Approach to Neurologic Emergencies

Indiana University School of Medicine

Emergency Medicine Clerkship

Objectives• From the IU EM Didactic Learning Objectives:

– 13. Discuss the differential diagnosis of patients presenting to the Emergency Department with altered mental status.

– 14. Identify the appropriate candidate for thrombolytic therapy in the Emergency Department.

– 36. Discuss the approach to the actively seizing patient, new onset seizure patient, chronic seizure patient, and the febrile seizure patient in the Emergency Department.

• NB: Febrile seizures not covered in this lecture; covered in Peds lecture

Case #1• You are working a late evening shift and

receive an EMS call– 94 year old female; unknown PMH– Normally A&O x3 at baseline; lives independently– Daughter called to “check in this evening” and had

no response– EMS found patient lying on floor, confused

Case #1• EMS glucose—146• The medic tells you that the patient’s pupils

were slightly sluggish, so he gave a dose of Narcan without any response

Coma Cocktail• Not routinely given, but considered• Glucose

– Check early and administer D50 if low • Consider empiric D50 if no meter available

• Naloxone (Narcan)– Reverses the effects of narcotics that may be affecting

mentation and or breathing• Use if patient apneic or suspect narcotic toxicity

– May precipitate withdrawal in chronic users• Thiamine

– Consider in alcoholics

• Does our patient have dementia or delirium?

Delirium DementiaOnset Sudden InsidiousCourse/day Fluctuating StableConsciousness ↓ / Clouded AlertAttention Abnormal NormalCognition Abnormal AbnormalOrientation Impaired Often impairedHallucinations Usu visual AbsentDelusions Transient AbsentMovements Asterixis/tremors Absent

Altered Mental Status-Differential Dx• A-Alcohol• E-Endocrine• I-Insulin- Diabetes• O-Oxygen and opiates• U-Uremia, hypertensive

encephalopathy

• T-trauma, temperature• I-infection• P-Psychiatric• S-Space occupying

lesion, stroke, subarachnoid hemorrhage, shock

Altered Mental Status-Differential Dx• Not all conditions listed on previous slide need

a test to rule them out• Use information obtained from history,

physical examination, family to narrow differential diagnosis and guide approach

Case #1• On arrival, the patient is awake and alert,

making moaning noises and not following commands well

• VS: P 86 BP 124/84 RR 24 T 100.8 Biox-84% on RA• Exam– Pupils 2 mm and reactive; no focal neurologic

weakness– Left lower lung rales

Vital Signs• Often provide clue to underlying etiology• Hypoxia- either as a cause of confusion or as a

result of hypoventilation because of neurologic insult– Needs to be rapidly recognized and treated

Vital Signs-continued• Hypotensive-shock

– May see tachycardia as well• Hypertensive- consider intracranial

hemorrhage• Fever

– Moves infectious etiologies higher on the list– Although some septic patients may be afebrile or

hypothermic

Altered Mental Status-Workup• Focus based on history and exam as possible

– Can be difficult especially when limited information present in H&P

• For our patient– CBC, BMP, ECG, U/A, CXR

Case #1• WBC 8,000• BMP WNL• ECG sinus tachycardia without ischemic

change• CXR next slide

Case #1

Case #1 Diagnosis• Community Acquired Pneumonia

– Causing hypoxia and resulting mental status changes

• Patient admitted for IV ATBx and oxygen therapy

Case #2• 75 year old male• Fell off ladder two days ago• Has been increasingly confused at home

Case #2• Vitals T 98.4 F BP 178/104 HR 72 RR 14 Biox

97%• Patient lying on the stretcher• Eyes closed, responds to voice• Speech confused• Moves all extremities spontaneously, follows

commands slowly

GCS• What’s his GCS score?

GCS• Glasgow Coma Scale• Minimum score = 3• Maximum score = 15• Assess eye opening, motor response, verbal

response

GCS-Mnemonic• Helps with maximum score in each category• Eyes- “Hey four eyes” (4)• Motor- “Six cylinder motor” (6)• Verbal- “Jackson Five” (5)

GCS-Eye Opening• 4-Spontaneously• 3-To Verbal• 2-To pain• 1-None

GCS-Best Verbal Response• 5- Oriented, converses• 4-Disoriented, confused• 3-Inappropriate words• 2-Incomprehensible sounds• 1-None

GCS-Best Motor Response• 6-Obeys commands• 5-Localizes pain• 4-withdraws to pain• 3-decorticate posturing• 2-decerebrate posturing• 1-none

Obtaining a History• In the altered patient, important to contact

family members, nursing staff at ECF, caregivers

• Review the EMR, look in wallet for alerts/medication lists

• They will often be the only potential history source and can provide crucial information

History-Altered Mental Status• Focus upon trying to find out their baseline• Recent illnesses?• New medications?• Ingestions/Polypharmacy?

Pupils-Altered Mental StatusGenerally preserved in metabolic causes– Unilateral dilated pupil in unresponsive patient

• Think uncal herniation secondary to bleed/space occupying lesion

Pupils-Altered Mental Status• Bilaterally fixed dilated pupils= anoxic injury• Pinpoint, nonreactive without systemic

response to Naloxone= pontine injury

Physical Exam-Altered Mental Status• Look for pallor (anemia), needle tracks (IVDU),

cyanosis (hypoxia)• Breath-smell for ETOH or ketones (fruity)• Head-look for abrasions, contusions,

craniotomy scars, shunts• Eyes-icterus, fundoscopic, gaze preference

Physical Exam-Altered Mental Status• Mouth-look for tongue lacerations (on the

sides) suggesting seizure• Neck-evaluate for meningismus; remember to

have a low threshold to immobilize the cervical spine if there is any question of trauma

• Lungs-wheezing or abnormal breath sounds; suggesting COPD leading to hypercarbia

Physical Exam-Altered Mental Status• Abdomen-ascites, stigmata of liver failure that

might tip you off to hepatic encephalopathy

Case #2• Concern for traumatic intracranial

hemorrhage given history of fall and new onset altered mental status

• CT obtained

Case #2

Case #2• Neurosurgery consulted• Patient admitted to NSICU

Case 3• 67 yo male brought in by ambulance with 2

hour history of right sided weakness and facial droop

• PMH: HTN, DM• VS: T: 36.3 BP: 130/80, HR: 90, SpO2: 99% on

RA

Case 3-Exam• Gen-awake, alert, GCS 15• PERRLA, EOMI, no nystagmus• Right facial droop; some slurring noted on

spontaneous speech• 4/5 strength RUE/RLE; remainder nonfocal• Follows commands well

Acute Stroke• #1 priority—is this patient a candidate for

thrombolytics?• Safe, effective administration of thrombolytics

is time and criteria dependent• Failure to follow time/criteria guidelines

increases the risk of iatrogenic intracranial bleed

Acute Stroke-Initial Priorities• Is this patient in the time window?

– 3-4.5 hours from symptom onset depending on institution (discussion to follow)

– Patients who went to bed normal and awoke with deficit-disqualified from consideration

– Priority-get patient quickly to CT to rule out ICH and remain within time window

Acute Stroke-Initial Priorities• Rule out other causes of neurologic findings

– ICH-Get head CT– Hypoglycemia-get finger stick glucose– Aortic dissection-assess for chest pain, abdominal

pain occurring with the neurologic symptoms– Obtain EKG to assess rhythm

Thrombolytics• Must weigh risks and benefits• Benefit: potential return of neurologic function• Risk: ICH, non CNS hemorrhage death, poor

functional outcome• Essential to discuss with patient, family, and

document this discussion• MUST apply current evidence and carefully apply

inclusion/exclusion criteria

Thrombolytics-Inclusion Criteria• Inclusion Criteria

– Age 18 or over– Clinical diagnosis of acute ischemic stroke causing

a measurable neurologic defect– Time of symptom onset well established to be less

than 180 minutes before treatment would begin• This excludes many patients as duration is

frequently longer than 3 hrs, includes time to obtain and read head CT

Thrombolytics-The evidence• Controversial

– study done by NINDS in 1995• NNT=9 for increase in normal function at 3 months• Significant Intracranial Hemorrhage rate about 6%

– NNH=15– Most with worse deficits than stroke

» About half of ICH fatal• Not reproduced outside of NINDS

– Until ECASS 3 published in 2008

NINDS study group 1995

Thrombolytics-ECASS 3• Prospective, randomized, double blind trial to

assess safety and efficacy of thrombolysis up to 4.5 hours from symptom onset– Higher rate of favorable outcome in treatment

group versus placebo (52% versus 45%)– Higher rate of ICH in treatment group (27% versus

17%)

Hacke et al 2008

Thrombolytics-ECASS 3• Thrombolytics less efficacious from 3-4.5

hours than from 0-3 hours– Odds ratio for favorable outcome

• 2.80 for 0-90 minutes• Only 1.40 for 3-4.5 hours

Hacke et al 2008

Thrombolytics-ECASS 3• ICH rate reported in study higher than original

NINDS trial

• Bottom line: From 3-4.5 hours, modest increase in improved functional outcome. Increase in intracranial hemorrhage risk

Hacke et al 2008

Case 3• Patient’s blood sugar normal, EKG is NSR, labs

drawn and patient sent for urgent head CT.• On return from head CT patients symptoms

have resolved– Normal motor function bilaterally on exam

• Head CT neg but defer on TPA as patients symptoms have resolved spontaneously.

• What is your next step?

Case 3-Diagnosis/Workup• TIA-transient ischemic attack• Patient needs Neurology consult

– Evaluation for reversible cause or stroke and risk factor modification

• Carotid us, MRI/MRA, Cardiac Echo– Frequently done as inpatient

• TIA patients at increased risk of stroke especially in the days after a TIA

• Can be done as outpatient if patients deficits have resolved and expedient workup can be arranged

TIA-Short Term Outcomes• JAMA study (2000)• 1707 TIA patients• Observed for rate of stroke, recurrent TIA,

cardiovascular events, death in 90 days after initial ED evaluation for diagnosis of TIA

Johnston et al 2000

TIA-Short Term Outcomes• 180 (10.5%) patients returned to ED with CVA• 91 of the CVAs occurred in the first 2 days

– Risk factors associated with risk of returning with CVA:

• Age >60 (odds ratio: 1.8)• Diabetes mellitus (OR: 2.0)• Symptom duration >10 minutes (OR: 2.3)• Weakness (OR: 1.9)• Speech disturbance (OR: 1.5) Johnston et al 2000

TIA Short Term Outcomes• Increased risk of CVA short term following TIA• Take risk factors into consideration when

making inpatient versus outpatient workup decision

Case 3-Treatment• Aspirin therapy

– Started on all patients with ischemic stroke or TIA• To prevent further stroke

• Platelet Aggregation– Clopidogrel, ticlopidine – Used in patients intolerant to ASA– Also in patients who have CVA while on ASA

Beware Stroke Mimics• Hypoglycemia• Todd’s Paralysis

– Post-ictal neurologic deficits• Complex Migraines• Conversion Disorder

Usually suspect given history and physical– Assume stroke if uncertain

Case 4• 22 year old female• Brought in by ambulance• Observed to have seizure like activity at home

and is now sleepy and confused• On arrival, the patient is sleepy, but opens her

eyes to voice, pushes away in response to pain• You note that she has urinated on herself

Case 4• VS: T: 36.3, HR 80, BP 120/80, RR 18, SpO2

100%• Finger stick blood glucose for EMS: 100• As you continue your assessment, the patient

begins having a generalized tonic clonic seizure

• What’s your next step?

Active Seizures-Treatment• First line-Benzodiazepines

– Lorazepam IV preferred agent– Lorazepam pediatric dose 0.1 mg/kg up to max of

1-2 mg per dose– Adults: Lorazepam 1-2 mg/dose, okay to repeat

every 1-3 minutes if seizures continue• Dosing ultimately limited by respiratory depression,

which can be managed with intubation if necessary

Active Seizures-Treatment• Supportive measures

– Ensure bed rails up, seizure pads (if available) in place

– Place supplemental oxygen (non rebreather) on patient

– Place oral/nasal airway as necessary to maintain patent airway

Active Seizures-Treatment• If no control despite multiple doses of benzos,

consider alternative agents– Fosphenytoin (18-20 PE/kg)– Phenobarbital (10-20 mg/kg)

– If you need to secure the patient’s airway, may need to involve neurology for EEG monitoring if the patient is paralyzed

Case 4• Seizure stops after 2 doses of lorazepam• The patient is maintaining her airway, and

appears postictal• The nurse asks you, “What are you going to do

to work her up?”

Seizure-Evaluation• Depth of workup depends upon whether or

not event is a first time seizure

First Time Seizure Workup• Electrolytes• CT of the head to evaluate for SAH, mass

lesion• Other tests dependent upon clinical scenario

– If suspicion for CNS infection, perform LP

First Time Seizure-Disposition• If no further seizure activity, returned to baseline and

competent caretaker with patient:– May return home with Neurology follow up

arranged– Will need outpatient MRI, EEG– No driving, no bathing/showering alone– Good dismissal instructions including reasons to

return

Breakthrough Seizure-Workup• Medication non compliance common-check

drug levels• Evaluate for infection• Check finger stick glucose• Most patients do not require neuroimaging

– Consider if long period of decreased LOC or other new focal neurologic finding

Breakthrough Seizure-Disposition• May be discharged home if neurologically

normal after postictal period and drug levels are within normal limits

References• NINDS study group. “Tissue plasminogen activator for acute

ischemic stroke”. New England Journal of Medicine. 333: 1581-1587.

• Hacke W et al. “Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke”. New England Journal of Medicine. 359: 1317-1329.

• Johnston SC et al. “Short-term prognosis after emergency department diagnosis of TIA”. JAMA. 284:2901-2906.