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.