WikEM - User contributions [en]

Bronchiolitis (peds)

2015-10-22T04:49:31Z

Jlcunningham:

==Background==
*<2yr old (peak 2-6mo age)
*Respiratory Syncytial Virus (RSV) causes ~70% of cases<ref>Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.</ref>
*Preemies, neonates, congenital heart dz are at risk for serious disease
*Peaks in winter
*Duration = 7-14d (worst during days 3-5)
*Inflammation, edema, and epithelial necrosis of bronchioles

==Clinical Features==
*Symptoms
**Rhinorrhea, cough, irritability, apnea (neonates)
*Signs
**Tachypnea, cyanosis, wheezing, retractions
**[[Fever]] is usually low-grade or absent
***If high-grade fever consider [[Otitis Media]], [[UTI]]
*Assess for dehydration (tachypnea may interfere with feeding)

==Differential Diagnosis==
*[[Asthma]]
*[[Croup]]
*[[PNA]]
*[[Foreign body]]
*[[Pertusis]]
*[[CHF]]
*Cystic fibrosis
*Vascular ring

==Diagnosis==
*Rapid RSV
**Obtain if <1mo old
**If positive then admit

*CXR
**Not routinely necessary
***May lead to unnecessary use of[[ antibiotics]] (atelectais mimics infiltrate)
**Consider if
***Diagnosis unclear
***Critically ill

===Concurrent infection risk===
''Infants <60 days with RSV bronchiolitis and fever''
*Low risk of bacteremia and [[meningitis]] in RSV+, still appreciable [[UTI]] risk
**[[UTI]] 5.4% in RSV+, 10.1% RSV-
**Bacteremia 1.1% RSV+, 2.3% RSV-
**[[Meningitis]] 0% RSV+, 0.9% RSV-

==Treatment==
===[[Oxygen]]===
*The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitis<ref name="AAP guides">Ralston S. et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 134(5) Nov. 2014. 1474 -e150 doi: 10.1542/peds.2014-2742 [http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.full.pdf+html PDF]</ref>

*O2 (maintain SaO2 >90%)
**oxygen saturation alone should not dictate admission<ref>Schuh S. et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637</ref>

===Suctioning===
*Nasopharyngeal suctioning may temporarily relieve symptoms
*The use of routine “deep” suctioning may lead to increased length of stay based on one small study <ref name="AAP guides"></ref>
There is insufficient data to make a recommendation about suctioning.

===Hypertonic Saline===
AAP recommends as a possible intervention, but SABRE trial found no change in discharge or adverse events with nebulised HS.<ref>Everard ML, Hind D, Ugonna K, et al. SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax. 2014;69(12):1105–1112. doi:10.1136/thoraxjnl-2014-205953.</ref>
*Only consider administer to infants who require hospitalization<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]]))
**Suction nares / nasal saline drops

===Not Indicated===
''Randomized controlled trials of bronchodilater or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.''<ref>Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.</ref><ref>Geelhoed GC. et al. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ. 1996;313:140-142</ref><ref>Ralston S. et al. Randomized, placebo-controlled trial of albuterol and epinephrine at equipotent beta-2 agonist doses in acute bronchiolitis. Pediatr Pulmonol. 2005;40:292-299</ref>
*[[Albuterol]]/bronchodialater ([[Evidence_Based_Recommendation_Levels|Class B]])<ref name="AAP guides"></ref>
*Racemic [[Epinephrine]] ([[Evidence_Based_Recommendation_Levels|Class B]])<ref name="AAP guides"></ref>
*Steroids<ref name="AAP guides"></ref><ref>Corneli HM, Zorc JJ, Mahajan P, et al; Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Net- work (PECARN). A multicenter, random- ized, controlled trial of dexamethasone for bronchiolitis [published correction appears in N Engl J Med 2008;359(18): 1972]. N Engl J Med. 2007;357(4):331–339</ref>

==Disposition==
===Consider Admission===
*Age <3months
*Preterm (<34wks)
*Underlying heart/lung disease
*Initial SaO2 <90%
**Sa02 alone should not be used as the only factor for admission<ref>Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.</ref>
*Unable to tolerate PO

===Consider Discharge===
*Conventional treatment used (epi, dex) and no rebound stridor in 2h<ref>Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.</ref><ref>Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.</ref>

==See Also==
*[[Croup]]

==References==
<references/>
[[Category:Peds]] [[Category:Pulm]]
[[Category:ID]] [[Category:Featured]]

Epiglottitis

2014-07-25T20:23:33Z

Jlcunningham:

==Background==
*Otolaryngologic emergency
**Can lead to rapid onset of life-threatening airway obstruction
*Most cases are seen in adults (since advent of H. flu vaccine)
*Etiology
**Strep, staph, H. flu (unvaccinated)
**Caustic burns

==Clinical Features==
*Three D's:
**Drooling
**Dysphagia
**Distress
*Pain with gentle palpation of larynx and upper trachea
*Stridor
*Respiratory distress

==Diagnosis==
*Bedside nasopharyngoscopy for direct visualization
*Imaging only required if diagnosis uncertain
*Lateral neck x-ray
**Obliteration of vallecula
**Edema of prevertebral and retropharyngeal soft tissues
**"Thumb sign" (enlarged epiglottis)

==Treatment==
*Emergent ENT consult
*O2 (humidified)
*IVF (hydration minimizes crusting in the airway)
*Nebulized [[Epinephrine]] to reduce edema
===Antibiotics===
;Empiric coverage for Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae
*[[Ceftriaxone]] 2gm IV is first line
**Consider [[Vancomycin]] in patients at risk for [[MRSA]]<ref>Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.</ref>

===Steroids===
[[Methylprednisolone]] 125mg IV

===Airway Managment<ref>Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72</ref>===
*First line therapy is fiberoptic [[Intubation]]
*Preparation should be made for simultaneous [[Cricothyrotomy|cricothyrotomy]] incase intubation fails

==Disposition==
*Admit with ENT notification

==Source==
*Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. Aug 2008;122(8):818-23
<references/>
[[Category:Peds]]
[[Category:ID]]
[[Category:ENT]]
[[Airway/Resus]]

Bacterial tracheitis

2014-07-25T20:18:49Z

Jlcunningham:

== Background ==
#Bacterial infection of tracheal epithelium
##Often secondary infection after viral illness
##S. Aureus most common, also strep spp, H. Influenza and anaerobes
#Peak age is 3-5 years old
##Occurs throughout childhood and adulthood

== Diagnosis ==
#Severely ill child, starts out as viral prodrome
##Followed by stridor, resp distress, and copious purulent secretions
#Difficult to differentiate from croup and epiglottis
##Severe decompensation, high fever, purulent secretions help differentiate
##May also have concomitant pneumonia

== Workup ==
#Clinical diagnosis
#XR neck may show subglottic narrowing with ragged tracheal epithelium
#CXR may show concominant [[Pneumonia]]
#Emergent bronchoscopy is diagnostic and therapeutic

== Treatment ==
#Intubation, emergent, usually necessary
#Bronchoscopy to confirm dx, rule out supraglottic pathology
#Antibiotics
##third gen cephalosporin and vanco/clinda

== Disposition ==
#ICU admit
#Often require prolong intubation, 4-5 days

== Source ==
Rosen

[[Category:Peds]]
[[Category:ID]]
[[Category:Airway/Resus]]
[[Category:Pulm]]

Amebiasis

2014-07-25T20:16:20Z

Jlcunningham:

==Background==
* Fecal oral transmission of Entamoeba histolytica cyst
* Excystation in intestinal lumen
* Trophozoites adhere and colonizes large intestine forming new cysts or invade the intestinal mucosa to cause colitis or abscesses
* Liver abscess-10x more common in men
==Clinical Features==
* Asymptomatic vs. dysentery vs. extraintestinal abscesses
* Intestinal- several weeks of crampy abdominal pain, weight loss, watery or bloody diarrhea
* Liver abscess-fever, cough, RUQ or epigastric pain, right-sided pleural pain or referred shoulder pain +/- GI upset
** Hepatomegaly with tenderness over the liver a typical finding
**Abscess rupture can involve associated peritoneum, pericardium, or pleural cavity
* Extrahepatic amebic abscesses in the lung, brain, and skin are rare

==Differential Diagnosis==
===Dysentery===
*Infectious- Shigella, Salmonella, Campylobacter, E.Coli.
*Noninfectious- Inflammatory bowel disease, ischemic colitis, diverticulitis, AV malformation.
===Liver abscess===
*Pyogenic liver abscess, necrotic hepatoma, Echinococcal cyst
==Workup==
*CBC
*Chem
*LFT
*Stool or abscess microscopy
*Stool, serum, or abscess fluid antigen
*Indirect hemagluttination (antibody)
==Management==
===Asymptomatic colonization===
*Paromomycin or Diloxanide
===Colitis===
*Flagyl
===Liver abscess===
*Flagyl, Tinidazole, Paromomycin, or Diloxanide
*Consider drainage of abscess if no response to abx in 5 days, abscess >5cm or left lobe involvement
==Disposition==
*Home if no complications
==Sources==
*Haque R, Huston C, Hughes M, Houpt E, Petri, W. ''Amebiasis''. N Engl J Med 2003; 348:1565-1573
[[Category:ID]]
[[Category:TropMed]]
[[Category:GI]]

Acute rheumatic fever

2014-07-25T20:14:01Z

Jlcunningham:

==Background==
*Primarily affects school age children 2-6wk after strep pharyngitis
*Connective tissue of heart, joints, CNS, subq tissues are targeted by immune reaction

==Diagnosis==
Modified Jones Criteria (1992) for Acute Rheumatic Fever

REQUIRE: 2 major or 1 major and 2 minor criteria and evidence of previous GAS pharyngitis.

#Major diagnostic criteria
##Carditis
###New or changing murmur, cardiomegaly, CHF, pericarditis
##Migratory polyarthritis
##Chorea
##Subcutaneous nodules
##Erythema marginatum
#Minor diagnostic criteria
##Fever
##Arthralgia
##History of previous attack of rheumatic fever
##Prolonged PR interval
##Elevated ESR, CRP
#Evidence of preceding streptococcal infection
##Increased ASO or other strep ab
##Positive throat culture for Group A strep
##Positive rapid GAS
##Recent scarlet fever

==Symptoms==
*Polyarthritis
**Most common symptom (75%)
**Migratory, fleeting polyarticular arthritis primarily affecting large joints
*Carditis (33%)
**Most serious complication and second most common
***New murmur, pericardial rub, CHF
*[[Chorea]] (10%)
**May appear months following strep infection, may be sole manifestation of RF
*Erythema marginatum
**Persists only for several days
**Usually coexists with presence of carditis in some form
**Nonpruritic, located on trunk and proximal limbs, never on face
*Nodules
**Located on extensor surfaces of wrists, elbows, knees

==DDX==
#JIA
#[[Septic Arthritis]]
#[[Kawasaki Disease]]
#Viral or other forms of cardiomyopathy
#Leukemia
#Vasculitis ([[HSP]], drug reaction)
#[[Hip Pain (Peds)]]

==Work-Up==
#CBC
#ECG
#CXR
#ESR, CRP

==Treatment==
*Penicillin
**Indicated for all pts w/ rheumatic fever even if cx for strep is negative
**600K units IM if <27 kg
**1.2 million units IM if >27 kg
**Penicillin V PO x10d
**Prophylaxis
***5yr if no cardiac involvement, lifetime if cardiac involvement
***Pen G IM q month or oral penicillin daily
**Erythromycin x10d if pen allergic
*Arthritis
**High-dose aspirin therapy (75-100 mg/kg/d)
*Carditis
**Prednisone 1-2mg/kg/d
*Chorea
**Haloperidol 0.01-0.03 mg/kg/d in four divided doses

==Disposition==
*Admit for confirmation of diagnosis

==Source ==
Tintinalli

[[Category:Peds]]
[[Category:ID]]
[[Category:Cards]]

Endocarditis

2014-07-25T19:21:31Z

Jlcunningham:

==Background==
*Consider in pts w/ unexplained fever and known risk factors
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Noninfectious vegetations can arise in pts w/ malignancy and SLE
*S. aureus is single most common cause
*Blood cultures are falsely negative ~5% (think HACEK organisms)
*Only 20% have an increase in a known murmur and only 48% have a new murmur<ref name="Hoen">Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 [http://www.cardioaragon.es/web/pdf/InfectiveEndocarditisNEJM2013.pdf PDF]</ref>

===Prophylaxis===
*No longer recommended at all in the United Kingdom<ref>Wilson W. et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):e376-e377.</ref>
*In United States, only recommended for ''Invasive dental procedures'' not routine cleanings and: <ref>Richey R, Wray D, Stokes T. Prophy- laxis against infective endocarditis: sum- mary of NICE guidance. BMJ 2008;336: 770-1.</ref>
#Prosthetic valves
#Prior endocarditis
#unrepaired congenital cyanotic heart disease

==Risk Factors==
#IVDA
##Tricuspid valve most commonly affected
#Prosthetic heart valve
#Structural heart disease
##Rheumatic heart disease
##Mitral valve prolapse
##Bicuspid aortic valve
#Hemodialysis
#HIV infection

==Clinical Features==
*Fever
**Present in almost all cases
*Heart murmur
**Preexisting murmur found in 85% of cases; new murmur only found in 5%
*CHF
**Acute or progressive (70%)
*Embolization manifestations
**CNS
***MCA stroke
***Central retinal artery occlusion
**Pulmonary
***PNA
***Empyema
**Cardiac
***MI
***Myocarditis
**Bowel, renal, splenic infarcts
**Derm
***Osler nodes, splinter hemorrhages, Janeway lesions

==Diagnosis==
Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED. Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.<ref>Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9</ref>

===Modified Duke Criteria<ref>Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.</ref>===
*2 major criteria OR
*1 major and 3 minor criteria OR
*5 minor criteria
===Major Criteria===
# Positive blood culture with typical IE microorganism, defined as one of the following:
#* Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
#** [[Streptococcus viridans|Viridans-group streptococci]], or
#** ''[[Streptococcus bovis]]'' including nutritional variant strains, or
#** [[HACEK]] group, or
#** ''[[Staphylococcus aureus]]'', or
#** Community-acquired ''[[Enterococci]]'', in the absence of a primary focus
#* Microorganisms consistent with IE from persistently positive blood cultures defined as:
#** Two positive cultures of blood samples drawn >12 hours apart, or
#** All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
#** ''[[Coxiella burnetii]]'' detected byone positive blood culture or IgG
# Evidence of endocardial involvement with positive echocardiogram defined as:
#* Valvular mass or supporting structures or
#* Abscess, or
#* New disruption of a prosthetic valve or new valvular regurgitation

===Minor Criteria===
# Predisposing factor: known cardiac lesion, recreational drug injection
# Fever >38°C
# Evidence of emboli: arterial emboli,pulmonary infarcts, [[Eponyms_(F-L)#Janeway_lesions|Janeway lesions]], conjunctival hemorrhage
# [[Glomerulonephritis]], [[Eponyms_(M-P)#Osler.27s_nodes|Osler's nodes]]
# Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection

==Work-Up==
#Blood culture (from 3 separate sites)<ref name="cultures">Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:
3546 – 3548</ref>
#CBC
##Staphylococcal endocarditis: Leukocytosis +/- thrombocytopenia
##Subacute endocarditis: WBC may be normal or elevated
#UA
##Hematuria
#ESR
##Elevated in >90% of cases
#ECG
##Ischemia, heart block
#CXR
##Pulmonary emboli, CHF
#[[Ultrasound: Cardiac|Ultrasound]]
##Obtain as soon as possible
##TEE may be required for:
###Prosthetic valves
###Difficulty obtaining clear TTE images (obesity, COPD)
###High clinical probability of endocarditis

==Management==
;Initial stabilization should focus on Airway, Breathing and Circulation optimization with early antibiotic and blood cultures
===[[CHF]]/[[Cardiogenic Shock]]===
*Often due to valve failure, rupture, or a new defect.
===[[Pulmonary edema]]===
*Often due to mitral or aortic valve rupture causing severe regurgitation
*Focus on after-load reduction
===Respiratory Failure (emboli)===
*Often requires intubation with failure either due to [[CHF]] or [[Pneumonia]]
*Multi-lobar pneumonia suggests a tricuspid or pulmonary valve lesion with emboli to lungs
==[[Antibiotics]]==
*Start after 3 sets of blood cultures are obtained (if possible)<ref name="cultures"></ref>
''Therapy should be based on:''
#''Whether the patient has received prior antibiotic therapy''
#''Prosthetic valves''
#''Local antibiotic resistance patterns or knowledge of prior endocarditis cultures''
#''Prior hospitalizations and risk of MRSA''

{{Endocarditis_Empiric_Antibiotics}}

==Disposition==
Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:<ref name="Hoen"></ref>
#New Heart failure suspected due to severe regurgitation
#Cardiogenic Shock
#Echocardiography demonstrating a new fistula

==Complications==
===Cardiac===
#[[Congestive Heart Failure (CHF)|Heart Failure]]
#*Most common cause of death due to IE
# Perivalvular Abscess
===Embolic===
#[[CVA]]
#Blindness
#Painful, ischemic extremities
#Unusual pain sydromes (due to splenic or renal infarction)
#Hypoxia
# MI
===Neurologic===
#[[CVA|Embolic stroke]]
#Acute encephalopathy
#[[Meningitis|Meningoencephalitis]]
#Purulent or aseptic meningitis
#Cerebral hemorrhage
#[[Seizure]]
#Spinal Abscess
===Renal===
#Infarction
#[[Glomerulonephritis]]
===Musculoskeletal===
#[[Osteomyelitis|Vertebral osteomyelitis]]

==External Links==
*[http://www.mdcalc.com/duke-criteria-for-infective-endocarditis/ MDCalc - Duke Criteria]

==Source==
<references/>

[[Category:ID]] [[Category:Cards]]

Stridor

2014-07-25T19:20:19Z

Jlcunningham:

==Intial Work-Up==
*Assess stability of airway
**If unstable, see [[Difficult Airway Algorithm]], see [[Intubation]] and consider surgical intervention/consultation
**If stable consider imaging with video laryngoscope [[GEMC:Airway Procedures]]
***CT of neck can be considered if mass/infection suspected but not dynamic like laryngoscope

==Differential Diagnosis==
===Trauma===
#[[Neck Trauma|Larynx fracture]]
#Tracheobronchial tear/injury
#Thyroid gland injury/trauma
#Trachea injury
#Electromagnetic, Physics, trauma, [[Radiation_Exposure_(Disaster)#Treatment|Radiation Causes]]
#[[Burns|Burns]], inhalation
===Infectious Disorders===
#Bacterial tracheitis
#[[Diphtheria]]
#Tetanus
#Tracheobronchial [[Tuberculosis]]
#Poliomyelitis, paralytic, bulbar
#Poliomyelitis, acute
#Fungal Laryngitis
===Abscesses===
#Abscess, parapharyngeal
#[[Epiglottitis]], acute
#Peritonsillar abscess
#Laryngotracheobronchitis, acute
#[[Retropharyngeal Abscess]]
===Neoplastic Disorders===
#Neoplasms/tumors
===Allergic and Auto-Immune Disorders===
#[[Croup]], spasmodic/tracheobronchitis
#[[Angioedema]]/Angioneurotic edema
===Metabolic, Storage Disorders===
#Cerebral Gaucher's of infants (acute)
#Tracheobronchial amyloidosis
===Biochemical Disorders===
#Tetany
===Congenital, Developmental Disorders===
#[[Angioedema]]/Angioneurotic edema, hereditary
===Psychiatric Disorders===
#Somatization disorder
===Anatomical or Mecanical===
#Foreign Body Aspiration
#Acute gastric acid/aspiration syndrome
##Airway obstruction
##Neck compartment hemorrhage/hematoma
===Vegetative, Autonomic, Endocrine Disorders===
#Esophageal free reflux/GERD syndrome
#Laryngospasm, acute
##Bilateral vocal cord paralysis
#Hypoparathyroidism
===Poisoning===
##Smoke inhalation
##[[Caustics|Chemical burn/esophagus]]

==See Also==
[[Stridor (Peds)]]

[[Category:Airway/Resus]]

[[Category:ENT]]

Benign paroxysmal positional vertigo

2014-07-25T19:02:49Z

Jlcunningham:

==Background==
*Due to canalolithiasis (migration of otoconia into one of the semicircular canals)
*Mean age is mid-50s; women are twice as likely to be affected as men
*Mean duration is 2 weeks

==Clinical Features==
*Sudden-onset vertigo and associated nystagmus precipitated by head movements
**Latency period <30s between provocative head position and onset of nystagmus
**Intensity of nystagmus increases to a peak before slowly resolving
**Duration of vertigo and nystagmus ranges from 5–40s
**Repeated head positioning causes vertigo and nystagmus to fatigue and subside
**Nystagmus reverses direction during the head down and head up portions of Dix-Hallpike
*[[Nausea/vomiting]] common
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*No associated hearing loss or tinnitus
*MUST distinguish from central vertigo. See [[Vertigo#HINTS Exam|HINTS Exam]], See [[Stroke syndromes]], See [[Cerebellar stroke]]

==DDX==
See [[Vertigo#DDX|Vertigo]]

==Diagnosis==
===Dix-Hallpike Maneuver===
*50-85% Sensitive for BPPV<ref>Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81</ref>
*Contraindications:<ref>Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.</ref>
*#Concern for [[Cervical Artery Dissection]]
*#Cerebrovascular disease
*#Concern for vertebrobasilar insufficiency, See [[Stroke syndromes]]
*#Spinal injury
*#Cervical spondylosis

====Procedure====
#Patient sits upright
#Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
#Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
#Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.
#'''A positive test for BPPV is evidenced by the rotational nystagmus
##fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground

===Epley Maneuver<ref>Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews </ref>===
#The Epley begins after the last step of the Dix Hallpike
#The patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
#The patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
##Maintain the 20 degree neck extension
#Keep the head and neck in a fixed position while the patient rolls onto their opposite shoulder. The patient is now looking downwards at a 45 degree angle.
#Keep the patient in the new position for 1 minute.
#Finally bring the patient up to sitting while holding the head in 45 degree rotation.

*Repeat the Epley up to 3 times

==Treatment==
*Epley maneuver:
**Dix-Hallpike maneuver plus additional maneuvers to replace the migrated otolith
**Each step should be done slowly (about 30s)
**May require multiple attempts, but you can d/c pt home with daily exercises
**See link below for YouTube How-To videos
*Medical management:
**Antihistamines
***Diphenhydramine (Benadryl) 25-50mg IM/IV/PO q4hr
***Meclizine (Antivert, Antrizine, Dramamine) 25mg PO QID
***Promethazine (Phenergan, Anergan, Prorex) 12.5-25mg PO/IM/IV q4-6hr
**Anticholinergic
***Scopolamine transdermal patch 0.5mg (behind ear) QID
**Benzodiazepines
***Lorazepam (Ativan), diazepam (Valium) or Klonopin (Clonazepam)
===Epley Maneuver===
[[File:Epley.jpg]]

==Disposition==
*Refer pts w/ persistent symptoms to ENT

==See Also==
*[[Vertigo]]
*[[Dizziness]]
*[[Cerebellar Stroke]]
*[[Vertigo#HINTS Exam|HINTS Exam]]

==Source==
*How to do Epley Manuever: http://www.youtube.com/watch?v=7ZgUx9G0uEs
*Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation: http://www.youtube.com/watch?v=eOuzUi5ckrk

<references/>
[[Category:ENT]]
[[Category:Neuro]]

Acute calculous cholecystitis

2014-07-25T18:51:00Z

Jlcunningham:

==Clinical Features==
*Upper abdominal pain (esp RUQ)
**Not necessarily related to meals or fatty food intolerance
*N/V, fever

==Diagnosis==
#Local Signs
##RUQ tenderness
##Murphy Sign
###Highest positive LR of any clinical finding or lab value
#Sysemtic signs
##Fever
##Leukocytosis
#Imaging
##[[Ultrasound: Gallbladder]]
###Gallstones
####Distinguish by characteristic "shadowing"
####Better seen with patient in left lateral decub
###GB wall thickening (>3mm)
####May also be seen w/ pancreatitis, ascites, heart failure, alcoholic hepatitis
###Pericholecystic fluid
###Sonographic Murphy's Sign (PPV 92%)
####May be absent in pts w/ DM, gangrenous cholecystitis
##CT
###Useful when US results are equivocal

==Treatment==
#Antibiotics
##Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
##Cefotaxime + metronidazole OR piperacillin/tazobactam OR ampicillin-sulbactam OR Cefoxitin
###Bacteria: Gm negative (75%), gm positive (15%), anaerobes (8%)
#Surgical consultation

==Disposition==
*Admit

==Complications==
#Gangrene
##Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
##Consider if pt presents with sepsis in addition to cholecystitis
#Perforation
##Occurs in 2% after development of gangrene
##Usually localized, leading to pericholecystic abscess
#Gallstone Ileus
##Due to cholecystoenteric fistula
#Emphysematous cholecystitis
##Due to secondary infection of GB by gas-forming organisms (C. perfringens)
##Presents like cholecystitis but often progresses to sepsis and gangrene
##IV abx and cholecystectomy are essential
##Ultrasound report may mistake GB wall gas for bowel gas
##Mortality as high as 15% due to gangrene or perforation
#Mirizzi Syndrome
##Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
##Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
##Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
###US and CT can usually delineate the fistula
##Treatment = open cholecystectomy
#Gallstone Ileus
##Bowel obstruction due to impaction of gallstone at terminal ileum
###Gallstone enters small bowel through biliary-duodenal fistula
##Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

==See Also==
*[[Gallbladder Disease (Main)]]
*[[Cholangitis]]
*[[Symptomatic Cholelithiasis]]

==Source==
*UpToDate
*Tintinalli

[[Category:GI]]
[[Category:ID]]

Acute calculous cholecystitis

2014-07-25T18:45:57Z

Jlcunningham:

==Clinical Features==
*Upper abdominal pain (esp RUQ)
**Not necessarily related to meals or fatty food intolerance
*N/V, fever

==Diagnosis==
#Local Signs
##RUQ tenderness
##Murphy Sign
###Highest positive LR of any clinical finding or lab value
#Sysemtic signs
##Fever
##Leukocytosis
#Imaging
##[[Ultrasound: Gallbladder]]
###Gallstones
####Distinguish by characteristic "shadowing"
####Better seen with patient in left lateral decub
###GB wall thickening (>3mm)
####May also be seen w/ pancreatitis, ascites, heart failure, alcoholic hepatitis
###Pericholecystic fluid
###Sonographic Murphy's Sign (PPV 92%)
####May be absent in pts w/ DM, gangrenous cholecystitis
##CT
###Useful when US results are equivocal

==Treatment==
#Antibiotics
##Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
##Cefotaxime + metronidazole OR piperacillin/tazobactam OR ampicillin-sulbactam OR Cefoxitin
###Bacteria: Gm negative (75%), gm positive (15%), anaerobes (8%)

==Disposition==
*Admit

==Complications==
#Gangrene
##Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
##Consider if pt presents with sepsis in addition to cholecystitis
#Perforation
##Occurs in 2% after development of gangrene
##Usually localized, leading to pericholecystic abscess
#Gallstone Ileus
##Due to cholecystoenteric fistula
#Emphysematous cholecystitis
##Due to secondary infection of GB by gas-forming organisms (C. perfringens)
##Presents like cholecystitis but often progresses to sepsis and gangrene
##IV abx and cholecystectomy are essential
##Ultrasound report may mistake GB wall gas for bowel gas
##Mortality as high as 15% due to gangrene or perforation
#Mirizzi Syndrome
##Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
##Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
##Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
###US and CT can usually delineate the fistula
##Treatment = open cholecystectomy
#Gallstone Ileus
##Bowel obstruction due to impaction of gallstone at terminal ileum
###Gallstone enters small bowel through biliary-duodenal fistula
##Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

==See Also==
*[[Gallbladder Disease (Main)]]
*[[Cholangitis]]
*[[Symptomatic Cholelithiasis]]

==Source==
*UpToDate
*Tintinalli

[[Category:GI]]
[[Category:ID]]

Acute calculous cholecystitis

2014-07-25T18:45:40Z

Jlcunningham:

==Clinical Features==
*Upper abdominal pain (esp RUQ)
**Not necessarily related to meals or fatty food intolerance
*N/V, fever

==Diagnosis==
#Local Signs
##RUQ tenderness
##Murphy Sign
###Highest positive LR of any clinical finding or lab value
#Sysemtic signs
##Fever
##Leukocytosis
#Imaging
##[[Ultrasound: Gallbladder]]
###Gallstones
####Distinguish by characteristic "shadowing"
####Better seen with patient in left lateral decub
###GB wall thickening (>3mm)
####May also be seen w/ pancreatitis, ascites, heart failure, alcoholic hepatitis
###Pericholecystic fluid
###Sonographic Murphy's Sign (PPV 92%)
####May be absent in pts w/ DM, gangrenous cholecystitis
##CT
###Useful when US results are equivocal

==Treatment==
#Antibiotics
##Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
##Cefotaxime + metronidazole OR piperacillin/tazobactam OR ampicillin-sulbactam OR Cofoxitin
###Bacteria: Gm negative (75%), gm positive (15%), anaerobes (8%)

==Disposition==
*Admit

==Complications==
#Gangrene
##Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
##Consider if pt presents with sepsis in addition to cholecystitis
#Perforation
##Occurs in 2% after development of gangrene
##Usually localized, leading to pericholecystic abscess
#Gallstone Ileus
##Due to cholecystoenteric fistula
#Emphysematous cholecystitis
##Due to secondary infection of GB by gas-forming organisms (C. perfringens)
##Presents like cholecystitis but often progresses to sepsis and gangrene
##IV abx and cholecystectomy are essential
##Ultrasound report may mistake GB wall gas for bowel gas
##Mortality as high as 15% due to gangrene or perforation
#Mirizzi Syndrome
##Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
##Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
##Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
###US and CT can usually delineate the fistula
##Treatment = open cholecystectomy
#Gallstone Ileus
##Bowel obstruction due to impaction of gallstone at terminal ileum
###Gallstone enters small bowel through biliary-duodenal fistula
##Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

==See Also==
*[[Gallbladder Disease (Main)]]
*[[Cholangitis]]
*[[Symptomatic Cholelithiasis]]

==Source==
*UpToDate
*Tintinalli

[[Category:GI]]
[[Category:ID]]

Acute respiratory distress syndrome

2014-07-25T08:44:20Z

Jlcunningham:

==Background==
*Non-cardiogenic pulmonary edema due to lung capillary endothelial injury
**Proteinaceous material accumulate in alveoli in a heterogeneous manner
*Symptom of an underlying disease

==Clinical Features==
*'''Diagnostic criteria'''<ref>Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>
#New onset respiratory symptoms
#Bilateral pulmonary opacities
#Symptoms not explained by cardiac etiology or volume overload

{{Table
|type = class="wikitable"
|title= ARDS Classifications
|hdrs= PaO2/FIO2 ratio !! Severity
|row1= 200-300{{!!}} Mild
|row2 = 100-200 {{!!}} Moderate
|row3 = < 100 {{!!}} Severe
}}

*'''Presentation'''
**Severe dyspnea
**Hypoxemia
**Diffuse crackles
*'''Imaging'''
**Diffuse patchy pulmonary infiltrates
*'''Causes'''
**[[Sepsis]]
**[[Pancreatitis]]
**[[Burns]]
**Aspiration
**Trauma
**[[Submersion Injuries (Drowning)|Near drowning]]
**Fat embolism
**[[Amniotic Fluid Embolus|Amniotic fluid embolism]]

==Differential Diagnosis==
*[[CHF]]
*[[Pneumonia]]
*[[PE]]
*Diffuse alveolar hemorrhage
*[[DIC]]

==Workup==
*CXR
*CBC
*Chem 10
*UA
*LFT
*Lipase
*PT/PTT
*Influenza (seasonal)
*Blood cultures
*Lactate
*Consider bedside echo
*Consider ABG/VBG
*Consider BNP

==Management==
*Treat underlying cause
**Cover for sepsis
***Pneumonia in addition to other identified source
**Tamiflu 75mg BID oral or NGT if influenza season <ref>http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm</ref>
*Supplemental O2
*[[Noninvasive Ventilation|Noninvasive ventilation]]
**Limited data to support use
*[[Ventilation (Main)|Ventilator Settings]]
**Permissive hypercapnia
**Tidal volume 6-8cc/kg of [http://www.mdcalc.com/ideal-body-weight/ ideal body weight]<ref>Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.</ref>
***Limit barotrauma to healthy area of lung
***Increase PEEP to improve oxygenation
****Ardsnet PEEP/FiO2 [http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf/ protocol card]<ref>Kallet RH, et al. "Respiratory controversies in the critical care setting. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults?" Respiratory Care. 2007. 52(4):461-75.</ref>
**Maintain plateau pressures < 30 <ref>Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14</ref>
**Ensure adequate sedation
***Better synchrony with vent
***Decreased oxygen consumption
***Less [[delirium]]
***Increased patient comfort
**Prone ventilation
***Preliminary data suggests prone positioning may increase survival
***Consider for refractory hypoxemia

==Disposition==
* Admit to ICU

==See Also==
*[[Pulmonary edema]]
*[[CHF]]
*[[EBQ:ARDSnet Trial]]

==Sources==
<references/>

[[Category:Pulm]][[Category:Critical Care]][[Category:Airway/Resus]]

Acute respiratory distress syndrome

2014-07-25T08:42:31Z

Jlcunningham:

Acute respiratory distress syndrome

2014-07-25T08:40:18Z

Jlcunningham: /* Management */

==Background==
*Non-cardiogenic pulmonary edema due to lung capillary endothelial injury
**Proteinaceous material accumulate in alveoli in a heterogeneous manner
*Symptom of an underlying disease

==Clinical Features==
*'''Diagnostic criteria'''<ref>Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>
#New onset respiratory symptoms
#Bilateral pulmonary opacities
#Symptoms not explained by cardiac etiology or volume overload

{{Table
|type = class="wikitable"
|title= ARDS Classifications
|hdrs= PaO2/FIO2 ratio !! Severity
|row1= 200-300{{!!}} Mild
|row2 = 100-200 {{!!}} Moderate
|row3 = < 100 {{!!}} Severe
}}

*'''Presentation'''
**Severe dyspnea
**Hypoxemia
**Diffuse crackles
*'''Imaging'''
**Diffuse patchy pulmonary infiltrates
*'''Causes'''
**[[Sepsis]]
**[[Pancreatitis]]
**[[Burns]]
**Aspiration
**Trauma
**[[Submersion Injuries (Drowning)|Near drowning]]
**Fat embolism
**[[Amniotic Fluid Embolus|Amniotic fluid embolism]]

==Differential Diagnosis==
*[[CHF]]
*[[Pneumonia]]
*[[PE]]
*Diffuse alveolar hemorrhage
*[[DIC]]

==Workup==
*CXR
*CBC
*Chem 10
*UA
*LFT
*Lipase
*PT/PTT
*Influenza (seasonal)
*Blood cultures
*Lactate
*Consider bedside echo
*Consider ABG/VBG
*Consider BNP

==Management==
*Treat underlying cause
**Cover for sepsis
***Pneumonia in addition to other identified source
**Tamiflu 75mg BID oral or NGT if influenza season <ref>http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm</ref>
*Supplemental O2
*[[Noninvasive Ventilation|Noninvasive ventilation]]
**Limited data to support use
*[[Ventilation (Main)|Ventilator Settings]]
**Permissive hypercapnia
**Tidal volume 6-8cc/kg of [http://www.mdcalc.com/ideal-body-weight/ ideal body weight]<ref>Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.</ref>
***Limit barotrauma to healthy area of lung
***Increase PEEP to improve oxygenation
****Ardsnet PEEP/FiO2 protocol card [http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf]<ref>Kallet RH, et al. "Respiratory controversies in the critical care setting. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults?" Respiratory Care. 2007. 52(4):461-75.</ref>
**Maintain plateau pressures < 30 <ref>Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14</ref>
**Ensure adequate sedation
***Better synchrony with vent
***Decreased oxygen consumption
***Less [[delirium]]
***Increased patient comfort
**Prone ventilation
***Preliminary data suggests prone positioning may increase survival
***Consider for refractory hypoxemia

==Disposition==
* Admit to ICU

==See Also==
*[[Pulmonary edema]]
*[[CHF]]
*[[EBQ:ARDSnet Trial]]

==Sources==
<references/>

[[Category:Pulm]][[Category:Critical Care]]

Acute respiratory distress syndrome

2014-07-25T08:27:05Z

Jlcunningham:

==Background==
*Non-cardiogenic pulmonary edema due to lung capillary endothelial injury
**Proteinaceous material accumulate in alveoli in a heterogeneous manner
*Symptom of an underlying disease

==Clinical Features==
*'''Diagnostic criteria'''<ref>Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>
#New onset respiratory symptoms
#Bilateral pulmonary opacities
#Symptoms not explained by cardiac etiology or volume overload

{{Table
|type = class="wikitable"
|title= ARDS Classifications
|hdrs= PaO2/FIO2 ratio !! Severity
|row1= 200-300{{!!}} Mild
|row2 = 100-200 {{!!}} Moderate
|row3 = < 100 {{!!}} Severe
}}

*'''Presentation'''
**Severe dyspnea
**Hypoxemia
**Diffuse crackles
*'''Imaging'''
**Diffuse patchy pulmonary infiltrates
*'''Causes'''
**[[Sepsis]]
**[[Pancreatitis]]
**[[Burns]]
**Aspiration
**Trauma
**[[Submersion Injuries (Drowning)|Near drowning]]
**Fat embolism
**[[Amniotic Fluid Embolus|Amniotic fluid embolism]]

==Differential Diagnosis==
*[[CHF]]
*[[Pneumonia]]
*[[PE]]
*Diffuse alveolar hemorrhage
*[[DIC]]

==Workup==
*CXR
*CBC
*Chem 10
*UA
*LFT
*Lipase
*PT/PTT
*Influenza (seasonal)
*Blood cultures
*Lactate
*Consider bedside echo
*Consider ABG/VBG
*Consider BNP

==Management==
*Treat underlying cause
**Cover for sepsis
***Pneumonia in addition to other identified source
**Tamiflu 75mg BID oral or NGT if influenza season <ref>http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm</ref>
*Supplemental O2
*[[Noninvasive Ventilation|Noninvasive ventilation]]
**Limited data to support use
*[[Ventilation (Main)|Ventilator Settings]]
**Permissive hypercapnia
**Tidal volume 6-8cc/kg of [http://www.mdcalc.com/ideal-body-weight/ ideal body weight]<ref>Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.</ref>
***Limit barotrauma to healthy area of lung
***Increase PEEP to improve oxygenation
****Link to Ardsnet PEEP/FiO2 protocol: http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf
**Maintain plateau pressures < 30 <ref>Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14</ref>
**Ensure adequate sedation
***Better synchrony with vent
***Decreased oxygen consumption
***Less [[delirium]]
***Increased patient comfort
**Prone ventilation
***Preliminary data suggests prone positioning may increase survival
***Consider for refractory hypoxemia

==Disposition==
* Admit to ICU

==See Also==
*[[Pulmonary edema]]
*[[CHF]]
*[[EBQ:ARDSnet Trial]]

==Sources==
<references/>

[[Category:Pulm]][[Category:Critical Care]]

Vertebral and carotid artery dissection

2014-07-25T08:18:56Z

Jlcunningham:

==Background==
*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)
*Symptoms may be transient or persistent
*Consider in trauma pt who has neurologic deficits despite normal head CT
*Consider in pt w/ CVA + neck pain

===Risk Factors===
#Neck trauma (often minor)
#Coughing
#Connective tissue disease
#History of migraine

==Clinical Features==
===Internal Carotid Dissection===
*Unilateral HA, face pain, anterior neck pain
**Pain can precede other symptoms by hours-days (median 4d)
**HA most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
*Partial Horner syndrome (miosis and ptosis)
*CN palsies
===Vertebral Artery Dissection===
*Posterior neck pain, HA
**May be unilateral or bilateral
**HA is typically occipital
*Unilateral facial paresthesia
*Dizziness
*Vertigo
*N/V
*[[Diplopia]] and other visual disturbances
*Ataxia

==Diagnosis==
#CTA/MRA
#Angiography
##Gold standard
##Consider if diagnosis still strongly suspected despite negative CTA/MRA

==Treatment<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>==
*tPA
**Do not give if dissection enters the skull (ie Intracranial)
**Do not give if aorta is involved
**Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
*Antiplatelet vs Anticoagulation Therapy (Very controversial with poor data)
**Heparin: If dissection causes neuro deficits and is EXTRACRANIAL
**Aspirin: If dissection is INTRACRANIAL
**Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thrombo-embolic event
**If tPA was given, wait 24hr before starting antiplatelet therapy
**Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
*Endovascular Therapy
**Option for pts who have contraindication to lytic therapy
**tPA use does not exclude pts from endovascular therapy

==Complications==
*CVA
*Risk of stroke or recurrent stroke is highest in the first 24hr after dissection

*SAH (if dissection extends intracranially)

==Sources==
*Patel RR, Adam R, et al. Cervical carotid artery dissection: current review of diagnosis and treatment Cardiology in Review. 2012 May-Jun; 20(3):145-52.
*Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcomes. Lancet Neurol 2009; 8:668.
*Engelter, ST, Brandt, T, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007;38:2605-2611
<references/>
*UpToDate: 'Spontaneous cerebral and cervical artery dissection: Treatment and prognosis'
[[Category:Neuro]]

Vertebral and carotid artery dissection

2014-07-25T08:17:53Z

Jlcunningham:

Pelvic fractures

2014-07-18T06:24:42Z

Jlcunningham:

==Background==
*Associated with:
**Hemorrhage requiring transfusion (esp w/ SI joint disruption) - 35%
**Intraabdominal injury - 16%
**Bladder/urethra injury - 6%
**Nerve deficits - 15%
***Especially with post ring fx, upper sacral fracture
**Thoracic aorta rupture - 1.5%
*If pelvic ring is disrupted there are usually two fractures
**Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
*Extension of fracture into the rectum or vagina = open fx

==Pelvic Ring Disruptions==
*Lateral Compression
**Most common
**Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
*Anteroposterior Compression
**Usually unstable as the iliac wings are forced outward, increasing pelvic volume
**Often assocciated with pelvic and retroperitoneal hemorrhage
**Coincident injuries of the thorax and the abdomen are the rule
*Vertical Shear
**Result from vertically oriented force delivered to the pelvis via the extended femurs
**Unstable; pelvic volume is increased

===Imaging===
#Plain films
##AP - Obtain in all unconscious blunt trauma patients
##Inlet - Better defines the pelvic brim
##Outlet - Better defines the sacrum and SI joints
##Judet - Better defines the acetabulum
#CT
##Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
###Exceptions include isolated pubic rami fx, avulsion fx
#Retrograde cystourethrogram
##Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
#US
##May confuse hemoperitoneum for uroperitoneum

===Management===
#Classify fx pattern as "stable" or "unstable"
##If unstable pelvis:
###Wrap with sheet or pelvic binder
###Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
#Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
#FAST Exam to rapidly detect hemoperitoneum
##If hemoperitoneum is present--> OR
##If vital signs are unstable--> OR for damage control laparotomy, not CT
##If vital signs are stable and no hemoperitoneum--> CTAP w/IV contrast
###Contact IR for possible pelvic angiographic embolization
#Look for vaginal or rectal bleeding, suggests open fx (uncommon)

==Other Pelvic Fractures==
#Straddle Injury
##Unstable
##Both rami fractured on both sides or both rami on one side w/ pubic symphysis diastasis
##High rate of urinary tract and bowel injury
#Acetabular Fractures
##Early ortho consultation and hospital admission is indicated for all
#Pelvic Avulsion Fracture
##Anterior superior iliac spine
###Occurs from forceful sartorius muscle contraction (adolescent sprinters)
###Bed rest for 3-4 wk w/ hip flexed and abducted, crutches, ortho f/u in 1-2wk
##Anterior inferior iliac spine
###Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
###Bed rest for 3-4 wk w/ hip flexed, crutches, ortho f/u in 1-2wk

==See Also==
*[[Fractures (Main)]]
*[[Pelvic X-ray]]

===Reference===
*UpToDate
*Harwood-Nuss
*Tintinalli

[[Category:Trauma]]
[[Category:Ortho]]

Cerebellar stroke

2014-07-18T06:05:45Z

Jlcunningham:

==Clinical Features==
*Sudden inability to walk is common finding
*May have additional signs of of Posterior Circulation Stroke- 5Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)

==Exam==
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Central nystagmus beats in multiple directions, is less likely to fatigue, and should be reproducible
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Stroke (Main)]]
*See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]

==See Also==
*[[Stroke syndromes]]
[[Category:Neuro]]

Cerebellar stroke

2014-07-18T06:02:07Z

Jlcunningham:

Cerebellar stroke

2014-07-18T05:58:25Z

Jlcunningham:

==Clinical Features==
*5 Ds of Posterior Circulation Stroke: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)

==Exam==
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Central nystagmus beats in multiple directions, is less likely to fatigue, and should be reproducible
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Stroke (Main)]]
*See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]

==Source==
#Lewandowski C, Santhakumar S. Posterior Circulation Stroke. Foundation for Education and Research in Neurologic Emergencies (FERNE). Review Article.

==See Also==
*[[Stroke syndromes]]
[[Category:Neuro]]

Cerebellar stroke

2014-07-18T05:44:42Z

Jlcunningham:

==Clinical Features==
*5 Ds of Posterior Circulation Stroke: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)

==Exam==
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
***Peripheral vs Central [[Nystagmus]]1
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Stroke (Main)]]
*See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]

==Source==
#Lewandowski C, Santhakumar S. Posterior Circulation Stroke. Foundation for Education and Research in Neurologic Emergencies (FERNE). Review Article.

==See Also==
*[[Stroke syndromes]]
[[Category:Neuro]]

Vertigo

2014-07-18T05:33:00Z

Jlcunningham:

== Background ==
*Perception of movement (rotational or otherwise) where no movement exists
*Pathophysiology
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
*Must distinguish peripheral from central cause
**Peripheral: 8th CN, vestibular apparatus
**Central: Brainstem, cerebellum

== Clinical Features==

{| width="400" border="1" cellpadding="1" cellspacing="1"
|-
|
| '''Peripheral'''
| '''Central'''
|-
| '''Onset'''
| Sudden
| Sudden or slow
|-
| '''Severity'''
| Intense spinning
| Ill defined, less intense
|-
| '''Pattern'''
| Paroxysmal, intermittent
| Constant
|-
| '''Aggravated by position/movement'''
| Yes
| Variable
|-
| '''Nausea/diaphoresis'''
| Frequent
| Variable
|-
| '''Nystagmus'''
| Horizontal
| Vertical or multidirectional
|-
| '''Fatigue of symptoms/signs'''
| Yes
| No
|-
| '''Hearing loss/tinnitus'''
| May occur
| Does not occur
|-
| '''Abnormal tympanic membrane'''
| May occur
| Does not occur
|-
| '''CNS symptoms/signs'''
| Absent
| Usually present
|}

==Diagnosis==
===Algorithm===
[[File:Vertigo_and_Dizziness.jpg]]

===HINTS Exam===
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref>
#Head Impulse Testing
##Tests vestibulo-ocular reflex
##Have pt fix their eyes on your nose
##Move their head in the horizontal plane to the left and right
###If reflex is intact their eyes will stay fixed on your nose
###If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
##It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
#Nystagmus
##Benign nystagmus only beats in one direction no matter which direction their eyes look
##Bad nystagums beats in every direction their eyes look
###If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
#Test of Skew
##Vertical dysconjugate gaze is bad
##Alternating cover test
###Have pt look at your nose w/ their eyes and then cover one eye
###When rapidly uncover the eye look to see if the eye quickly moves to re-align
##If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

^Sensitivity (for posterior ischemic CVA):
*HINTS = 100%?
*MRI <48hrs after symptom onset = 83%
*MRI >48hrs = 100%?
*CT = 16%

== DDX ==
#Vestibular/otologic
##[[Benign Paroxysmal Positional Vertigo (BPPV)]]
##Traumatic (following head injury)
##Infection
###[[Labyrinthitis]]
###[[Vestibular Neuritis (Neuronitis)]]
###Ramsay Hunt syndrome
#Syndrome
##[[Meniere Disease]]
##Neoplastic
##Vascular
##Otosclerosis
##Paget disease
##Toxic or drug-induced: aminoglycosides
#Neurologic
##Vertebrobasilar insufficiency
###Head turning causes vertigo, [[Diplopia|diplopia]], dysarthria, b/l loss of vision, syncope
##Lateral Wallenberg syndrome
##Anterior inferior cerebellar artery syndrome
##Neoplastic: cerebellopontine angle tumors
##Cerebellar disorders: hemorrhage, degeneration
##Basal ganglion diseases
##Multiple sclerosis
##Infections: neurosyphilis, tuberculosis
##Epilepsy
##Migraine (basilar)
##Cerebrovascular disease
#General
##Hematologic: anemia, polycythemia, hyperviscosity syndrome
##Toxic: alcohol
##Chronic renal failure
##Metabolic
###[[Thyroid Disease]]
###[[Hypoglycemia]]

==Work-up==
#Glucose check
#Full neuro exam
#TM exam
#?CT/MRI - if symptoms consistent with central cause

==Management==
=== Peripheral ===

Symptomatic control
#Antihistamines
##Meclizine (antivert) 25mg PO QID
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
#Anticholinergics
##Scopolamine transdermal patch 0.5mg (behind ear) QID
#Antidopaminergics
##Metoclopramide 10-20 IV or PO TID

Cause Reversal
#Epley maneuver (see [[BPPV]])

===Central===
#R/O [[CVA]]
#MRI
#R/O Vascular insufficiency

== Disposition ==
*Most pts w/ peripheral vertigo can be discharged home
*Most pts w/ central vertigo require urgent imaging and consultation while in the ED

==See Also==
*[[Dizziness]]
*[[EBQ:HINTS_Exam]]
*[[Cerebellar Stroke]]
*[[Stroke syndromes]]

== Source ==
*Tintinalli
<references/>
[[Category:Neuro]]

Stroke syndromes

2014-07-18T04:39:43Z

Jlcunningham: edit

===Anterior Circulation===
*Blood supply via internal carotid system
*Includes [[Stroke_(Main)#Anterior_Cerebral_Artery_.28ACA.29|ACA]] and [[Stroke_(Main)#Middle_Cerebral_Artery_.28MCA.29|MCA]]
====Anterior Cerebral Artery (ACA)====
'''Signs and Symptoms:'''
*Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
*Left sided lesion: akinetic mutism, transcortical motor aphasia
*Right sided lesion: Confusion, motor hemineglect
====Middle Cerebral Artery (MCA)====
'''Signs and Symptoms:'''
*Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
*Motor deficits found more commonly in face and upper extremity than lower extremity
*Dominant hemisphere involved: aphasia
*Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
*Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
===Posterior circulation===
*Blood supply via the vertebral vertebral artery
*Branches include, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]]
'''Signs and Symptoms:'''
*Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
*Multiple, simultaneous complaints are the rule
*5 Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
*Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
====Basilar artery====
'''Signs and Symptoms:'''
*Quadriplegia, coma, locked-in syndrome
====Posterior Cerebral Artery (PCA)====
'''Signs and Symptoms:'''
*Unilateral headache (most common presenting complaint)
*Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
*Motor function is typically minimally affected
====Posteroinferior Cerebellar Artery (PICA)====
'''Signs and Symptoms:'''
*Vertigo, gait instability, limb ataxia, Headache, dysarthria, Nausea and Vomitting, [[Cranial Nerve]] abnormalities

==See Also==
*[[Stroke (Main)]]
*[[Cerebellar Stroke]]
[[Category:Neuro]]

Stroke syndromes

2014-07-18T04:36:08Z

Jlcunningham: links

===Anterior Circulation===
*Blood supply via internal carotid system
*Includes [[Stroke_(Main)#Anterior_Cerebral_Artery_.28ACA.29|ACA]] and [[Stroke_(Main)#Middle_Cerebral_Artery_.28MCA.29|MCA]]
====Anterior Cerebral Artery (ACA)====
'''Signs and Symptoms:'''
*Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
*Left sided lesion: akinetic mutism, transcortical motor aphasia
*Right sided lesion: Confusion, motor hemineglect
====Middle Cerebral Artery (MCA)====
'''Signs and Symptoms:'''
*Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
*Motor deficits found more commonly in face and upper extremity than lower extremity
*Dominant hemisphere involved: aphasia
*Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
*Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
===Posterior circulation===
*Blood supply via the vertebral vertebral artery
*Branches include, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]]
'''Signs and Symptoms:'''
*Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
*Multiple, simultaneous complaints are the rule
*Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
*Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
====Basilar artery====
'''Signs and Symptoms:'''
*Quadriplegia, coma, locked-in syndrome
====Posterior Cerebral Artery (PCA)====
'''Signs and Symptoms:'''
*Unilateral headache (most common presenting complaint)
*Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
*Motor function is typically minimally affected
====Posteroinferior Cerebellar Artery (PICA)====
'''Signs and Symptoms:'''
*Vertigo, gait instability, limb ataxia, Headache, dysarthria, Nausea and Vomitting, [[Cranial Nerve]] abnormalities

==See Also==
*[[Stroke (Main)]]
*[[Cerebellar Stroke]]
[[Category:Neuro]]

Cerebellar stroke

2014-07-18T04:33:08Z

Jlcunningham: edt

==Clinical Features==
*5 Ds of Posterior Circulation Stroke: Dizziness, Dysarthria, Dystaxia, Diplopia, Dysphagia
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)

==Exam==
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Stroke (Main)]]
*See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]

==See Also==
*[[Stroke syndromes]]
[[Category:Neuro]]

Cerebellar stroke

2014-07-18T04:32:45Z

Jlcunningham: edit

Cerebellar stroke

2014-07-18T04:29:41Z

Jlcunningham: edits

Ataxia (peds)

2014-07-18T04:26:41Z

Jlcunningham: link

==Background==
*any disturbance in coordination of movement
*most cases in ED will be acute (<72h), but can also be episodic or chronic
*etiology usually benign in previously healthy child
*most cases will be postinfectious cerebellitis, drug ingestion, or [[Guillain Barre]]

==Clinical Features==
*unsteady gait in all cases
*postinfectious cerebellitis 1-3 wks post URI like illness or immunization, truncal ataxia and gait instability, normal mental status, normal vitals, ONLY ataxia
*[[Guillain Barre]] extremity ataxia more than truncal ataxia, areflexia or hyporeflexia, respiratory failure possible
*drug ingestion altered mental status, eye findings (nystagmus)
*intracranial mass headache, vomiting, gradual onset, visual changes, papilledema, focal neuro deficits
*[[Meningitis]]/[[Encephalitis]] fever, meningismus, bulging fontanelle, rash, altered mental status, seizure 

==DDx==
*postinfectious cerebellitis (acute cerebellar ataxia)
*drug ingestion/ toxin exposure (anticonvulsants, antihistamines, benzos, alcohol, dextromethorphan, others)
*[[Guillain Barre]] syndrome
*[[Hypoglycemia]]
*post vaccination (varicella)
*[[Encephalitis]]/[[Meningitis]]
*intracranial mass lesion
*hydrocephalus
*[[Intracranial Bleed]]
*[[Stroke]]
*vertebrobasilar dissection
*migraine
*vasculitis
*paraneoplastic syndrome
*epilepsy

==Workup==
*exam
*tox screen, alcohol level
*accuchek
*drug levels as indicated (ex. antiepileptic level if possible ingestion)
*[[Head CT]] if concern for trauma or mass lesion
*[[Lumbar Puncture]] in most cases unless etiology is known
*EEG if poss [[Seizure|seizure]] related

==Treatment==
*most postinfectious cerebellitis self limited, resolve within 3 months without sequelae
*tox ingestion: supportive. social work or DCFS as indicated
*[[Guillain Barre]] admit for IVIG, observation of respiratory status
*[[Meningitis]]/[[Encephalitis]] admit, IV abx, see meningitis section
*intracranial mass: neurosurgery consultation

==Disposition==
*consider d/c home mildly symptomatic, well appearing child with hx and exam c/w postinfectious cerebellitis with excellent follow-up (give injury prevention precautions)
*otherwise, admission indicated for further workup, observation

==See Also==
*[[Ataxia]]
*[[Weakness]]
*[[Cerebellar Stroke]]

==Source==
Harwood-Nuss

[[Category:Peds]]
[[Category:Neuro]]

Ataxia

2014-07-18T04:26:07Z

Jlcunningham: link

==Background==
*Sign of a variety of disease processes; not a diagnosis in itself
*Isolated lesion of cerebellum is NOT the most common cause
*Must distinguish between motor (cerebellar) and sensory (cord, peripheral nerves) ataxia
**Sensory ataxia may be compensated to a degree w/ visual sensory information

==Diagnosis==
#Sensory versus motor ataxia
##Romberg test
###Comparison of posture stability when eyes are open versus eyes closed
###If ataxia worsens w/ loss of visual input suggestive of sensory ataxia
###If ataxia does not significantly change w/ eyes closed suggests motor ataxia
#Systemic versus isolated nervous system disease
#CNS versus PNS
#Cerebellar versus posterior column (proprioceptive)
##Finger to nose
###Performing test w/ eyes closed tests proprioception
##Heel-to-shin test
###Posterior column disease: Difficult locating knee
###Cerebellar disease: Action completed w/ series of jerky movements

==Work-Up==
*Depends on rapidity of symptoms
*If acute consider CT, MRI, LP

==DDX==
#Systemic conditions
##Intoxications with diminished alertness
###Ethanol
###Sedative-hypnotics
##Intoxications with relatively preserved alertness
###Phenytoin
###Carbamazepine
###Valproic acid
###Lead, organic mercurials
##Other metabolic disorders
###Hyponatremia
###Inborn errors of metabolism
###Wernicke's disease
#Disorders predominantly of the nervous system
##Conditions affecting predominantly one region of the CNS
###Cerebellum
####Hemorrhage
####Infarction
####Degenerative changes
####Abscess
###Cortex
####Frontal tumor, hemorrhage, or trauma
####Hydrocephalus
###Subcortical
####Thalamic infarction or hemorrhage
####Parkinson's disease
####Normal pressure hydrocephalus
###Spinal cord
####Cervical spondylosis
####Posterior column disorders
##Conditions affecting predominantly the peripheral nervous system
###Peripheral neuropathy
###Vestibulopathy

==See Also==
*[[Altered Mental Status]]
*[[Ataxia (Peds)]]
*[[Weakness]]
*[[Cerebellar Stroke]]

==Source==
Tintinalli

[[Category:Neuro]]

Cerebellar stroke

2014-07-18T04:23:29Z

Jlcunningham: page edits

==Clinical Features==
*See [[Stroke syndromes]]
*5 Ds of Posterior Circulation Stroke: Dizziness, Dysarthria, Dystaxia, Diplopia, Dysphagia
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)

==Exam==
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Stroke (Main)]]
*See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]

[[Category:Neuro]]

Stroke (main)

2014-07-18T04:10:40Z

Jlcunningham: Reformat

==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment
*Accurate determination of last known time when pt was at baseline is essential
See [[Stroke syndromes]]

==Clinical Features==
*Thrombotic
**Stuttering or waxing and waning
**TIA involving same vascular distribution
*Embolic
**Sudden onset of symptoms
**TIAs involving different vascular distributions
**A-fib
**Valvular replacement
**Recent MI
*Hemorrhagic
**Sudden onset of symptoms
**Preceded by severe headache
**Recent neck trauma/manipulation

===Causes===
#Ischemic (87%)
##Thrombotic (80% of ischemic CVA)
###Atherosclerosis
###Vasculitis
###Arterial dissection
###Polycythemia
###Hypercoagulable state
###Infection
##Embolic (20% of ischemic CVA)
###Valvular vegetations
###Mural thrombi
###Arterial-arterial emboli from proximal source
###Fat emboli
###Septic emboli
##Hypoperfusion
###Cardiac failure resulting in systemic hypotension
#Hemorrhagic (13%)
##Intracerebral
###HTN
###Amyloidosis
###Anticoagulation
###Vascular malformations
###Cocaine use
##SAH
###Berry aneurysm rupture
###Vascular malformation rupture

==DDX==
#[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
#[[Syncope]]
##No persistent or associated neurologic symptoms
#Brain neoplasm or abscess
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural hematoma
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
#[[Hypoglycemia]]
##Can be detected by bedside glucose measurement, history of DM
#[[Hyponatremia]]
##History of diuretic use, neoplasm, excessive free water intake
#Hypertensive encephalopathy
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
#[[Meningitis]]/[[encephalitis]]
##Fever, immunocompromise may be present, meningismus, detectable on LP
#[[Hyperosmotic Coma]]
##Extremely high glucose levels, history of DM
#Wernicke Encephalopathy
##History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
#[[Labyrinthitis]]
##Predominantly vestibular symptoms; pt should have no other focal findings
#Drug toxicity
##Lithium, phenytoin, carbamazepine
#[[Bell's Palsy]]
##Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
#Complicated [[migraine]]
##History of similar episodes, preceding aura, HA
#[[Meniere Disease]]
##History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
#Demyelinating disease ([[MS]])
##Gradual onset, may have hx of multiple episodes of findings in multiple distributions
#Conversion disorder
##No cranial nerve findings, nonanatomic distribution of findings

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
===Ischemic===
*tPA AND non-tPA candidates:
**Prevent dehydration
**Maintain SpO2 >92%
**Prevent fever
**Controversial

====tPA Candidate====
#tPA
##See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
#Hypertension
##Lower SBP to <185, DBP to <110
##Options:
###Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
###Nitroglycerin paste, 1–2 in. to skin OR
###Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
####When desired blood pressure attained reduce to 3mg/hr

====Non-tPA Candidate====
#Hypertension
##Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
#Aspirin 325mg (within 24-48hr)
#Anticoagulation not recommended for acute stroke (even for A-fib)

===Hemorrhagic===
*See [[Intracerebral Hemorrhage (ICH)]]

===Cerebellar===
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
*See [[Cerebellar Stroke]]

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracranial Hemorrhage (ICH)]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]
*[[NIH Stroke Scale]]

==External Links==
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]

==Source==
*Tintinalli
*UpToDate
*AHA/ASA Acute Stroke Guidelines
*EMCrit

[[Category:Neuro]]

Cerebellar stroke

2014-07-18T04:06:35Z

Jlcunningham: Page

*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

[[Category:Neuro]]

Stroke (main)

2014-07-18T03:54:37Z

Jlcunningham: link

==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment
*Accurate determination of last known time when pt was at baseline is essential
See [[Stroke syndromes]]
===Causes===
#Ischemic (87%)
##Thrombotic (80% of ischemic CVA)
###Atherosclerosis
###Vasculitis
###Arterial dissection
###Polycythemia
###Hypercoagulable state
###Infection
##Embolic (20% of ischemic CVA)
###Valvular vegetations
###Mural thrombi
###Arterial-arterial emboli from proximal source
###Fat emboli
###Septic emboli
##Hypoperfusion
###Cardiac failure resulting in systemic hypotension
#Hemorrhagic (13%)
##Intracerebral
###HTN
###Amyloidosis
###Anticoagulation
###Vascular malformations
###Cocaine use
##SAH
###Berry aneurysm rupture
###Vascular malformation rupture

==Clinical Features==
*Thrombotic
**Stuttering or waxing and waning
**TIA involving same vascular distribution
*Embolic
**Sudden onset of symptoms
**TIAs involving different vascular distributions
**A-fib
**Valvular replacement
**Recent MI
*Hemorrhagic
**Sudden onset of symptoms
**Preceded by severe headache
**Recent neck trauma/manipulation

==Cerebellar Stroke==
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==DDX==
#[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
#[[Syncope]]
##No persistent or associated neurologic symptoms
#Brain neoplasm or abscess
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural hematoma
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
#[[Hypoglycemia]]
##Can be detected by bedside glucose measurement, history of DM
#[[Hyponatremia]]
##History of diuretic use, neoplasm, excessive free water intake
#Hypertensive encephalopathy
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
#[[Meningitis]]/[[encephalitis]]
##Fever, immunocompromise may be present, meningismus, detectable on LP
#[[Hyperosmotic Coma]]
##Extremely high glucose levels, history of DM
#Wernicke Encephalopathy
##History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
#[[Labyrinthitis]]
##Predominantly vestibular symptoms; pt should have no other focal findings
#Drug toxicity
##Lithium, phenytoin, carbamazepine
#[[Bell's Palsy]]
##Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
#Complicated [[migraine]]
##History of similar episodes, preceding aura, HA
#[[Meniere Disease]]
##History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
#Demyelinating disease ([[MS]])
##Gradual onset, may have hx of multiple episodes of findings in multiple distributions
#Conversion disorder
##No cranial nerve findings, nonanatomic distribution of findings

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
===Ischemic===
*tPA AND non-tPA candidates:
**Prevent dehydration
**Maintain SpO2 >92%
**Prevent fever
**Controversial

====tPA Candidate====
#tPA
##See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
#Hypertension
##Lower SBP to <185, DBP to <110
##Options:
###Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
###Nitroglycerin paste, 1–2 in. to skin OR
###Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
####When desired blood pressure attained reduce to 3mg/hr

====Non-tPA Candidate====
#Hypertension
##Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
#Aspirin 325mg (within 24-48hr)
#Anticoagulation not recommended for acute stroke (even for A-fib)

===Hemorrhagic===
*See [[Intracerebral Hemorrhage (ICH)]]

===Cerebellar===
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracranial Hemorrhage (ICH)]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]
*[[NIH Stroke Scale]]

==External Links==
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]

==Source==
*Tintinalli
*UpToDate
*AHA/ASA Acute Stroke Guidelines
*EMCrit

[[Category:Neuro]]

Stroke (main)

2014-07-18T03:50:00Z

Jlcunningham: causes

==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment
*Accurate determination of last known time when pt was at baseline is essential

===Causes===
#Ischemic (87%)
##Thrombotic (80% of ischemic CVA)
###Atherosclerosis
###Vasculitis
###Arterial dissection
###Polycythemia
###Hypercoagulable state
###Infection
##Embolic (20% of ischemic CVA)
###Valvular vegetations
###Mural thrombi
###Arterial-arterial emboli from proximal source
###Fat emboli
###Septic emboli
##Hypoperfusion
###Cardiac failure resulting in systemic hypotension
#Hemorrhagic (13%)
##Intracerebral
###HTN
###Amyloidosis
###Anticoagulation
###Vascular malformations
###Cocaine use
##SAH
###Berry aneurysm rupture
###Vascular malformation rupture

==Clinical Features==
*Thrombotic
**Stuttering or waxing and waning
**TIA involving same vascular distribution
*Embolic
**Sudden onset of symptoms
**TIAs involving different vascular distributions
**A-fib
**Valvular replacement
**Recent MI
*Hemorrhagic
**Sudden onset of symptoms
**Preceded by severe headache
**Recent neck trauma/manipulation

==Cerebellar Stroke==
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
*[[EBQ:HINTS Exam|HINTS Exam]] can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==DDX==
#[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
#[[Syncope]]
##No persistent or associated neurologic symptoms
#Brain neoplasm or abscess
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural hematoma
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
#[[Hypoglycemia]]
##Can be detected by bedside glucose measurement, history of DM
#[[Hyponatremia]]
##History of diuretic use, neoplasm, excessive free water intake
#Hypertensive encephalopathy
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
#[[Meningitis]]/[[encephalitis]]
##Fever, immunocompromise may be present, meningismus, detectable on LP
#[[Hyperosmotic Coma]]
##Extremely high glucose levels, history of DM
#Wernicke Encephalopathy
##History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
#[[Labyrinthitis]]
##Predominantly vestibular symptoms; pt should have no other focal findings
#Drug toxicity
##Lithium, phenytoin, carbamazepine
#[[Bell's Palsy]]
##Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
#Complicated [[migraine]]
##History of similar episodes, preceding aura, HA
#[[Meniere Disease]]
##History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
#Demyelinating disease ([[MS]])
##Gradual onset, may have hx of multiple episodes of findings in multiple distributions
#Conversion disorder
##No cranial nerve findings, nonanatomic distribution of findings

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
===Ischemic===
*tPA AND non-tPA candidates:
**Prevent dehydration
**Maintain SpO2 >92%
**Prevent fever
**Controversial

====tPA Candidate====
#tPA
##See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
#Hypertension
##Lower SBP to <185, DBP to <110
##Options:
###Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
###Nitroglycerin paste, 1–2 in. to skin OR
###Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
####When desired blood pressure attained reduce to 3mg/hr

====Non-tPA Candidate====
#Hypertension
##Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
#Aspirin 325mg (within 24-48hr)
#Anticoagulation not recommended for acute stroke (even for A-fib)

===Hemorrhagic===
*See [[Intracerebral Hemorrhage (ICH)]]

===Cerebellar===
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracranial Hemorrhage (ICH)]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]
*[[NIH Stroke Scale]]

==External Links==
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]

==Source==
*Tintinalli
*UpToDate
*AHA/ASA Acute Stroke Guidelines
*EMCrit

[[Category:Neuro]]

Stroke syndromes

2014-07-18T03:48:38Z

Jlcunningham: page

===Anterior Circulation===
*Blood supply via internal carotid system
*Includes [[Stroke_(Main)#Anterior_Cerebral_Artery_.28ACA.29|ACA]] and [[Stroke_(Main)#Middle_Cerebral_Artery_.28MCA.29|MCA]]
====Anterior Cerebral Artery (ACA)====
'''Signs and Symptoms:'''
*Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
*Left sided lesion: akinetic mutism, transcortical motor aphasia
*Right sided lesion: Confusion, motor hemineglect
====Middle Cerebral Artery (MCA)====
'''Signs and Symptoms:'''
*Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
*Motor deficits found more commonly in face and upper extremity than lower extremity
*Dominant hemisphere involved: aphasia
*Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
*Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
===Posterior circulation===
*Blood supply via the vertebral vertebral artery
*Branches include, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]]
'''Signs and Symptoms:'''
*Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
*Multiple, simultaneous complaints are the rule
*Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
*Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
====Basilar artery====
'''Signs and Symptoms:'''
*Quadriplegia, coma, locked-in syndrome
====Posterior Cerebral Artery (PCA)====
'''Signs and Symptoms:'''
*Unilateral headache (most common presenting complaint)
*Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
*Motor function is typically minimally affected
====Posteroinferior Cerebellar Artery (PICA)====
'''Signs and Symptoms:'''
*Vertigo, gait instability, limb ataxia, Headache, dysarthria, Nausea and Vomitting, [[Cranial Nerve]] abnormalities

[[Category:Neuro]]

Stroke syndromes

2014-07-18T03:46:12Z

Jlcunningham: New page

==Stroke Syndromes==
===Anterior Circulation===
*Blood supply via internal carotid system
*Includes [[Stroke_(Main)#Anterior_Cerebral_Artery_.28ACA.29|ACA]] and [[Stroke_(Main)#Middle_Cerebral_Artery_.28MCA.29|MCA]]
====Anterior Cerebral Artery (ACA)====
'''Signs and Symptoms:'''
*Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
*Left sided lesion: akinetic mutism, transcortical motor aphasia
*Right sided lesion: Confusion, motor hemineglect
====Middle Cerebral Artery (MCA)====
'''Signs and Symptoms:'''
*Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
*Motor deficits found more commonly in face and upper extremity than lower extremity
*Dominant hemisphere involved: aphasia
*Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
*Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
===Posterior circulation===
*Blood supply via the vertebral vertebral artery
*Branches include, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]]
'''Signs and Symptoms:'''
*Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
*Multiple, simultaneous complaints are the rule
*Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
*Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
====Basilar artery====
'''Signs and Symptoms:'''
*Quadriplegia, coma, locked-in syndrome
====Posterior Cerebral Artery (PCA)====
'''Signs and Symptoms:'''
*Unilateral headache (most common presenting complaint)
*Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
*Motor function is typically minimally affected
====Posteroinferior Cerebellar Artery (PICA)====
'''Signs and Symptoms:'''
*Vertigo, gait instability, limb ataxia, Headache, dysarthria, Nausea and Vomitting, [[Cranial Nerve]] abnormalities

[[Neurology]]

Stroke (main)

2014-07-17T05:39:31Z

Jlcunningham: Improved format

==Background==
*Vascular injury that reduces CBF to specific region of brain causing neuro impairment
*Accurate determination of last known time when pt was at baseline is essential

===Stroke Syndromes===
*Anterior Circulation (internal carotid system)
**ACA
***Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
***Left sided lesion: akinetic mutism, transcortical motor aphasia
***Right sided lesion: Confusion, motor hemineglect
**MCA
***Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
***Motor deficits found more commonly in face and upper extremity than lower extremity
***Dominant hemisphere involved: aphasia
***Nondominant hemisphere involved: inattention, neglect, dysarthria without aphasia
***Homonymous hemianopsia and gaze preference toward side of infarct may also be seen
*Posterior circulation (vertebral system)
**Vertebral artery
***Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
***Multiple, simultaneous complaints are the rule
****Vertigo, headache, nausea, visual disturbances, oculomotor palsies, ataxia
***Isolated events are not attributable to vertebral occlusive disease:
****e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks
**Basilar artery
***Quadriplegia, coma, locked-in syndrome
**Posterior cerebral
***Unilateral headache (most common presenting complaint)
***Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
***Motor function is typically minimally affected
**Posteroinferior cerebellar
***Vertigo, gait instability, limb ataxia, HA, dysarthria, N/V, CN abnormalities

===Causes===
#Ischemic (87%)
##Thrombotic (80% of ischemic CVA)
###Atherosclerosis
###Vasculitis
###Arterial dissection
###Polycythemia
###Hypercoagulable state
###Infection
##Embolic (20% of ischemic CVA)
###Valvular vegetations
###Mural thrombi
###Arterial-arterial emboli from proximal source
###Fat emboli
###Septic emboli
##Hypoperfusion
###Cardiac failure resulting in systemic hypotension
#Hemorrhagic (13%)
##Intracerebral
###HTN
###Amyloidosis
###Anticoagulation
###Vascular malformations
###Cocaine use
##SAH
###Berry aneurysm rupture
###Vascular malformation rupture

==Clinical Features==
*Thrombotic
**Stuttering or waxing and waning
**TIA involving same vascular distribution
*Embolic
**Sudden onset of symptoms
**TIAs involving different vascular distributions
**A-fib
**Valvular replacement
**Recent MI
*Hemorrhagic
**Sudden onset of symptoms
**Preceded by severe headache
**Recent neck trauma/manipulation

==Cerebellar Stroke==
*Sudden inability to walk is common finding
*Can be confused w/ acute vestibular syndrome (e.g. labyrinthitis)
*HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
**1. Head Impulse Testing
***Tests vestibulo-ocular reflex
***Have pt fix their eyes on your nose
***Move their head in the horizontal plane to the left and right
***If reflex is intact their eyes will stay fixed on your nose
***If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
***It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
**2. Nystagmus
***Benign nystagmus only beats in one direction no matter which direction their eyes look
***Bad nystagums beats in every direction their eyes look
****If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
**3. Test of Skew
***Vertical dysconjugate gaze is bad
***Alternating cover test
****Have pt look at your nose w/ their eyes and then cover one eye
*****When rapidly uncover the eye look to see if the eye quickly moves to re-align
**If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

==DDX==
#[[Seizures]]/postictal paralysis (Todd paralysis)
##Transient paralysis following a seizure which typically disappears quickly
##Note: seizures can be secondary to a CVA
#[[Syncope]]
##No persistent or associated neurologic symptoms
#Brain neoplasm or abscess
##Focal neurologic findings, signs of infection, detectable by imaging
#Epidural/subdural hematoma
##History of trauma, ETOH, anticoagulant use, bleeding disorder; detectable by imaging
#[[Hypoglycemia]]
##Can be detected by bedside glucose measurement, history of DM
#[[Hyponatremia]]
##History of diuretic use, neoplasm, excessive free water intake
#Hypertensive encephalopathy
##Gradual onset; global cerebral dysfunction, HA, delirium, HTN, cerebral edema
#[[Meningitis]]/[[encephalitis]]
##Fever, immunocompromise may be present, meningismus, detectable on LP
#[[Hyperosmotic Coma]]
##Extremely high glucose levels, history of DM
#Wernicke Encephalopathy
##History of ETOH or malnutrition; triad of ataxia, ophthalmoplegia, and confusion
#[[Labyrinthitis]]
##Predominantly vestibular symptoms; pt should have no other focal findings
#Drug toxicity
##Lithium, phenytoin, carbamazepine
#[[Bell's Palsy]]
##Neuro deficit confined to isolated peripheral 7th nerve palsy; often a/w younger age
#Complicated [[migraine]]
##History of similar episodes, preceding aura, HA
#[[Meniere Disease]]
##History of recurrent episodes dominated by vertigo symptoms, tinnitus, deafness
#Demyelinating disease ([[MS]])
##Gradual onset, may have hx of multiple episodes of findings in multiple distributions
#Conversion disorder
##No cranial nerve findings, nonanatomic distribution of findings

==Work-Up==
#Bedside glucose
#Bedside Hb (polycythemia)
#CBC
#Chemistry
#Coags
#Troponin
#ECG (esp A-fib)
#[[Head CT]]
##Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
#Also consider:
##Pregnancy test
##CXR (if infection suspected)
##UA (if infection suspected)
##Utox (if ingestion suspected

==Treatment==
===Ischemic===
*tPA AND non-tPA candidates:
**Prevent dehydration
**Maintain SpO2 >92%
**Prevent fever
**Controversial

====tPA Candidate====
#tPA
##See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
#Hypertension
##Lower SBP to <185, DBP to <110
##Options:
###Labetalol 10–20mg IV over 1–2 min; may repeat x1 OR
###Nitroglycerin paste, 1–2 in. to skin OR
###Nicardipine 5mg/hr, titrate up by 2.5mg/hr at 5-15min intervals; max dose 15mg/hr
####When desired blood pressure attained reduce to 3mg/hr

====Non-tPA Candidate====
#Hypertension
##Allow permissive HTN unless SBP >220 or DBP >120 (lower by 10-25%)
#Aspirin 325mg (within 24-48hr)
#Anticoagulation not recommended for acute stroke (even for A-fib)

===Hemorrhagic===
*See [[Intracerebral Hemorrhage (ICH)]]

===Cerebellar===
*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracranial Hemorrhage (ICH)]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]
*[[NIH Stroke Scale]]

==External Links==
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]

==Source==
*Tintinalli
*UpToDate
*AHA/ASA Acute Stroke Guidelines
*EMCrit

[[Category:Neuro]]

File:Urology Form2.jpg

2013-07-17T20:36:33Z

Jlcunningham:

File:Urology Form1.jpg

2013-07-17T20:36:14Z

Jlcunningham:

File:Rheum Form.jpg

2013-07-17T20:32:16Z

Jlcunningham:

Harbor:ED follow-up options

2013-07-17T20:31:56Z

Jlcunningham:

==ED Follow-Up==
# [[Primary Care Follow Up Options]]
# [[Breast Clinic]]
# [[Coumadin Clinic]]
# [[Expedited Workup Clinic]]
# [[GI Referrals]]
# [[Neurology Referrals]]
# [[Rheum Clinic]] (See form)
# [[Elective Surgery Referrals]]
# [[Urology Referrals]]
* Make sure you clarify with the specialist what kind of form is needed. Many times, the intrafacility form has replaced the specific specialty forms. And ALWAYS get the name of your consultant!

==Specialty Clinics We Can Book Into After Consultation==
* Trauma
* Ortho (have a form but often not asked for)
* Derm
* Ophtho (same day appointments)
** Discharge the patient from the ED to ophtho clinic, unless you feel they have ongoing medical issues that require them coming back to ED
** If they require admission, can be admitted from there or sent back to ED
* GYN UC (often all booked so have to call)
* Cardiology
* Family Medicine Sports Clinic (Fridays)—only SPORTS related injuries

NEVER REFER TO PAIN CLINIC!

==Scheduling Outpt Studies==
* Stress Testing
** Form in Affinity
*** Fill out and print to heart station
*** Patient Charting
*** Click Chart Assessment Tab
*** Click RECORD
*** Click on Exercise Treadmill
*** Complete form entirely
*** SAVE AS FINAL
*** Print to HEART
*** Clerk makes appointment and PUTS order in computer
*** Can only schedule treadmills on an urgent basis (<72 hrs); if you want a MIBI or stress ECHO can use same process but it will be a mail-out

* US or MRI
** In general: DON’T DO IT!
**Never do it for DVT: US bounces all of these back
**In select cases in which a specific follow-up clinic requests a test, you can order it via Affitnity, similar to above, with the following caveat:
***DO NOT PUT YOUR NAME OR ER AS THE ORDERING PHYSICIAN OR DEPARTMENT. PERIOD

* Outpt Labs
** Okay in certain circumstances
** ONLY if patient will have a follow-up appointment in one of our clinics within 1-2 days of the lab draw!
** How to do it?
*** Get lab draw slip from clerk
*** Clerk can order the outpatient labs that you want
*** Recommend you don’t do this unless you talked to somebody who is willing to have their name go on the lab slip and follow-up the results

[[Category:Admin]]

File:Neurology2.jpg

2013-07-17T20:29:13Z

Jlcunningham: Neurology form back

Neurology form back

File:Neurology Form.jpg

2013-07-17T20:26:23Z

Jlcunningham:

File:Expedited form.jpg

2013-07-17T20:22:23Z

Jlcunningham:

Harbor:Coumadin clinic

2013-07-17T20:07:14Z

Jlcunningham:

* For appointments during the Day can often call the clinic (x8252, 5141/49) or page the on call RN (p9995, only on call until 8pm)
* [[Coumadin Clinic Form]] not always necessary if you can make a live appointment, otherwise should be filled out and can be faxed to the clinic directly.

File:Coumadin Clinic Form.jpg

2013-07-17T19:52:59Z

Jlcunningham:

Harbor:Coumadin clinic

2013-07-17T19:51:48Z

Jlcunningham: Created page with "* For appointments during the Day can often call the clinic (x8252, 5141/49) or page the on call RN (p9995, only on call until 8pm) * Coumadin Clinic Form not always necessar..."

Harbor:ED follow-up options

2013-07-17T19:39:32Z

Jlcunningham:

==ED Follow-Up==
# [[Primary Care Follow Up Options]]
# [[Breast Clinic]]
# [[Coumadin Clinic]]
# [[Expedited Workup Clinic]]
# [[GI Referrals]]
# [[Neurology Referrals]]
# [[Rheum Clinic]]
# [[Elective Surgery Referrals]]
# [[Urology Referrals]]
* Make sure you clarify with the specialist what kind of form is needed. Many times, the intrafacility form has replaced the specific specialty forms. And ALWAYS get the name of your consultant!

==Specialty Clinics We Can Book Into After Consultation==
* Trauma
* Ortho (have a form but often not asked for)
* Derm
* Ophtho (same day appointments)
** Discharge the patient from the ED to ophtho clinic, unless you feel they have ongoing medical issues that require them coming back to ED
** If they require admission, can be admitted from there or sent back to ED
* GYN UC (often all booked so have to call)
* Cardiology
* Family Medicine Sports Clinic (Fridays)—only SPORTS related injuries

NEVER REFER TO PAIN CLINIC!

==Scheduling Outpt Studies==
* Stress Testing
** Form in Affinity
*** Fill out and print to heart station
*** Patient Charting
*** Click Chart Assessment Tab
*** Click RECORD
*** Click on Exercise Treadmill
*** Complete form entirely
*** SAVE AS FINAL
*** Print to HEART
*** Clerk makes appointment and PUTS order in computer
*** Can only schedule treadmills on an urgent basis (<72 hrs); if you want a MIBI or stress ECHO can use same process but it will be a mail-out

* US or MRI
** In general: DON’T DO IT!
**Never do it for DVT: US bounces all of these back
**In select cases in which a specific follow-up clinic requests a test, you can order it via Affitnity, similar to above, with the following caveat:
***DO NOT PUT YOUR NAME OR ER AS THE ORDERING PHYSICIAN OR DEPARTMENT. PERIOD

* Outpt Labs
** Okay in certain circumstances
** ONLY if patient will have a follow-up appointment in one of our clinics within 1-2 days of the lab draw!
** How to do it?
*** Get lab draw slip from clerk
*** Clerk can order the outpatient labs that you want
*** Recommend you don’t do this unless you talked to somebody who is willing to have their name go on the lab slip and follow-up the results

[[Category:Admin]]

File:GI Referral Form.jpg

2013-07-17T19:31:28Z

Jlcunningham: