Neurologic emergencies

Report
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.
– 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
• 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 #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
• 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
• Does our patient have dementia or delirium?
Delirium
Dementia
Sudden
Insidious
Course/day
Fluctuating
Stable
Consciousness
↓ / Clouded
Alert
Attention
Abnormal
Normal
Cognition
Abnormal
Abnormal
Orientation
Impaired
Often impaired
Hallucinations
Usu visual
Absent
Delusions
Transient
Absent
Asterixis/tremors
Absent
Onset
Movements
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 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 #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
• 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
• 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
• 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 #1
• WBC 8,000
• BMP WNL
• ECG sinus tachycardia without ischemic
change
• CXR next slide
Case #1
Case #1 Diagnosis
• Community Acquired Pneumonia
– Causing hypoxia and resulting mental status
changes
• Patient admitted for IV ATBx and oxygen
therapy
Case #2
• 75 year old male
• Fell off ladder two days ago
• Has been increasingly confused at home
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
GCS
• What’s his GCS score?
GCS
•
•
•
•
Glasgow Coma Scale
Minimum score = 3
Maximum score = 15
Assess eye opening, motor response, verbal
response
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
• 4-Spontaneously
• 3-To Verbal
• 2-To pain
• 1-None
GCS-Best Verbal Response
• 5- Oriented, converses
• 4-Disoriented, confused
• 3-Inappropriate words
• 2-Incomprehensible sounds
• 1-None
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
• 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
•
•
•
•
Focus upon trying to find out their baseline
Recent illnesses?
New medications?
Ingestions/Polypharmacy?
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 Status
• Bilaterally fixed dilated pupils= anoxic injury
• Pinpoint, nonreactive without systemic
response to Naloxone= pontine injury
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 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 Status
• Abdomen-ascites, stigmata of liver failure that
might tip you off to hepatic encephalopathy
Case #2
• Concern for traumatic intracranial
hemorrhage given history of fall and new
onset altered mental status
• CT obtained
Case #2
Case #2
• Neurosurgery consulted
• Patient admitted to NSICU
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
• 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
• #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
• 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 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
• 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
• 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
• 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
• 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 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 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 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
• 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
• 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 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)
Johnston et al 2000
Speech disturbance (OR: 1.5)
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
• 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
• Hypoglycemia
• Todd’s Paralysis
– Post-ictal neurologic deficits
• Complex Migraines
• Conversion Disorder
Usually suspect given history and physical
– Assume stroke if uncertain
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 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
• 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-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-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 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
• Depth of workup depends upon whether or
not event is a first time seizure
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
• 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
• 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
• May be discharged home if neurologically
normal after postictal period and drug levels
are within normal limits
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.

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