Download Neurology Evaluation in the ED

Neurology Evaluation
in the ED
Nicholas Cascone, PA-C
Components of Neuro
Evaluation in ED
• Mental Status – emotional and intellectual
function
– Thought process
– Mood
– Insight
– Sensorium
– Attention
– Memory, short and long-term
Components of Neuro
Evaluation in ED
• Glasgow Coma Scale – measure of
sensorium/consciousness
– Eye opening:
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4 = spontaneous
3 = opens to speech
2 = opens to pain
1 = none
– Verbal response:
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5 = alert, oriented
4 = disoriented but verbal
3 = nonsensical
2 = moans/unintelligible speech
1 = none
Components of Neuro
Evaluation in ED
• Glasgow Coma Scale (cont’d)
– Motor response
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6 = follows commands
5 = localizes pain
4 = withdraws from pain
3 = decorticate – flexion
2 = decerebrate – extension
1 = none
Components of Neuro
Evaluation in ED
• Higher cerebral function
– Language
• Dysarthria – mechanical disorder of speech from
weakness of facial/oral muscles
• Dysphasia – problem with language of
cortical/subcortical origin
– Fluent (Wernicke’s) or nonfluent (Broca’s)
– Comprehension – tested by ability to follow commands
Components of Neuro
Evaluation in ED
• Cranial nerves
– I – rarely tested
– II/III – direct/indirect pupillary response
– III/IV/VI – extraocular muscle movements
– V/VII – corneal reflex
– VIII – hearing, balance
– IX/X – gag reflex
– XI – shoulder shrug
– XII – tongue protrusion
Components of Neuro
Evaluation in ED
• Sensory exam
– Touch in all extremities
– If negative, test proprioception or vibration sense
– Further investigation involves testing individual
dermatomes to localize lesions
Components of Neuro
Evaluation in ED
• Motor system
– Muscle tone – passive movement of muscle
groups with patient not resisting
– Muscle bulk – atrophy, wasting
– Muscle strength – 0-4 scale, 0=complete paresis,
1=minimal contraction, 2=active movement when
gravity counteracted, 3=movement against gravity
only, 4=movement against resistance
– Reflexes, Babinski response
Components of Neuro
Evaluation in ED
• Cerebellar testing
– Posture, truncal movements test central
cerebellum
– Appendicular movements test lateral cerebellum
– Dysdiadokokinesis – inability to execute rapidly
alternating movements
Components of Neuro
Evaluation in ED
• Gait and station
– Most important neurological test
– Watch as patient sits upright, rises, stands, walks, turns,
heel walks, toe walks
– Gait disturbance examples
• Ataxic – wide-based, unsteady, irregular steps, inability to
negotiate barriers; cerebellar lesions
• Apraxic – cannot initiate gait; nondominant hemispheric lesions
• Equine – high step present due to foot drop; peroneal muscle
weakness
• Festination – narrow-based, shuffling; Parkinsonism
• Waddling – weakness of lower trunk/pelvic girdle
Introduction to
Psychiatric Emergencies
Nicholas Cascone, PA-C
Psychiatric Presentations in the ED
• Estimated that up to 1/3 of ED patients have a
psychiatric diagnosis
• ED task: to evaluate patient’s risk of harm to
self and/or others
• Psychiatric Dx accomplished through criteria
defined in DSM-IV
• Psychiatric evaluation includes five axes
Axis I disorders in ED
• Cognitive disorders
– Dementia
• Hallmark is cognitive deficit, including memory,
abstraction, judgment, language, spatial ability
– Delirium
• Hallmark is clouding of consciousness, reduction of
awareness of external environment, loss of alertness
Axis I disorders in ED
• Substance-Induced Disorders
– Intoxication
• Recent ingestion of exogenous substance producing
maladaptive behavior, impairment of judgment,
perception, attention, emotional control
• Usually Dx by laboratory tests
– Withdrawal
• Syndromes vary according to substance of abuse
• Usually Dx by identification of withdrawal syndrome
and evidence of recent use
Axis I disorders in ED
• Psychotic disorders present to the ED due to:
• Exacerbation of chronic psychosis from stress or
noncompliance with medications
• Side effects of antipsychotic medications
• Suicidality
• Violence directed towards self or others
• Chronic psychosis leads to disregard for other medical
conditions, precipitating need for emergency care
Axis I disorders in ED
• Mood disorders present in the ED due to:
– Suicidality in depressive disorders
– Mania in bipolar disorders causing erratic behavior
or overt psychosis
• Anxiety disorders present in the ED due to:
– Panic disorder mimicking angina/MI
– Violent/impulsive behaviors in PTSD
Axis I disorders in ED
• Somatoform disorders present in the ED due
to:
– Conversion disorder presenting with sudden
neurological deficit
– Hypochondriasis presenting with somatic illusion
of serious illness
– Factitious disorders/malingerers presenting in ED
with fake/self-created symptoms
Axis I disorders in ED
• Personality disorders frequently seen in ED:
– Antisocial personality disorder
• Violence
• Criminality
• Substance abuse
– Borderline personality disorder
• Suicidality
• Substance abuse
Emergency Psychiatric Evaluation
• History – obtain from patient and collaterals
– Changes in behavior
– Acute stressors
– Previous psychiatric diagnoses/treatment
• Neurologic symptoms
– Dizziness, syncope, disorientation, confusion, loss
of consciousness, headaches, difficulty with
speech/routine tasks
Emergency Psychiatric Evaluation
• Other medical comorbidities
– Fever, head trauma, HIV, exposure/ingestion of toxins
• Medication history: benzodiazepines, stimulants,
antipsychotics, anticonvulsants, anticholinergics,
steroids, β-blockers, fluoroquinolones, opioids,
salicylates, SSRIs, thiazide diuretics, antiparkinsonian
agents
• Drug history: alcohol, PCP, LSD, amphetamines,
cocaine, barbiturates
Emergency Psychiatric Evaluation
• Mini Mental Status Exam (MMSE)
• Complete physical exam
– Abnormal vital signs should not be ascribed to
stress/anxiety
– Trauma signs
– Neuro exam
• Laboratory investigations
– Minimally, urine toxicology and blood alcohol
Altered Mental Status
in the ED
Nicholas Cascone, PA-C
Delerium
• Transient disorder of attention and cognition
– Distortion of attention, perception, thinking,
memory
– Reduced alertness
– Activity level may increase or decrease
– Sleep/wake cycle disrupted – “sundowning”
– Psychosis may be present; hallucinations tend to
be visual
Delerium - Causes
• Infection: pneumonia, UTI, meningoencephalitis, sepsis
• Metabolic: hypoglycemia, electrolyte abnormalities, hepatic
encephalopathy, thyroid disorder
• Neurological: stroke/TIA, seizure/post-ictal state, SAH,
subdural hematoma, space-occupying lesion
• Cardiopulmonary: CHF, MI, PE, hypoxia
• Drug-related: drug/EtOH withdrawal, antihistamines,
antiparkinson agents, antiemetics, antidepressants,
antipsychotics, sedative-hypnotics, narcotic analgesics,
antispasmodics/muscle relaxants, digoxin
Delerium – evaluation
• History from collaterals
– Acute onset
– Fluctuating severity
– Exacerbation at night
• Medication history
– Medication side effects/toxicity can be observed in elderly
patients at normally safe doses
• Physical examination
– Directed at discovering underlying process
• Labs
– Electrolytes, LFTs, kidney function, urinalysis/tox,CXR
Delerium – Management
• Tx directed at underlying cause(s)
– Environment: adequate lighting, psychosocial
support, reduced stimulus
– Sedation to relieve agitation
– Majority of patients will be hospitalized
Dementia
• Memory and cognitive impairment of gradual
onset
– Early: memory loss, naming problems, forgetting
items
– Middle: loss of reading, loss of social skills,
spatial/direction problems
– Late: disorientation, loss of self-care, personality
changes
Dementia – causes
• Degenerative – Alzheimer’s, Huntington’s, Parkinson’s
• Vascular – multiple infarcts, hypoperfusion, subdural
hematoma, SAH
• Infectious – meningoencephalities, neurosyphilis
• Metabolic – B12/folate deficiency, thyroid disease, uremia
• Psychiatric – depression
• Inflammatory – SLE, demyelinating disease
• Neoplastic – primary tumors/metastasis, pareneoplastic
syndromes
• Other – trauma,toxins (EtOH, medications), hydrocephalus
Dementia – evaluation
• History from patient and collaterals
– Course of progression
• Acute onset of symptoms suggests reversible process
• Specific dates of worsening associated with vascular dementia
– Family history: some causes of dementia are inherited (e.g.,
Huntington’s)
• Physical exam
– Directed at associated causes – examples:
• Focal neurologic signs suggest vascular dementia or space-occupying
lesion
• Extrapyramidal signs suggest Parkinson’s
• Labs
– CBC, electrolytes, glucose, calcium, kidney function, LFTs, TFTs, B12
– CT/MRI
Dementia – treatment in ED
• Environmental/psychosocial interventions
• Antipsychotic medications for those with persistent
psychotic features or dangerous/extremely disruptive
behaviors
• Admission:
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Patients with superimposed delerium
Treatable causes of dementia
Comorbid medical problems
Rapid progression
Unsafe/uncertain home situation
Special Psychiatric Emergency
Presentations
Nicholas Cascone, PA-C
Emergencies related to
psych medications
• Antipsychotics side effects
– Akathisia responds to β-blocker therapy such as
propranolol
– Dystonia (torticollis, oculogyric crises, etc.) respond to
anticholinergics (e.g. benztropine, diphenhydramine)
– Parkinsonism requires dose reduction and anticholinergic
therapy as above
– Neuroleptic malignant syndrome: emergency presentation
with rigidity, fever, tachycardia, BP lability, and altered
mental status – discontinue antipsychotic and give
dantrolene or bromocriptine, hydration, supportive
treatment in intensive care setting
Emergencies related to
psych medications
• Benzodiazepines
– Used frequently in the ED for anxiolysis or sedation
• Anxiolytics: alprazolam (Xanax®), lorazepam (Ativan®), clonazepam
(Klonopin®)
• Longer-acting anxiolytics/mild sedatives: diazepam (Valium®),
chlordiazepoxide (Librium®)
• Sedative-hypnotics: temazepam (Restoril®), triazolam (Halcion®),
flurazepam (Dalmane®)
– Overdose is treated with flumazenil
– Paradoxical response requires discontinuation
Anorexia nervosa
• Dx by usual signs and symptoms
– BMI 16, < 85% of expected weight for height
– Unexplained primary amenorrhea
– Derangement of body image
• ED treatment:
– Volume repletion
– Correction of electrolytes
– Aggressive refeeding leads to hypertonic
dehydration, hypernatremia, pancreatitis
Anorexia nervosa
• Criteria for hospitalization:
– Weight loss of 30% or more in 3 months
– Severe metabolic disturbance
– Suicidality
– Failure to maintain outpatient weight contract
– Family crisis or denial
– Severe bingeing and purging
– Need to initiate therapy (psychotherapy, family
therapy, pharmacotherapy)
Panic attack
• Symptoms
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Palpitations/tachycardia
Chest pain/pressure
SOB/smothering
Diaphoresis
Tremor
Choking sensation/globus
Nausea/abdominal complaints
Dizziness/lightheadedness/syncope
Paresthesia
Chills/hot flashes
Fear of: going crazy, loss of control, dying, syncope
Derealization/depersonalization
Panic attack – medical differential
• Cardiovascular: angina, MI, MVP, PACs
• Pulmonary: angina, PE, hyperventilation
• Endocrine: hyperthyroid, hypoglycemia,
pheochromocytoma, Cushing’s
• Neurological: stroke/TIA, partial seizure, migraine,
Ménière’s
• Drugs/medications: caffeine, cocaine, thyroid meds,
SSRIs, cannabis, steroids, β-agonists, triptans,
nicotine, hallucinogens, anticholinergics
• Withdrawal syndromes: alcohol, barbiturates,
benzodiazepines, opiates
Panic attack – treatment
• In ED: benzodiazepines
• Referrals
– Psychotherapy – cognitive-behavioral
– Psychiatry
• SSRI
• Buspirone
• Short-term “bridging” benzodiazepines
Emergencies involving alcohol
• Trauma – assault, MVA, other injuries
– 25% of assaults involve alcohol
– 45% of fatal MVAs involve alcohol
– Head trauma often overlooked when presenting
with alcohol intoxication
• Obtain CT of head when:
– History of head injury
– No improvement in 3 hours
– Worsening of mental status while under observation
Emergencies involving alcohol
• Withdrawal
– Four steps of alcohol withdrawal
• 6 – 8 hours since last drink: autonomic hyperactivity –
tachycardia, diaphoresis, tremor
• 24 hours since last drink: tactile and visual
hallucinations
• 24 – 48 hours since last drink: motor seizures
• 3 – 5 days since last drink: delerium tremens – altered
mental status, convulsive seizures, 5 – 15% mortality
Emergencies involving alcohol
• Treatment of alcohol withdrawal
– Fluid resuscitation with D5NS or D5LR and thiamine (100
mg/L)
– Patient placed in a quiet area with minimal stimulation
– Lorazepam 2 – 4 mg IV q 15-30 minutes until light sedation
is achieved
– MgSO4: 4 g IV in 1 – 2 hours
– For pts with seizures:
• CT indicated if head trauma, focal seizure, persistent post-ictal
defect in consciousness
Emergencies involving alcohol
• Criteria for admission
– Medical complications such as CHF, infection
– More than 8 mg of lorazepam needed
• Referral for treatment of alcoholism
Tests for conversion disorder/ malingering
• Sensation
– Yes/no test: pt closes eyes and responds yes/no to touch
stimulus – “no” response favors conversion
– Bowlus & Currier test:
• pt extends crossed arms, thumbs down, palms touching,
interlocking fingers, arms then rotated towards chest
• False response to sensory stimulus difficult d/t distortion of
position
– “Strength” test: pt closes eyes and moves touched finger
to assess “strength”. True sensory loss would not allow pt
to determine which finger is being tested
Tests for conversion disorder/ malingering
• Pain
– Gray test of abdominal pain
• With psychological pain, pt closes eyes during palpation
• With organic pain, pt watches palpation so they can guard tender areas
• Motor
– Drop test: “paralyzed” extremity dropped from above the face will
miss it
– Thigh adductor test: examiner places hands against inner thighs of
patient. Pt is told to adduct normal leg against resistance. In
pseudoparalysis, other leg will also adduct
– Hoover test: examiner cups both heels of patient. Pt is told to elevate
normal leg. In pseudoparalysis, other leg will push downward. Pt is
told to elevate weak leg. Absence of downward pressure indicates
noncompliance.
Tests for conversion disorder/ malingering
• Coma
– Corneal reflexes retained in awake patient
• Seizure
– Resistance to covering of mouth & nose indicates
pseudoseizure
– Palpation of abdominal muscles reveals lack of contraction
in pseudoseizure
• Blindness
– Opticokinesis: tape with alternating black and white
sections pulled laterally in front of patient’s open eyes
induces nystagmus in patient with intact vision
Headache/Vertigo
in the ED
Nicholas Cascone, PA-C
Headache in the ED
• 4% of all ED visits are due to headache
– 4% of these headache visits have serious or
secondary pathology
• Objectives of evaluation:
– Appropriately select patients for emergency
investigation when critical secondary causes are
present
– Provide effective treatment for primary and
benign secondary headaches
Evaluation of Headache in ED
• History
– Pattern – worst ever, first severe, steady
worsening, differences from prior headaches
– Onset – sudden headaches that begin during
exertion – up to 25% of such HA are SAH
– Associated symptoms – dizziness, nausea,
confusion, LOC, fever, neck pain/stiffness, visual
changes, seizure
Evaluation of Headache in ED
• History (cont’d.)
– Medical history – trauma, previous lumbar
puncture, use of nitrates, MAOIs, exposure to
toxics (e.g., CO)
– Family history – migraines, SAH run in families
Evaluation of Headache in ED
• Physical examination
– Temperature, blood pressure
– Palpate sinuses, temporal artery,
temporomandibular joint
– Eye exam for acute glaucoma, fundoscopy for
signs of hypertension, papilledema
– Thorough neurological exam
• Labs
– CT scan, lumbar puncture if indicated
Killer Headaches
• Subarachnoid hemorrhage
– More common in women
– Severe, constant occipitonuchal HA, “worst in my
life”
– Often presents suddenly, with vomiting and
alteration of consciousness
– History may indicate activities which raise blood
pressure (e.g., intercourse, defecation, coughing)
Killer Headaches
• Subarachnoid hemorrhage (cont’d)
– Dx: plain CT 93% sensitivity within 24 h of onset
– If CT nondiagnostic, LP
• Xanthochromia on spectrophotometry nearly 100%
sensitive
• Naked-eye detection only 50% sensitive
– Tx: angiogram and surgery consult, nimodipine,
prohylactic phenytoin, antiemetics, decrease BP if
elevated
Killer Headaches
• Meningitis
– Occipitonuchal headache with fever, meningeal
signs, altered consciousness
– Dx: immediate LP in pts without neurological
signs, normal LOC and no papilledema
• If LP delayed and bacterial meningitis suspected,
initiate empiric antibiotic tx
Killer Headaches
• Subdural hematoma
– History of remote trauma with headache
– High risk patients:
• Anticoagulation
• Chronic alcoholics
• Elderly patients
– If plain CT nondiagnostic, contrast CT or MRI
– Tx: surgery consult
Killer Headaches
• Brain tumor
– Headache may be unilateral/bilateral,
intermittent/continuous
– Classic presentation is headache with vomiting,
worse upon arising
– Reliable pt with no neuro findings and no
papilledema can follow-up as outpatient within 24
hours (worst at night and awakens pt)
Other Headaches
• Secondary headaches
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Temporal arteritis
Acute glaucoma
Hypertensive headache
Sinusitis
Post-LP
Drug-related/toxic
• Primary headaches
– Migraine
– Cluster
– Tension
Vertigo
• Sensation of movement where none exists
• Peripheral causes vs. central causes – peripheral
causes usually benign, central causes can be urgent
– Peripheral vertigo: sudden onset, intense, paroxysmal,
aggravated by position/movement, associated with nausea
or hearing loss/tinnitus, horizontal nystagmus, fatiguable,
CNS signs absent
– Central vertigo: any onset, ill-defined, constant, variable
association with position/movement/nausea, not
associated with hearing loss/tinnitus, vertical nystagmus,
not fatiguable, CNS signs usually present
Vertigo – causes
• Peripheral causes
– BPPV, Ménière’s disease, labrynthitis, ototoxicity,
head injury
• Central causes
– Cerebellar stroke, VBI, MS, migraine, epilepsy,
neoplasm
• General causes
– Anemia, EtOH intoxication, hypoglycemia, renal
failure, thyroid disease
Vertigo - evaluation
• History
– Description of sensation – vertigo, syncope/near-syncope,
disequilibrium
– Onset
– Associated symptoms
• Peripheral associated with nausea/vomiting, tinnitus/hearing loss,
photophobia
• Central associated with diplopia, dysarthria, visual abnormalities
• Headache suggests migraine or space-occupying lesion
• Head trauma, medications
Vertigo - evaluation
• Physical exam
– Ear: otoscopy, hearing exam, Webber/Rinne
– Eye: nystagmus, EOMs
– Heart rate, rhythm, murmurs
– Cranial nerves
– Cerebellar testing
– Proprioception/vibration
– Test patients with near-syncope for orthostasis
Vertigo – evaluation
• Dix-Hallpike position testing: pt seated
upright, head turned 45° to right, swiftly
reclined with head tilted backward additional
45°; repeated with head turned to left
– Warn pt that test may produce vertigo
– Positive test indicated by nystagmus; positive side
is side with lesion
– Contraindicated in patients with carotid bruits,
cervical spondylosis
Vertigo – evaluation
• Labs
– Depend on suspected etiology
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Labrynthitis: CBC, blood culture
Head injury: CT for bleeding
Near-syncope: ECG, cardiac monitoring, CBC for anemia
Electrolytes, glucose, kidney function, thyroid
Vertigo – symptomatic treatment
• Pharmacotherapy
– Scopolamine
– Antihistamines – diphenhydramine (Benadryl®),
meclizine (Antivert®)
– Neuroleptics – metoclopramide (Reglan®),
promethazine (Phenergan®)
– Benzodiazepines for anxiety – diazepam (Valium®),
clonazepam (Klonopin®)
Seizures in the ED
Nicholas Cascone, PA-C
Seizures in the ED
• Episode of abnormal neurologic function
caused by inappropriate electrical discharge of
neurons
• 6 – 10% of individuals experience a seizure, 1
– 2% have recurrent seizures
• Peak incidence among age < 20, second peak
among age > 60
Classification of seizure
• Classification
– Partial: unilateral clonic/tonic movements, sensory
hallucinations (tactile, olfactory, gustatory), visual
symptoms
• Simple (no alteration of consciousness) vs. complex (loss of
consciousness)
– Generalized: loss of consciousness with or without motor
manifestations
• Tonic-clonic
• Absence
• Myoclonus and others
Seizure – evaluation
• History
– Aura, onset, duration, post-ictal condition
– If known epileptic: precipitants, medication Hx,
sleep Hx, infection
– If no previous history: head injury, headache,
drug/alcohol use/abuse
• Previous behaviors that may point to unrecognized
seizures: enuresis, blank spells, unexplained injury,
tongue biting
Seizure – evaluation
• Physical exam
– Injuries to head/spine
– Fractures, dislocations, bruising, tongue lacerations
– Neuro exam
• Labs
– Glucose, electrolytes, Ca, Mg, hCG, tox screen, UA for
rhabodmyolisis
– Wide anion gap metabolic (lactic) acidosis up to 1 hour
after event
– Anticonvulsant levels
– First seizure: non-contrast CT to rule out structural lesion
Seizure – treatment in ED
• Seizing patient – expectant management
– Clear area to prevent injury
– Turn to side to prevent aspiration
– After seizure, insure airway
• Patient with previous seizures:
– Eliminate precipitants
– Supplement anticonvulsant levels if necessary
Special cases
• Seizure in pregnancy
– Epilepsy in pregnancy: antiepileptics are potentially
teratogenic, but uncontrolled seizures also potentially
dangerous
• Risk to fetus minimized with single-drug therapy, folate and
vitamin K supplementation
– Eclampsia: seziures beyond 20 weeks, with HTN, edema,
proteinuria; may present with HA, blurry vision, epigastric
pain, hyperreflexia
• Manage with MgSO4, definitie treatment is delivery
Special cases
• Seizure associated with alcohol
– Missed doses of anticonvulsant, sleep deprivation,
propensity for head injury, toxic coingestions,
electrolyte derangement
– Seizures in alcohol withdrawal:
• No anticonvulsant if first seizure, benzodiazepines and
referral for detoxification
Special cases
• Status epilepticus
– More than 5 minutes of seizure activity
– 2 or more seizure episodes without full recovery of
consciousness between
• Management of SE
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Large-bore IV, intubation, O2
Dextrose, thiamine, magnesium if needed
IV lorazepam, then IV phenytoin
IV phenobarbital if phenytoin fails
General anesthesia with
midazolam/propofal/pentoparbital if phenobarbital fails
CNS Infection
Nicholas Cascone, PA-C
Meningitis
• Infection in subarachnoid space – bacterial,
viral, fungal
– Noninfectious meningitis from neoplastic, toxic,
autoimmune processes
• In ED, early suspicion and empiric treatment is
critical
• Pt presents with fever, HA, neck pain/stiffness,
photophobia, AMS
Meningitis – evaluation
• History
– Living conditions: barracks, dormitories, day care centers
– Head trauma/neurosurgery
– Immunocompromise: asplenism, steroids, HIV
• Examination
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Assess meningeal signs: Brudzinski, Kernig
Skin: petechial rash of N. meningitidis
Assess sinuses, ears for evidence of primary infection
Fundoscopy for papilledema
Neurological exam
Meningitis – evaluation
• Labs
– Lumbar puncture when safe
– CSF analysis:
• Bacterial: ↑↑ opening pressure, ↑↑ WBCs, ↑ PMNs,
↑ protein, ↓ glucose
• Viral: ↑ opening pressure, ↑ WBCs, normal PMNs,
normal protein, normal glucose
• Fungal: ↑↑ opening pressure, ↑ WBCs, normal PMNs,
↑ protein, ↓ glucose
Meningitis – management
• Initiate empiric antibiotic treatment – does
not affect results of LP if performed within 2
hours
– Neonates: ceftriaxone for S. pneumoniae and E.
coli
– Infants, children, adults: ceftriaxone and
vancomycin for S. pneumoniae and N. meningitidis
– Immunocompromised patients, adults over 50:
add ampicillin for L. monocytogenes
Meningitis – management
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Anti-inflammatory
Antipyretic
Monitor sodium to avoid SIADH
Phenytoin loading for seizures
Cerebral edema – elevate head, hyperventilate,
administer mannitol
• Chemoprophylaxis for close contacts of patients with
N. meningitidis or H. influenzae
– Rifampin, ceftriaxone or ciprofloxacin
Encephalitis
• Viral infection of brain parenchyma
– West Nile virus
– Arboviruses
– Rabies
• Presentation: meningeal signs with cognitive
deficit, seizure, psych symptoms, movement
disorder
• Patients should be admitted
Cerebrovascular Events
in the ED
Nicholas Cascone, PA-C
Cerebrovascular Events in the ED
• Stroke
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Interruption of blood supply to focal region of the brain
3rd leading cause of death in US
20% of stroke patients die within the first year
One-third of stroke patients are under the age of 65
Early diagnosis and treatment of patients arriving at ED
with stroke lessens impact of disease
Cerebrovascular Events in the ED
• Ischemic stroke syndromes
– Anterior cerebral artery: LE > UE weakness,
perseveration, motor slowing
– Middle cerebral artery: face/UE>LE, aphasia if in
dominant hemisphere, apraxia, homonymous
hemianopia
– Posterior cerebral artery: vision loss, paresthesia,
sensory loss, dizziness, N/V
– Cerebellar: “drop attack”, vertigo, HA, nausea,
neck pain, cranial nerve abnormalities
Evaluation of Stroke in the ED
• History
– Hx of HTN, CAD, DM suggests thrombotic stroke
– Hx of A fib, mechanical/replacement valves, MI
suggests embolic stroke
– TIAs: prior TIA in same vascular distribution
suggests thrombosis, multiple TIAs in different
distributions suggest embolism
Evaluation of Stroke in the ED
• History (cont’d)
– Onset: sudden (embolic or hemorrhagic) vs.
stuttering/waxing and waning (thrombotic or
hypoperfusion)
– Onset during straining/coughing suggests rupture of
aneurysm
– Associated complaints: HA (hemorrhagic), N/V, trauma
– Recent neck injury: MVA, chiropractic adjustment, sportsrelated suggests carotid dissection
Evaluation of Stroke in the ED
• Physical exam
– Temperature
– Skin signs of embolism (Janeway lesions, Osler
nodes), bleeding dyscrasias (petechiae,
ecchymosis)
– Fundoscopy (papilledema, hypertensive
retinopathy)
– Cardiopulmonary auscultation (S3, rales, carotid
bruits)
Evaluation of Stroke in the ED
• Labs
– Emergent non-contrast CT distinguishes
hemorrhagic stroke from ischemic
– EKG
– CBC, coagulation studies, type & screen,
electrolytes, glucose, toxicology, cardiac enzymes
Management of Stroke in the ED
• O2, elevate head, cardiac monitor, IV access
• Volume repletion, antipyretic
• Manage hypertension only if severe – higher
pressure may help save penumbra of stroke
• Secondary prevention: antiplatelet agent,
anticoagulation
Management of Stroke in the ED
• Thrombolytic treatment
– Contraindications
• Absolute: previous hemorrhagic stroke, any other
stroke in past year, suspected dissection, pericarditis,
intracranial tumor
• Relative: BP over 180/110, chronic severe hypertension,
age over 75, anticoagulation, trauma/internal bleeding
within 4 weeks, surgery within 3 weeks, peptic ulcer,
hemodynamically unstable, pregnant
Violence and
Suicide in the ED
Nicholas Cascone, PA-C
Violence in the ED
• 50% of all health care providers will be involved in violence
during their careers
• ED patients/collaterals are frequently fatigued, hungry,
frustrated, anxious, higher proportion of substance abuse
• 5% of patients presenting to the ED carry weapons
• Most perpetrators of violence in ED are males with Hx of
substance abuse
– Education, ethnicity, marital status, diagnosis are not reliable
predictors
• Factors predisposing ED to violence: long waiting times, staff
shortages, overcrowding, patient expectations, patient
financial problems
Violence in the ED
• Prodrome of violence:
– Phase 1: Anxiety
• Movement with no purpose other than to expend
energy
– Pacing, wringing of hands, clenching of fists, unwillingness to
stay in waiting/treatment area
• Loud, pressured speech
• Appropriate response: develop rapport, listen to and
address concerns
Violence in the ED
– Phase 2: Defensiveness
• Verbal abuse, profanity
– Directed towards staff or others in the department
– Statements regarding age, weight, heritage, gender
• Body posturing
• Appropriate response:
– Set simple, clear, enforceable and consistent limits
– Offer patient reasonable choices
– Isolate patient and provide show of force by uniformed
security personnel
Violence in the ED
– Phase 3: Physical Aggression
• Total loss of control
• Physical aggression directed towards staff or others in
the department
• Aggressive patients must be confronted and controlled
physically for the safety of themselves, other patients,
visitors and staff
– Requires personnel skilled in control techniques
– Should never be attempted by unskilled personnel or singlehandedly
Restraint in the ED
• Review your organization’s rules for restraint
• JCAHO policy:
– Only licensed independent practitioner (LIPs) can
order restraint
• Written order must include type of restraint, reason for
restraint, time limit for restraint
– If LIP is not available, restraint may be initiated by
caregivers but LIP must perform face-to-face
evaluation within 1 hour
Restraint in the ED
– Restrained patients must be evaluated q15min,
including examinations for:
•
•
•
•
•
•
•
•
Injury
Hydration/nutrition
Circulation/ROM
Vital signs
Hygiene/elimination
Comfort
Psychological status
Readiness for discontinuation of restraint
Restraint in the ED
– Reason for restraint must be explained to the
patient
– Patient in restraint should never be abandoned
– No patient who has been restrained should be
allowed to leave the ED AMA
– Patients brought to the ED in restraint should
remain in restraint until thoroughly assessed for
threat of violence and medical condition
Medical management
of violent behavior
• Used when patients are too violent, even
under restraint to perform adequate
evaluation
– Antipsychotics: haloperidol (Haldol®) 5 mg IM q3045min
– Benzodiazepines: lorazepam (Ativan®) 2-4 mg IM
q30min
– More effective when used in combination; more
rapid onset and fewer injections needed
Suicide
• Suicidality is associated with severe
depression, isolation, loss, stressful life events
• Providers’ negative attitudes towards those
who attempt suicide exacerbate patient risk
Risk of suicide
• High risk
– Male
– Separated/widowed
divorced
– Chaotic/conflictual
family, FHx of suicide
– Unemployed
– Recent conflict or loss
– Weak or no religious
suicide taboo
• Low risk
– Female
– Married
– Stable family
– Employed
– Stable relationships
– Strong religious taboo
against suicide
Risk of suicide
• High risk (cont’d)
– Acute/chronic illness
– Excessive drug/alcohol use
– Depression/bipolar/
schizophrenia/panic
– Disruptive behavior
– Helplessness/
hopelessness
– Frequent, intense, prolonged
suicidal ideation
• Low risk (cont’d)
–
–
–
–
–
Stable health
Little or no drug/alcohol use
No axis I mental disorders
Directable
Hopeful, future-oriented
– Infrequent, transient ideation
Risk of suicide
• High risk (con’td)
– Prior suicide attempts
– High-risk, dangerous
attempts
– Realistic plan
– Guilt regarding suicide
ideation
– Lack of concern
regarding attempts
– Social isolation
• Low risk (cont’d)
– No prior attempts
– Attempts with high
likelihood of rescue
– No plan
– Embarrassment
regarding ideation
– Insight regarding affect
on others
– Social integration
Markers for ongoing risk
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Psychosis
Hopelessness/helplessness
Exhaustion
Lack of anger/remorse/embarassment
History of prior attempts, especially high-risk
attempts
• Continuing intention to die
Criteria for discharge
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Medically stable
Pt agrees to return to ED if suicidal intent recurs
Not intoxicated, delerious, demented
Means of self-harm has been removed
Treatment of psychiatric diagnoses has been arranged
Acute precipitants of suicide have been addressed/resolved
Patient and family agrees to follow-through on treatment
Patient’s caregivers/family agrees to discharge plan
“No harm” contract has been established
• Document all criteria
• If in doubt, obtain psychiatric consult or hospitalize