Grand Rounds Recap 01.06.2021
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Consultant of the quarter WITH Dr. Rob Neel
Basics of Neurology
It is better to make something out of nothing rather than nothing out of something
Assume the problem is neurologic until proven wrong
Be careful about labeling someone as psychogenic/functional
Location:
Focal, multifocal, diffuse
If focal or multifocal:
CNS vs PNS
R v L v Bilateral
Acute vs Subacute vs chronic
Acute: sec to minutes
Subacute: hours to days
Chronic: >6 weeks
Progressive or non-progressive
Stable - non-progressive
Plateau
Fluctuating (relapsing/remitting) - will not get back to 100% (MS, Sarcoid)
Paroxysmal - will get back to 100% (seizures, migraines)
Differential
VITAMIN C + D(degenerative) E(Epilepsy)
Acute focal and diffuse
Vascular, Iatrogenic, Trauma, Epilepsy
Subacute and focal
Inflammatory and Infectious (Toxo, abscess), Encephalitis
Subacute and diffuse
Metabolic, Infectious (meningitis), Toxic, Autoimmune, Paraneoplastic
Chronic focal
Neoplastic, Infectious (actinomyces, cryptococcus)
Chronic diffuse
Degenerative (ALS), Metabolic
Weakness:
Distribution and pattern:
PNS:
Distal symmetric
Proximal symmetric
Myotomal (asymmetric) - along a nerve root
Nerve (asymmetric) -usually more patchy involvement
CNS:
Pyramidal - Corticospinal tracts, Upper Motor Neurons (all extensors are weak in the arm, leg in the flexors are weaker)
Spinal
Subcortical-white matter: face/arm/leg weakness
Cortical-more vascular patterns due to cortex perfusion
Distal or proximal: roots and nerves are affected the same
Axial - Trunk vs Appendicular (limbs)
Bulbar - throat
EOM - just eyes
6 levels of the PNS
Motor Neuron - in the spinal cord
Neve roots
Plexus
Nerve
NMJ
Muscle
Symptoms:
Positive vs Negative
Pain/motor/sensory
Root, plexus (is very painful), nerve
Motor and no pain/sensory
Anterior horn cell, NMJ, Muscle
Danger concepts in neuromuscular diseases
Dyspnea from a cardiac/pulmonary etiology
Pulmonary/airway
Ventilation vs oxygenation
Oxygenation is NOT a NM issue
Vent failure: early vs terminal respiratory insufficiency
If early: dyspnea when lying flat
Early morning headaches
If terminal: more sleepy, more confusion
Airway issues
Soft tissue obstruction
Aspiration
Cardiac Issues
Arrhythmia: bradycardia/tachycardia/blocks
Systolic/Diastolic dysfunction
Autonomic dysfunction
Falls and weakness
Myasthenia Gravis: antibodies to the nicotinic acetylcholine receptors
Symptoms: fluctuating weakness/fatiguability
Ocular, bulbar, limb and neck weakness
Relapsing and remitting
Thymus abnormalities - especially in peds, need a non con chest CT
Crisis: need hospital and ICU
Life threatening bulbar symptoms
Dysarthria/dysphagia but especially SOB
Weakness of intercostal muscles and the diaphragm results in the CO2 retention due to hypoventilation
Weakness of the pharyngeal muscles may collapse the upper airway (like OSA)
Hospitalization:
ICU, intubation, plasmapheresis
Needs respiratory therapy q2-4 hrs
Bedside counting 1-2-3-4…: >50-70 is normal, impaired <40
FVC:
>20 cc/kg: acceptable, 15-20: ICU, 10-15: voluntary intubate, <10 intubate
Secretions: worse with the meds they are on
Aspiration: swallowing eval and keep HOB elevated
Medications can cause a Crisis:
Quinolones, aminoglycosides, chloroquines, statins
Plasmapheresis can be done if the line is in fast
IVIG can be started in the ED
Guillen-Barre Syndrome
Polyradiculoneuropathy, 50% will have a lot of pain (especially back pain)
Symptoms: ascending paralysis, motor>sensory
Cardiac, pulmonary and airway emergencies
Reflexes are a progressive and may be present initially
Diagnosis:
Clinical: Hyporeflexia and areflexia
10% of CSF is normal at 10 days - albuminocytologic dissociation
Death: Cardiovascular Instability (dysautonomia)
Cardiovascular Instability - Dysautonomia
PE
Respiratory failure
33% develop respiratory failure if difficulty with neck flexion/extension
Cash for cases
Altered 16 yo Female with normal vitals and blood sugar
PE:
HEENT: Normal
Neuro: Awake but not oriented. normal CN, no Motor/sensory deficits
Difficulty communicating - more word finding difficulties/expressive
A little agitated and not great at following commands
No gross ataxia or dysmetria
Cardio/Pulm: normal
Abdomen: normal
Skin: normal and no evidence of trauma.
Social: occasional smoking, marijuana, EtOH
Labs: Normal CTH, normal CMP
LP showed 74 WBC with 45% PMH, protein 345, low glucose
Dx: Acute lyme disease
Case Report: http://dx.doi.org/10.1016/j.annemergmed.2015.01.011
49 yoM who passed out while working on his car outside
Felt lightheaded first with some nausea prior to the syncopal event
Walked inside and laid on the couch for about 8 hours until his wife prompted him to come to the ED
Now: +Nausea, fatigue, headache, photophobia -Vomiting, chest pain, SOB
PMH: HTN, lisinopri/HCTZl, no allergies
Social: 4-5 beers per day, 1ppd
Vitals: 188/112, otherwise normal
PE:
HEENT: head laceration, appears uncomfortable. Frontal hematoma and occipital scalp lac
Lungs/heart/abdomen - normal
Neuro: GCS - 14 (one off for eyes), otherwise normal
Workup:
EKG with anterior TWI
CTH non-con: normal
LP: shows RBC in tubes 1 and 4
Diagnosis: Subarachnoid Hemorrhage - dx with LP >6 hours after the event
Oral boards cases
Case 1: Pediatric Appendicitis
Appendicitis is the most common surgical emergency in children
Pediatric appendicitis in young children presents with perforation 70% of the time.
This is due to low index of suspicion by providers/family, communication limitations of the child, and anatomic factors.
When thinking about risk of appendicitis:
Historical factors have poor LR+/LR-
The most helpful exam feature in a child that can participate, is pain with cough or hop (LR+ around 7.5)
CRP > 3 can help rule-in appendicitis and WBC < 10k can help rule it out.
A positive right-lower quadrant ultrasound should be sufficient to call surgery without further imaging.
If the clinical exam/appearance or labs are concerning with a negative ultrasound or an ultrasound without visualization:
Call a surgical consult for admission and serial exams or further imaging.
Case 2: Left MCA Acute Ischemic Stroke at a Non-Stroke Center
Know the exclusion criteria for tPA:
ICH on non contrast head CT
Possible SAH at presentation
H/o ICH
Neurosurgery, TBI, or stroke in the last 3 months
BP > 185/110
Glucose < 50
Known intracranial AVM, neoplasm, or aneurysm
Active internal bleeding
Suspected/confirmed endocarditis
Known bleeding diathesis
PLT < 100k
INR > 1.7
DOAC use
There are significant disparities in stroke quality metrics for urban vs rural hospitals and certified vs non-certified stroke centers.
In one study, about 82% of patients cared for by certified stroke centers received tPA within 2 hours.
In rural non-certified centers, that number goes down to only 38%.
EMS transport time and availability of neurology (in-person or tele radiology) are factors
Offering tPA to a qualifying stroke is considered standard of care.
Be sure to consent the patient and/or family about the risks/benefits.
Case 3: PE with Undiagnosed Malignancy
Patients with cancer are 3x more likely to have VTE
3x more likely to die of VTE than their counterparts without a malignancy.
CTPAs in ED patients can pick up non-PE findings.
One multicenter retrospective study of all ED patients with CTPAs found that up to 11% had an alternate finding needing immediate action.
Of those, 81% had pneumonia, 7% had a lung mass, and 7% had a thoracic aortic aneurysm.
Communication is key in the oral boards.
Make sure you update your patient and family frequently
Allowing them an opportunity to ask questions.
Inform them of all relevant diagnostic findings and be explicit about their disposition.
