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.

Podcast #304: Nostalgia

Author: Dylan Luyten, MD

Educational Pearls

  • Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation.

 

  • Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.

 

  • In the civil war, over 5000 soldiers were given medical leave for nostalgia.
  • Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.)

 

References

Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

Podcast #298: Seizures

Author: Sam Killian, M.D. 

Educational Pearls

  • The availability of antiepileptic treatment has changed in the last 30 years.
  • A recent study in JAMA followed 18,000 pts with epilepsy for 30 years to assess the effectiveness of looked at seizure control.
  • The study found that although there have been new drugs introduced over the last 30 years, there has not been much of an improvement in seizure control.
  • Side effect profiles and medicine compliance may have improved in this time period, but the main goal of reducing seizure frequency has not been reached.

References: Chen Z, Brodie MJ, Liew D, Kwan P. Treatment Outcomes in Patients with Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic DrugsA 30-Year Longitudinal Cohort Study. JAMA Neurol. Published online December 26, 2017. doi:10.1001/jamaneurol.2017.3949