Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
· GCS 15 ≠ 14 ≠ 13
· Know what each CDR gets you
· Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
· Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)
Case #2 (TBI on warfarin) – SLIDE #49
· Very high risk… be liberal with imaging
· No CDR to identify the low-risk patient
· Order INR on arrival
· Reversal of anticoagulation = resuscitation!
Case #3 (severe TBI) – SLIDE #94
· RSI with neuroprotective drugs
· Hyperosmolar therapy with either hypertonic saline or mannitol
· Do not hyperventilate unless there is clear clinical evidence of herniation
1. Remember to consider spontaneous cervical artery dissection in the differential diagnosis of a headache patient.
2. The majority of patients who develop an spontaneous cervical artery dissection will not develop a stroke.
3. Cerebral ischemia caused by cervical dissection is usually embolic rather than hemodynamic compromise caused by dissection-related stenosis or occlusion.
4. Stroke prevention is with antiplatelet or anticoagulant therapy, with no data supporting improved outcomes with either therapy compared to the other.
5. Endovascular therapy is increasingly being used in the acute treatment of stroke related to spontaneous cervical artery dissection.
The mnemonic for systematically evaluating a non-contrast head CT is “Blood Can Be Very, Very Bad”.
A Reassuring CT:
· No Blood is seen
· All Cisterns are present and open
· Brain is symmetric with normal gray-white differentiation
· Ventricles are symmetric without dilation
· No hyperdense Vessels are present
· No Bone fractures
- Only approximately 5% of all headaches that present in the ED are true emergencies
- After evaluating for potential emergencies and performing a full neuro exam, pause and consider if any of the following Red Flags are present:
To diagnose migraine, need 5 separate episodes of headache characterized by:
"Migraine” or undifferentiated benign headache, you can treat the same way in the ED
Best evidence for acute headache treatment includes the following:
Avoid narcotics and barbiturates out of concern for dependency and rebound effect
•Intracranial complications of acute bacterial rhinosinusitis include meningitis, brain abscess, subdural empyema and cavernous sinus thrombosis. Most common presenting feature of meningitis complicating sinusitis is seizure activity.
•IDSA encourages use of antibiotics for acute bacterial sinusitis when strict diagnostic criteria are met. Amoxicillin/clavulinateremains first line therapy.
NEONATAL VESICULAR RASH
•Many causes of vesicular rashes in the neonate are benign, but serious bacterial and viral infection must be evaluated.
•Neonatal scabies infestation presents with vesicular rash affecting the hands, feet, wrists and face of neonates. Treatment is with a single application of permethrin 5% cream, or 5-10% sulfur suspension in petroleum.
•Pancreatic cancer presents often in late stage due to vague symptoms of weakness, abdominal pain, diarrhea and jaundice.
•Recurrent visits for similar chronic complaints carry high risk. Consider serious pathology as underlying source.
Case 1 - S/P Arrest w/ STEMI
Case 2 - Ear Pain and Facial Palsy
Case 3 - Ataxia and Headache after Rollercoster Ride
Thyrotoxicosis and Cardiomyopathy