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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

Approach to Neurologic Emergencies

Indiana University School of Medicine

Emergency Medicine Clerkship

objectives
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
case 1
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
case 11
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
coma cocktail
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
altered mental status differential dx
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
altered mental status differential dx1
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
case 12
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
vital signs
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
vital signs continued
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
altered mental status workup
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
case 13
Case #1
  • WBC 8,000
  • BMP WNL
  • ECG sinus tachycardia without ischemic change
  • CXR next slide
case 1 diagnosis
Case #1 Diagnosis
  • Community Acquired Pneumonia
    • Causing hypoxia and resulting mental status changes
  • Patient admitted for IV ATBx and oxygen therapy
case 2
Case #2
  • 75 year old male
  • Fell off ladder two days ago
  • Has been increasingly confused at home
case 21
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
slide19
GCS
  • What’s his GCS score?
slide20
GCS

Glasgow Coma Scale

Minimum score = 3

Maximum score = 15

Assess eye opening, motor response, verbal response

gcs mnemonic
GCS-Mnemonic
  • Helps with maximum score in each category
  • Eyes- “Hey four eyes” (4)
  • Motor- “Six cylinder motor” (6)
  • Verbal- “Jackson Five” (5)
gcs eye opening
GCS-Eye Opening
  • 4-Spontaneously
  • 3-To Verbal
  • 2-To pain
  • 1-None
gcs best verbal response
GCS-Best Verbal Response
  • 5- Oriented, converses
  • 4-Disoriented, confused
  • 3-Inappropriate words
  • 2-Incomprehensible sounds
  • 1-None
gcs best motor response
GCS-Best Motor Response
  • 6-Obeys commands
  • 5-Localizes pain
  • 4-withdraws to pain
  • 3-decorticate posturing
  • 2-decerebrate posturing
  • 1-none
obtaining a history
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
history altered mental status
History-Altered Mental Status
  • Focus upon trying to find out their baseline
  • Recent illnesses?
  • New medications?
  • Ingestions/Polypharmacy?
pupils altered mental status
Pupils-Altered Mental Status

Generally preserved in metabolic causes

  • Unilateral dilated pupil in unresponsive patient
    • Think uncal herniation secondary to bleed/space occupying lesion
pupils altered mental status1
Pupils-Altered Mental Status
  • Bilaterally fixed dilated pupils= anoxic injury
  • Pinpoint, nonreactive without systemic response to Naloxone= pontine injury
physical exam altered mental status
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
physical exam altered mental status1
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
physical exam altered mental status2
Physical Exam-Altered Mental Status
  • Abdomen-ascites, stigmata of liver failure that might tip you off to hepatic encephalopathy
case 22
Case #2
  • Concern for traumatic intracranial hemorrhage given history of fall and new onset altered mental status
  • CT obtained
case 24
Case #2
  • Neurosurgery consulted
  • Patient admitted to NSICU
case 3
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
case 3 exam
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
acute stroke
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
acute stroke initial priorities
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
acute stroke initial priorities1
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
thrombolytics
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
thrombolytics inclusion criteria
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
thrombolytics the evidence
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

thrombolytics ecass 3
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

thrombolytics ecass 31
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

thrombolytics ecass 32
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

case 31
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?
case 3 diagnosis workup
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
tia short term outcomes
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

tia short term outcomes1
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

tia short term outcomes2
TIA Short Term Outcomes
  • Increased risk of CVA short term following TIA
  • Take risk factors into consideration when making inpatient versus outpatient workup decision
case 3 treatment
Case 3-Treatment
  • Aspirin therapy
    • Started on all patients with ischemic stroke or TIA
      • To prevent further stroke
  • Platelet Aggregation
    • Clopidogrel, ticlopidine
    • Used in patients intolerant to ASA
    • Also in patients who have CVA while on ASA
beware stroke mimics
Beware Stroke Mimics
  • Hypoglycemia
  • Todd’s Paralysis
    • Post-ictal neurologic deficits
  • Complex Migraines
  • Conversion Disorder

Usually suspect given history and physical

    • Assume stroke if uncertain
case 4
Case 4
  • 22 year old female
  • Brought in by ambulance
  • Observed to have seizure like activity at home and is now sleepy and confused
  • On arrival, the patient is sleepy, but opens her eyes to voice, pushes away in response to pain
  • You note that she has urinated on herself
case 41
Case 4
  • VS: T: 36.3, HR 80, BP 120/80, RR 18, SpO2 100%
  • Finger stick blood glucose for EMS: 100
  • As you continue your assessment, the patient begins having a generalized tonic clonic seizure
  • What’s your next step?
active seizures treatment
Active Seizures-Treatment
  • First line-Benzodiazepines
    • Lorazepam IV preferred agent
    • Lorazepam pediatric dose 0.1 mg/kg up to max of 1-2 mg per dose
    • Adults: Lorazepam 1-2 mg/dose, okay to repeat every 1-3 minutes if seizures continue
      • Dosing ultimately limited by respiratory depression, which can be managed with intubation if necessary
active seizures treatment1
Active Seizures-Treatment
  • Supportive measures
    • Ensure bed rails up, seizure pads (if available) in place
    • Place supplemental oxygen (non rebreather) on patient
    • Place oral/nasal airway as necessary to maintain patent airway
active seizures treatment2
Active Seizures-Treatment
  • If no control despite multiple doses of benzos, consider alternative agents
    • Fosphenytoin (18-20 PE/kg)
    • Phenobarbital (10-20 mg/kg)
    • If you need to secure the patient’s airway, may need to involve neurology for EEG monitoring if the patient is paralyzed
case 42
Case 4
  • Seizure stops after 2 doses of lorazepam
  • The patient is maintaining her airway, and appears postictal
  • The nurse asks you, “What are you going to do to work her up?”
seizure evaluation
Seizure-Evaluation
  • Depth of workup depends upon whether or not event is a first time seizure
first time seizure workup
First Time Seizure Workup
  • Electrolytes
  • CT of the head to evaluate for SAH, mass lesion
  • Other tests dependent upon clinical scenario
    • If suspicion for CNS infection, perform LP
first time seizure disposition
First Time Seizure-Disposition
  • If no further seizure activity, returned to baseline and competent caretaker with patient:
    • May return home with Neurology follow up arranged
    • Will need outpatient MRI, EEG
    • No driving, no bathing/showering alone
    • Good dismissal instructions including reasons to return
breakthrough seizure workup
Breakthrough Seizure-Workup
  • Medication non compliance common-check drug levels
  • Evaluate for infection
  • Check finger stick glucose
  • Most patients do not require neuroimaging
    • Consider if long period of decreased LOC or other new focal neurologic finding
breakthrough seizure disposition
Breakthrough Seizure-Disposition
  • May be discharged home if neurologically normal after postictal period and drug levels are within normal limits
references
References
  • NINDS study group. “Tissue plasminogen activator for acute ischemic stroke”. New England Journal of Medicine. 333: 1581-1587.
  • Hacke W et al. “Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke”. New England Journal of Medicine. 359: 1317-1329.
  • Johnston SC et al. “Short-term prognosis after emergency department diagnosis of TIA”. JAMA. 284:2901-2906.