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


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


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/


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


Podcast #168: GSW with Neurogenic Shock

9f97856c-43b7-48c2-8b2f-b915b1ba4316Run Time:  4 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Some of the main causes of hypotension in a trauma patient are hypovolemia, hemorrhagic shock, tension pneumothorax, and cardiac injury (including pericardial effusion). However; a patient with a gunshot wound presents to the ED with a SBP in the 90s, a HR in the 120s, 300mL of fluid from the chest tube, and on a dopamine drip, which is unusual for a trauma patient.
  • After a neurologic exam was performed on the patient, the patient was unable to move his lower extremities. The patient was sent to CT scan which showed that the bullet traversed from the right clavicle to the T12 vertebral body.
  • Another cause of shock in a trauma patient is Neurogenic shock, where the spinal cord loses sympathetic tone causing the blood vessels to dilate.
  • Treatment of neurogenic shock is different than other causes of shock in trauma. Usually early IV fluids and vasopressors are used for blood pressure support until the sympathetic nervous system responds. Classically Levophed is used, but other patients may respond better to other vasopressors.
  • Neurogenic shock is a diagnosis of exclusion. Other causes of traumatic shock that need more aggressive treatment should be considered first before jumping to treating neurogenic shock.

Link to Podcast:  http://medicalminute.madewithopinion.com/gsw-with-neurogenic-shock/#

References: http://www.jems.com/articles/print/volume-39/issue-11/features/assessment-and-treatment-spinal-cord-inj.html


Podcast #166: Subdural Hematoma

00c86def-a234-422b-a345-2431643f87c8Run Time: 6 minutes

Author: Peter Bakes M.D.

Educational Pearls:

  • There are 3 layers of tissue between skull and brain – the dura which is adhered to the skull, the arachnoid, and the pia which is adhered to the brain.
  • There are bridging veins between the pia-arachnoid space, when these rupture the blood accumulates under the dura between the arachnoid space, usually in the temporal lobe, but can occur anywhere, resulting in a subdural hematoma.
  • Acute SDH: manifests as a hyperintense on imaging in the first 2 days, and manifests as an isodense from 2-14 days.
  • Chronic SDH: greater than 14 days manifest as hypodense.
  • Any SDH greater than 5mm is considered for surgical intervention if the patient is symptomatic, and any SDH greater than 10mm or with significant midline shift, regardless of symptoms are surgically treated.
  • A craniotomy (remove skull and put it back) is performed to evacuate the hematoma.
  • A craniectomy (remove skull and don’t put it back) is performed if the patient has underlying tissue damage and expected interval swelling.
  • Chronic SDH are only treated with trephination (poke a hole in it) if the patient is significantly symptomatic, in case there is a future need to perform a craniotomy.

Link to Podcast: http://medicalminute.madewithopinion.com/subdural-hematoma/

References: http://neurosurgery.ucla.edu/acute-subdural-hematomas