorrhage

  25. To ID Stroke Precipitant/Etiology:Findings Suggesting Embolic CVA • Most often anterior circulation process • Abrupt Sx onset, worst deficit at onset • Carotid bruit: carotid artery occlusion and source of embolism • A Fib: embolism source of MCA stroke • Heart murmur: valve pathology, embolism

  26. To ID Stroke Precipitant/Etiology:Findings Suggesting Thrombotic CVA • Most often posterior circulation process • Gradual Sx onset, stepwise deficit • Carotid bruit: evidence of atherosclerosis • LV Heave: cardiac hypertrophy • Aorta: AAA indicated vasculopathy • Extremities: poor pulses, atherosclerosis

  27. To ID Stroke Precipitant/Etiology:Findings Suggesting Hemorrhagic CVA • Impaired consciousness key element • Abrupt Sx onset, usu max deficit early • HTN, bradycardia • Papilledema, hemorrhages

  28. To ID Stroke Precipitant/Etiology:Findings Suggesting Subarachnoid • Impaired consciousness key element • Varied Sx onset and deficit progression • Severe headache, neck stiffness • Retinal hemorrhages • Meningismus

  29. Rationale for a Directed Neuro Exam:To Determine Further Dx Tests • Very few further tests in the ED: • EKG for dysrhythmia • CXR to rule out tumor, CHF • Contrast Head CT for abcess, tumor • Angiography for suspected SAH, aneurysm • CT, US for suspected large AAA • ECHO for suspected acute cardiac lesions • MRI, other tests rarely indicated

  30. Rationale for a Directed Neuro Exam:To Determine ED Therapies • Very few specific ED therapies. • Embolic, thrombotic CVAs: • ASA, Heparin, tPA • Hemorrhagic CVA • Mannitol, decadron, phenytoins • Operative intervention • Subarachnoid hemorrhage • Nimodipine, ?? OR

  31. Rationale for a Directed Neuro Exam:To Allow for Proper Documentation • What was the clinical state of the pt when in our ED, and under our care? • Did we complete exam sufficient to direct Rx that would optimize this pt’s care? • Did our clinical Rx follow our exam? • If necessary, could a NIHSS score be assigned in retrospect

  32. Acute Stroke: Historical Elements • When did symptoms begin? Onset? • Prior history of similar symptoms? • When was the patient last seen normal? • Risk factors? • Medical hx that would preclude tPA use?

  33. Acute Stroke: Physical Exam • Vital signs, pulse ox, accucheck • HEENT: Pupils, papilledema, airway • Neck: Bruits, nuchal rigidity • Chest: Rales (CHF, aspiration) • Cardiac: Gallop, murmur, dysrhythmias, ventricular heave

  34. Acute Stroke: Physical Exam • Abd: Evidence of AAA • Ext: Evidence of CHF, DVT, vascular Dx • Skin: Evidence of infectious etiology • Neuro: Mental status, CN, eye exam, motor, sensory, reflexes, cerebellar, visual, language, neglect

  35. Neurologic Exam: Mental Status • Level of consciousness (AVPU) • Alert • Responds to verbal • Responds to painful • Unresponsive • Glasgow Coma Scale (GCS) score • Designed for trauma, TBI • Still is a reproducible, systematic scale • Delirium: AMS, inappropriate, wax/wane

  36. Neurologic Exam: Cranial Nerves • Cranial Nerves: Anterior vs. posterior? • Anterior: CN, body deficits on same side • Posterior: CN and body deficits are on opposite sides of the body (alternating hemiplegia) • Face motor, sensory (LT) only • Gag reflex (intubation) • Eye Closure (Bell’s palsy)

  37. Neurologic Exam: Eye Exam • Pupils: location of brain stem lesion • EOM: CN palsies, often not due to CVA • Vertigo: assists with DDx of CVA

  38. Neurologic Exam: Motor • Motor: upper & lower extremities • Upper: Pronator drift, hand grasp • Lower: Leg lift, foot push on hand

  39. Neurologic Exam: Sensory • Sensory: Light touch OK, pinprick ?? • No other sensory testing is indicated unless a posterior circulation infarct or a spinal cord syndrome is suspected • No heat, vibration, proprioception

  40. Neurologic Exam: Reflexes • Suggest UMN control of LMN • Corneal, gag, DTRs all are normal • Pathologic reflexes • Babinski, Chadduck • Clonus • Unclear whether or not these add to our overall impression of CVA severity

  41. Neurologic Exam: Cerebellar • Truncal ataxia perhaps useful • Ataxic gait, Rhomberg: No • Extremity tests not useful in paralysis • Past-pointing • Hand alternating movements

  42. Neurologic Exam: Visual • Visual field deficit • Homonomous hemianopsia • Neglect of one side • Preferential gaze

  43. Neurologic Exam: Language • Dysarthria: Poor speech, motor dysfunction • Aphasia: Disturbed language processing • Expressive: can’t speak • Receptive: can’t process the spoken word

  44. Acute Neurologic Exam Answers • The Hx should lead to a provisional Dx. • The Px exam should detect co-morbidity and suggest the stroke etiology. • The neuro exam should confirm the Dx. • Few exam findings specifically direct Rx or direct outcome. • AMS, coma are the most important findings. • The NIHSS directs your neuro exam. • Standardization of your document is key.

  45. Acute Ischemic Stroke H & P:Some Practical Answers • The exam directs us to a provisional Dx. • We do localize the lesion by identifying the provisional stroke syndrome. • The CT will identify a large ICH or ischemic stroke, but many times the CT is negative, in which case the exam is key. • Completing all parts of the neuro exam is not necessary, use it to confirm your Dx.

  46. Neuro Exam: Internet Sites • Search engine: Google • Key words: Neurologic Exam • Some web sites: • www.medinfo.ufl.edu/year1/bcs/clist/neuro.html • www.dundee.ac.uk/ medicine/StrokeSSM/ClinExamNeuro.htm

  47. Neurologic Exam: NIH Stroke Scale • 13 item scoring system, 7 minute exam • Integrates neurologic exam components • CN, motor, sensory, cerebellar, visual, language, LOC • Maximum score is 42, signifying severe stroke • Minimum score is 0, a normal exam • Scores greater than 15-20 are more severe

  48. NIH Stroke Scale: Important Questions • Which elements are consistently collected? • Which correlate with outcome? • Which improve with tPA? • Which suggest a complicated tPA course? • Which parts overlap with one another?

  49. NIH Stroke Scale: Practical Suggestions • Know the general categories of the NIHSS • Let these 7 areas guide your exam • Know how to score an approximate NIHSS • Go to the web to score your exam fully

  50. NIH Stroke Scale: Internet Calculator • Allows calculation on-line • Will add values, provide total • http://info.med.yale.edu/ neurol/Residency/nihss.htm • Other sites: • www.stanford.eud/group/neurologystroke.nihss.html • www.thebraincentre.org/NIHSS/NIHSS.htm

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