Podcast # 361: Vertiginous Dizziness

Author: Peter Bakes, MD

Educational Pearls:

  • Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.”
  • Differentiate central vs. peripheral vertigo
  • Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).
  • Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.
  • Episodic? BPPV or Meniere’s Disease. BPPV has not auditory symptoms and is associated with head position; Meniere’s has hearing loss, tinnitus, and ear fullness.
  • Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).

References

Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.

Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.

Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.

Podcast # 360: Epidural Abscess Screening

Author: Dylan Luyten, MD.

Educational Pearls:

  • Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
  • Young person with back pain needs to be evaluated for injection drug use (major risk factor).
  • Patient with focal neurologic deficits (FND) require an MRI.  Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
  • Treatment is IV antibiotics and surgical debridement.

References

Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

Podcast # 345: Epidural Abscess

Author: Sue Chilton, MD

Educational Pearls:

  • IV drug use and spinal procedures are major risk factors.
  • Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
  • MRSA is most common organism, but GNR and MSSA are also possible.

 

References

Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.

Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.

Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.

Podcast # 335: Blunt Head Trauma

Author: Peter Bakes, M.D.

Educational Pearls:

  • Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance.
  • Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.

 

References

Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9.

Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.

Podcast #333: TBI Prognosticators

Author: Michael Hunt, MD

Educational Pearls:

  • Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3.
  • Alternative scoring system is the GCS-P score which is GCS score – number of non-reactive pupils.
  • GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months.
  • GCS-P score is a better prognostic indicator than GCS score.

 

References:

Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52.

Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma.  24(2):232-8.

The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.

Check out this episode!

Podcast # 329: Hypokalemic Periodic Paralysis

Author: Dylan Luyten , MD

Educational Pearls:

  • Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
  • Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
  • Supplemental potassium can rapidly reverse symptoms.
  • Important to rule out thyrotoxicosis (get a TSH!).
  • Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

 

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

Podcast #321: Migraine Treatment in ED

Author: Jared Scott, M.D.

Educational Pearls:

  • Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED.
  • Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid.
  • Compazine + Benadryl is a superior migraine treatment than Dilaudid.

References:

Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082

Podcast #318: Nystagmus

Author: Erik Verzemnieks, M.D. 

Educational Pearls:

-Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication

-Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates)

-If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources

References:
Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. ?Annals of

Neurology.? 4(5):471-3.
Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive

alcohol intake. ?Journal of Clinical Neuroophthalmology?. 7(1):23-5.

Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. ?Journal of Emergency Medicine.? 18(4):447-51.

Podcast #312: SCIWORA

Author: Sam Killian, M.D.

Educational Pearls:

  • Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.
  • Term was established in  1970’s before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.
  • Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.
  • Treatment involves prolonged immobilization (up to 12 weeks).

 

References:

Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) ? Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

Podcast #311: Recurrence of Seizures in Pediatrics

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Recurrence rate for first time unprovoked seizures – 5% after 48 hours, 14% at 2 weeks , 30% after 4 months.
  • Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation.
  • Useful for counseling patients and recommending follow up.

References:

Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.