UMEM Educational Pearls - By Danya Khoujah

Category: Neurology

Title: All this is giving me a headache!

Keywords: analgesia, headache, opioids (PubMed Search)

Posted: 6/26/2019 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Primary headaches (not secondary to a life-threatening disease) can be challenging to manage. Remember the following pearls:

  • Things that DO NOT work: IV fluids, 5-HT3 Antagonists (aka Zofran), diphenhydramine (aka Benadryl), opioids

  • Things that KINDA work: oxygen for all headaches, sphenopalatine ganglion block (4% lido spray) 

  • Things that REALLY work: ketorolac, metoclopramide, prochlorperazine, triptans and ergots, oxygen for cluster headaches
  • Things that PREVENT recurrence: dexamethasone for migraine headaches 


Category: Neurology

Title: Cervical Spine Disease

Keywords: MRI, neuro exam, bladder, gait (PubMed Search)

Posted: 4/24/2019 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Cervical spondylotic disease is the most common cause of myelopathy in patients over the age of 55 years and accounts for 25% of all hospitalizations for spastic quadriparesis.
It can be confused with lumbar spine disease as the most common presentation is a slowly progressive spastic gait dysfunction with 15-20% presenting with bladder disturbance.

Take Home Message: Don’t rush to localizing a lesion to the lumbar spine without performing a thorough neuro exam. 

Show References


Elderly patients (mean age of 84 years) living in the community who are seen and discharged from the Emergency Department due to illness or injury are at increased risk for further disability and functional decline for at least six months after their visit.  This is associated with increased mortality, cost and need for long term care in previously self-functioning individuals. *   When appropriate to discharge from the ED, we should consider discharge planning that includes coordination with care management services to be sure these individuals have adequate home support systems in place and access to close outpatient follow-up. 

*It should be noted that the risk is even greater after inpatient hospitalization.

Show References


Category: Neurology

Title: Cauda Equina - How Good is the H&P?

Keywords: spinal cord, physical exam, assessment (PubMed Search)

Posted: 2/28/2019 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Back pain with lower extremity symptoms can be concerning for cauda equina. Some pointers regarding the H&P:

  • Symptoms develop within less than 24 hours in 90% of patients
  • Urinary retention develops before incontinence, but up to 30% of patients will have neither.
  • Saddle anesthesia or hypoesthesia is present in 81% of patients. Perineal numbness may be patchy, mild, and unilateral initially, making it difficult to elicit.

None of these symptoms independently predicts cauda equina syndrome with an accuracy greater than 65%.

Bottom Line: do not depend on any one finding to reliably exclude or confirm cauda equina.

Show References


Yes.

Serum creatinine decreases with age with the decrease in lean body mass. However, the number of functioning glemeruli and kidney function decrease with age as well, making the creatinine an unreliable indicator of renal function in older adults.

The solution? Calculate the creatinine clearance (CrCl) (or GFR) for a more accurate assessment of the renal function. You can use simple equations such as the Cockroft-Gault equation which incorporate the body weight and age.

CrCl (mL/min) =      (140-age) x lean body weight (kg)   x (0.85 if female) 

                                      serum creatinine (mg/dL) x 72

 

Show References


Takeaways

Intravenous (IV) thrombolytics for stroke remain a controversial topic for emergency medicine (EM) physicians, with numerous editorials and articles questioning the strength of the recommendations by the AHA in 2018. Nevertheless, it is prudent for the emergency medicine provider to be aware that administration of IV tPA is a Level I recommendation in any stroke patient with a time of onset (or last known normal) up to 4.5 hours in patients with no contraindications. Clinical judgement should always direct care, and documentation for deviation from the guidelines (if any) should be done.

Show More In-Depth Information

Show References


Category: Neurology

Title: Seeing Double?

Keywords: diplopia, imaging, radiology, CT, ophthalmology (PubMed Search)

Posted: 11/28/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:

 

Clinical Situation

Suspected Diagnosis

Imaging Study

Diplopia + cerebellar signs and symptoms

Brainstem pathology

MRI brain

6th CN palsy + papilledema

Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)

CT/CTV brain

3rd CN palsy (especially involving the pupil)

Compressive lesion (aneurysm of posterior communicating or internal carotid artery)

CT/CTA brain

Diplopia + thyroid disease + decreased visual acuity

Optic nerve compression

CT orbits

Intranuclear ophthalmoplegia

Multiple sclerosis

MRI brain

Diplopia + facial or head trauma

Fracture causing CN disruption

CT head (dry)

Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis

Unilateral, decreased visual acuity

Orbital apex pathology

CT orbits with contrast

Uni- or bi-lateral, normal visual acuity

Cavernous sinus thrombosis

CT/CTV brain

C.N.: cranial nerve

 

Show References


Category: Neurology

Title: Neurosyphilis

Keywords: CSF, lumbar puncture, infectious diseases (PubMed Search)

Posted: 10/24/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.

Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:

1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results

2. positive CSF VDRL OR positive CSF FTA-ABS test result 

3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)

4. clinical symptoms

This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.  

Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.

 

Show References


Category: Neurology

Title: Must transverse myelitis be symmetrical?

Keywords: weakness, sensory symptoms, MRI, LP (PubMed Search)

Posted: 9/26/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Although transverse myelitis classically presents with bilateral and symmetric symptoms, it may be “partial” - symptoms would be asymmetric, or specific only to particular anatomic tracts.
In patients with risk factors (e.g. recent infection, history of autoimmune disease or cancer) and subacute ascending weakness/sensory symptoms, perform a thorough neurological exam, and obtain a gadolinium-enhanced MRI of the entire spine and/or lumbar puncture if you suspect transverse myelitis. 

Show References


Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.

1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.

2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.

This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.

 

Show References


Category: Neurology

Title: Weakness.. and a rash?

Keywords: shingles, weakness, infection (PubMed Search)

Posted: 8/22/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

In patients presenting with acute weakness of the limb or trunk, be sure to ask about history of shingles or rash. They may have segmental zoster paresis.

Patients may develop weakness in a myotomal distribution similar to the dermatomal sensory symptoms and rash. However, weakness may develop up to 4 weeks after the rash, making the connection between the two presentations less apparent. 

Show References


Category: Geriatrics

Title: Where Can I Find a Hearing Amplifier in my ED? (By Dr. Lauren Southerland)

Keywords: HoH, stethoscope, trick of the trade (PubMed Search)

Posted: 8/5/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Is your older patient hard of hearing (HoH)? Instead of shouting, get a stethoscope. Put the ear buds in your patient's ears and talk into the bell. It is a hearing amplifier you carry with you.

Bonus pearl: If you use the disposable stethoscopes, then the patient can keep it in their room and use it whenever anyone wants to talk to them.


Category: Neurology

Title: An ischemic stroke.. of the spinal cord?

Keywords: infarct, paralysis, numbness (PubMed Search)

Posted: 7/25/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

An infarct of the spinal cord is technically considered a stroke

The most common risk factor is a recent aortic surgery. Can also occur with straining and lifting (rare)

Patients will present with symptoms of spinal cord involvement with a hyperacute onset (less than 4 hours)

Although the “classic” presentation is anterior cord syndrome (flaccid paralysis, dissociated sensory loss (pinprick and temperature), preserved dorsal column function), patients may present with loss of all functions below the level of infarct due to spinal shock, confusing the clinical picture.

The most common level is T10

Show References


Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.


Category: Neurology

Title: Can my patient with dementia refuse treatment?

Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)

Posted: 6/27/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:

  • communicate a consistent choice

  • understand (and express) the risks, benefits, alternatives and consequences

  • appreciate how the information applies to the particular situation

  • reason through the choices to make a decision

There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry. 

 

BONUS PEARLS:

 

 

  • Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time

  •  

  •  

  • Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.  

Show References


Category: Geriatrics

Title: What is a fever, really?

Keywords: fever, infection, physiology (PubMed Search)

Posted: 6/3/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Older patients are less likely than their younger counterparts to mount a fever in response to an infection. One explanation is that their basal temperature is lower. Some experts suggest redefining fever in older patients to match this decrease of 0.15C per decade. Therefore, your 80 year old patient would be considered “febrile” if their temperature is above 37.3C, rather than the traditional 38C.

Show References


Category: Neurology

Title: Lhermitte's Sign

Keywords: myelopathy, myelitis, physical exam (PubMed Search)

Posted: 5/23/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Lhermitte’s phenomenon is as a sign of cervical spinal cord demyelination. It is considered positive if flexion of the neck causes a tingling sensation moving down the limbs or trunk, and may be reported as a symptom or elicited as a sign. This is due to stretching of the dorsal column sensory fibers, the commonest cause of which is multiple sclerosis. Other causes include other myelopathies, such as B12 deficiency, radiation and toxic (due to chemotherapy) or idiopathic myelitis. Its sensitivity is low at 16%, but its specificity for myelopathy is high at 97%.

Show References


Category: Geriatrics

Title: Pneumonia in the Elderly (Submitted by Dr. Amal Mattu)

Keywords: pneumonia, infection, delirium, atypical (PubMed Search)

Posted: 5/6/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

- Half of elderly patients presenting with pneumonia will manifest signs of delirium

- Tachypnea is the most reliable and earliest vital sign abnormality

- Classic symptoms are not often helpful at predicting severity of illness

- Symptoms are unreliable

- Cough (63-84%)

- Dyspnea (58-74%)

- Fever by history (53-60%)

- Fever at arrival (12-32%)

- Pleuritic chest pain (8-32%)

- Sputum (30-65%)

Show References


Category: Geriatrics

Title: Do POLSTs Really Change What We Do? (Submitted by Dr Liz Clayborne)

Keywords: palliative, advance directive, end-of-life (PubMed Search)

Posted: 4/1/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

25% of U.S. health care spending goes to the 6% of people who die every year. ICUs account for 20% of all health care costs. A new study has shown that patients with POLST (Physician Orders for Life-Sustaining Treatments) forms are less likely to receive unwanted life sustaining treatments when compared to patients with traditional Do-Not-Resuscitate orders (http://www.ohsu.edu/polst/). Using the POLST did not impact the degree of comfort care received for symptom management and helped individuals make more informed choices about the type and level of end-of-life care they wish to receive.

Show References


Category: Neurology

Title: Atypical Stroke Symptoms

Keywords: stroke, altered mental status, gender, sex, confusion (PubMed Search)

Posted: 3/28/2018 by Danya Khoujah, MBBS (Updated: 12/7/2019)
Click here to contact Danya Khoujah, MBBS

Patients may present atypically with ischemic strokes, reporting symptoms such as face or hemibody pain, lightheadedness, mental status change, headache and non-neurological symptoms.

Up to 25% of patients will have these symptoms.

Women are more likely than men to present with these atypical (or “nontraditional”) symptoms, especially altered mental status.

Show References