Podcast #259: Transient Ischemic Attacks

Author: Peter Bakes, M.D.

Educational Pearls

  • A TIA is defined as focal neurological deficit that resolves within 24 hours and has negative imaging. The etiology is a transient thrombus, embolus, or narrowing of a branch of a cerebral artery.
  • Screening tests are generally negative and low-yield. MRI and vascular imaging are usually done to look for reversible causes.
  • Patients presenting with TIA are usually admitted because of a higher risk for stroke. However, there are some patients that are low-risk and do not require admission. Risk can be assessed using the “ABCD” mnemonic: Age>60, BP (history of HTN), Clinical presentation (area of deficit), Diabetes/Duration of symptoms. See reference link for scoring sheet.
  • Patients with a low enough score may be eligible for outpatient follow-up.

References: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID

Podcast #241: Sphenopalatine Nerve Block

Author: Don Stader, M.D.

Educational Pearls

  • Cluster headaches are usually intense, unilateral,  and involve the periorbital area..
  • CN V (Trigeminal) provides sensory and autonomic innervation the face and eyes, which play roles in headache pathology.
  • Cluster headaches can be treated with high flow oxygen, but a new treatment involves blocking the sphenopalatine ganglion (SPG) with lidocaine. Because sensory and autonomic branches of the trigeminal traverse the SPG, lidocaine will effectively treat a cluster headache.
  • To block the ganglion, intranasal lidocaine may be used, or a Q-tip soaked in 4% lidocaine can be applied to the most posterior aspect of the pharynx for 10-15 minutes.

References: https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

Podcast #230: Concussive Treatment

Author: Aaron Lessen, M.D.

Educational Pearls

  • 2 studies this past year looked at pediatric and adolescent patients following a concussion. They found people who returned to activity sooner did better than those who went on “brain rest”.  
  • While patients should still follow up with their PCP following a concussion, it is ok for patients to return to physical activity as tolerated.

References: Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux A, Osmond MH, Zemek R, for the Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396

Podcast #214: Dizziness

Author: Aaron Lessen, M.D.

Educational Pearls:

  • We can differentiate vertigo into benign problems such as vestibular problem (peripheral problem), or something more worrisome that originates in the brain (central problem).
  • Dizziness + other symptoms makes us think about origination in the CNS.  Symptoms include Dizziness, Diplopia, Dysarthria, Dysphagia, Dysmetria.

References:  http://www.medicalnewstoday.com/knowledge/160900/vertigo-causes-symptoms-treatments

http://www.mayoclinic.org/diseases-conditions/dizziness/basics/causes/con-20023004

Podcast #200: Non-traumatic Back Pain

Author: Don Stader M.D.

Educational Pearls:

  • Non-traumatic back pain is a very common complaint in the Emergency Department.
  • Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer.
  • Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright.

References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

 

Podcast #194: Atruamatic ICH

Author: Peter Bakes, M.D

Educational Pearls

  • Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles.
  • Subarachnoid aneurysm causes about 50% of all ICH.
  • Amyloid deposition can lead to ICH in elderly patients.
  • Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology.
  • ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH.
  • CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor.
  • Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is <140 systolic. Monitor ICP if patient has AMS. Neurosurgical intervention is indicated when there is significant expansion of the hematoma with AMS or if the bleed is cerebellar.

References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Podcast #191: Blunt Cervical Trauma

Author: Chris Holmes M.D.

Educational Pearls:

  • Mechanism of injury involves hyperextension/hyperflexion
  • Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
  • Neurologic deficit is common.
  • Other risk factors include facial fracture and cervical-spine fracture.
  • Treat with anticoagulation – aspirin or other antiplatelet agents are appropriate.
  • Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

 

Podcast #183: Ventriculoperitoneal Pediatric Shunt Malfunctions

345df232-fab3-44fb-a6fb-b85042e5b19dRun Time:  1:56

Author: Dr. Iverson

Educational Pearls:

  • Placement of a VP shunt is associated with premature delivery, hydrocephalus, or some other kind of injury as a means of draining excess CSF
  • A malfunctioning VP shunt presents with vomiting, headache, altered mental status
  • Workup includes the “shunt series”: xrays, head CT/rapid MRI
  • In rapid MRI, need to take into consideration whether the VP shunt is programmable because the MRI could erase the programming
  • Special attention needs to be given to patients that present with increased ICP.  You can give these patients 3% saline as a bridging measure but they need to be taken to the OR as soon as possible.

Link to Podcast: http://medicalminute.madewithopinion.com/pediatric-vp-shunt-malfunction/

References: http://www.healthline.com/health/ventriculoperitoneal-shunt

https://www.youtube.com/watch?v=Yb9dSjDykpI

Podcast #179: Concussions

b3a1b8b3-ea78-4c07-bbc8-8db303511de8Run Time: 1 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Patients with concussions are frequently seen in the ED, and generally are given good home health care precautions.
  • A new study for post concussion management looked at driving performance after a concussion.
  • The study showed that 48 hours after symptoms had resolved, patients who were diagnosed with a concussion did worse on a standard performance test than people without a concussion.

Link to Podcast: http://medicalminute.madewithopinion.com/concussions/

References: http://psycnet.apa.org/journals/neu/24/4/493/

http://emedicine.medscape.com/article/92095-overview

Podcast #172: CPSSS

fc67e872-002b-4713-931e-7f8a76b41e3cRun Time:  3 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • The most recent data on value on interventional neuroradiology suggests that the patients who receive the most benefit from neuroradiology are those with a large vessel occlusion, and can have up to 50% reduction in mortality.
  • The question is for EMS, when should you bypass other hospitals to go directly to a comprehensive stroke center with neuroradiology.
  • The CPSSS – Cincinnati prehospital stroke severity score – is an augmentation of the Cincinnati prehospital stroke scale to help identify a large vessel occlusion.
  • CPSSS is a 4 point score: 2 – eye deviation, 1- abnormal LOC, 1 – arm drift.
  • A score of 2 or more is 80% sensitivity for a large vessel occlusion. However the specificity is not of this scale is not as good.
  • There is a large push to standardize the CPSSS to allow EMS to bypass other hospitals in order to get to comprehensive stroke center.

Link to Podcast: http://medicalminute.madewithopinion.com/cpsss/

References: http://stroke.ahajournals.org/content/46/6/1508.short

http://jnis.bmj.com/content/early/2016/02/17/neurintsurg-2015-012131.full.pdf