em 8.1 - nervous system

A patient says, "I have migraines." What should you clarify first?

🔴When did they start🔴/where they were actually diagnosed; many patients self-diagnose. For example, not all migraines are headaches.

Why is a new headache beginning after about age 50-55 concerning?

It raises concern for a secondary cause such as 🔴intracranial tumor🔴.

In a patient with known migraines, what key question should you ask?

🔴Is today's headache different from your baseline?🔴

What headache question screens for SAH? Why?

🔴How long did it take to get to its worst point?🔴 Fast = bad.

What character red flags are important in headache?

Unbearable and constant.

What associated headache red flags are high yield? [6]

Fever, AMS, focal neuro deficit, vision change, nuchal rigidity, seizure.

What history makes a headache more concerning?

No prior headache history or change/worsening of the usual pattern.

What medications increase concern in headache patients?

Anticoagulants (worried about brain bleed) and immunosuppressants (worried about a bad infection)

What 3 conditions increase concern in a headache patient?

Cancer, SLE, and pregnancy.

SLE can lead to what kind of symptoms?

Headache, backache.

Pregancy + headache shoudl make you think of?

Pre-eclampsia.

What exam must be documented for every ED headache?

A neurologic exam.

What meningeal finding should be documented as absent in benign headache? What physical exam test does this realte to?

Meningismus/nuchal rigidity.

Negative Brudzinski's: "Patient able to touch chin to chest without grimace or discomfort."

🔴Are routine IV fluids effective migraine treatment according to the lecture?

No.

Why is fundoscopic exam important in headache?

To look for papilledema from increased ICP.

What 3 components make up the migraine cocktail?

1 Antiemetic

1 Benadryl

1 Toradol

What is a disclaimer in using Toradol in the migraine cocktail?

Only use if we're positive there isn't a brain bleed.

Which antiemetics are listed for migraine treatment? How would you give it

Promethazine (Phenergan) [give it with a 250 bolus] or Metoclopramide (Reglan)

Adverse effect of IV Promethazine (Phenergan) ?

Necrotizing effects of extravasation.

What can be tried if the initial 3migraine cocktail fails?

Haldol 5 mg.

A counseling caution for patients post being given a migraine cocktail? How long to wait before discharging them?

• They will be sleepy; it's better if they have a ride

• But if not, caution should be advised and documented if driving

• If they are a regular - you don't always need to wait to document

improvement (we know the treatment works)

• you can just treat and discharge

What imaging is first-line for a headache with major red flags? Why?

🔴 Noncontrast head CT. Because if you're just looking for bleed and blood will be white on CT. You don't need dye to see this.

If there is associated trauma, what may head CT non contrast show?

Subdural or epidural issue.

What type of drugs are triptans?

Abortive migraine medications.

In spontaneous severe headache without trauma, what bleed is a major concern?

Subarachnoid hemorrhage (SAH).

What is the lecture's diagnostic sequence for suspected SAH?

Noncontrast CT → LP if CT is nondiagnostic (sentinel bleed may not show up) and suspicion remains high.

If high suspicion of tumor but CT normal, what is the next step?

MRI with PCP.

What LP finding is classically associated with SAH?

Xanthochromia.

How can a traumatic tap differ from true SAH?

RBCs may clear from early to later LP tubes. So draw 4 tubes to see the pattern!

What major SAH risk factors were emphasized?

Family history, Marfan, Ehlers-Danlos, PKD, HTN, smoking.

What pathophysiologic sequence occurs with intracranial bleeding?

Bleed → increased ICP → decreased cerebral perfusion.

What BP goals does the lecture give for head bleed? Why?

SBP less than 160 mmHg or MAP less than 110 mmHg.

The blood pressure will increase when there is an obstruction.

Intracranial hemorrhage- what forms of medicines should you use to control blood pressure and why? Which one's specifically?

Use IV meds easy to titrate on & off.

Nicardipine, or esmolol.

For a brain bleed, make sure to also call ___.

Neuro.

When investigating for subarachnoid hemorrhage, consider ___ prophylaxis.

Seizure.

In concern for subarachnoid hemorrhage, what medicine should you use, and should you not?

1 gram keppra, NO phenytoin.

What positioning helps with increased ICP?

Elevate the head of the bed.

What may be considered if herniation is suspected? What if that doesn't work?

3% hypertonic saline 250 mL.

Mannitol can also be given.

What's an important pearl regarding subarachnoid hemorrhages and triptans?

Triptans can help the pain; don't be fooled if your patient gets better with these.

Does improvement with a triptan rule out SAH?

No.

How sensitive is CT for SAH within about 6 hours per the lecture?

Nearly 100%.

In the context of a brain bleed, vomiting is an __ sign.

Ominous.

If CT is negative but SAH suspicion remains high, what should you do?

Proceed with further evaluation, especially LP.

What is pseudotumor cerebri now called?

Idiopathic intracranial hypertension (IIH).

Pseudotumor cerebri (idiopathic intracranial hypertension) is a ____ diagnosis.

🔴"Cannot-miss."

What symptoms suggest idiopathic intracranial hypertension (IIH)?

Headache + visual changes.

What classic patient/findings suggest IIH?

Overweight woman with headache, visual changes, and papilledema; risk is permanent blindness.

IIH- What should you do for physical exam?

Fundoscopic exam to look for papilledema; can also look at the optic nerve via ultrasound.

How do you diagnose pseudotumor cerebri?

MRI.

Pseudotumor cerebri treatment in the ER?

LP and IV steroids with specialty consultation.

Definitive IIH traetment?

Neurosurgery.

What are the major parts of a high-yield ED neuro exam?

Mental status, CN II-XII, strength, sensation, coordination, and reflexes when indicated.

How do you check via questions if a patient is alert and oriented?

Ask their name, where they are, the date/day, and why they're here.

What should you assess during mental-status evaluation?

Orientation, ability to give a clear history, and coherent timeline.

2 questions to ask to assess a patient's mental status? What should you do if both of these are true?

Can they give a clear history? Do they demonstrate a coherent timeline?

Document: "Patient has a normal mental status with regard to baseline" "Patient is grossly oriented"

When mental status is deem to be abnormal on interview, what objective score should be calculated?

Glasgow Coma Scale (GCS).

What 3 categories make up the GCS?

Eye opening + verbal response + motor response.

What is the highest possible GCS?

15.

What is the lowest possible GCS?

3.

How often should you recheck the GCS?

Periodically.

GCS eye opening: 4 / 3 / 2 / 1?

Spontaneous / voice / pain / none.

GCS verbal: 5 / 4 / 3 / 2 / 1.

Oriented / confused / inappropriate words / sounds / none.

GCS motor: 6 / 5 / 4 / 3 / 2 / 1.

Obeys / localizes / withdraws / flexes / extends / none.

Why may GCS need serial reassessment?

Mental status can evolve over time.

What quick commands assess gross upper-extremity strength?

Squeeze fingers; push and pull.

What quick commands assess gross lower-extremity strength?

Hip flexion, knee extension/flexion, dorsiflexion, plantar flexion.

How to test Cranial Nerves II-XII?

-Shine light in each eye (CN2/3)

-"Follow my finger"- H pattern (CN3/4/6)

-Visual fields- "Which finger is moving" (CN2)

-Open up and say "ah" & "stick out tongue(CN9/10/12)

-"Hear this on both sides" (CN8)

-"Shrug your shoulders" (CN11)

"Clinch your jaw" (CN5)

-"Eyebrows and happy face" (CN7)

🔴PERRL + EOMs and absent ptosis means?

Pons is w/out lesion or brainstem stroke.

What are the 5 UE motor roots?

C5, C6, C7, C8, T1

What movement tests C5?

Shoulder abduction. Chicken Wing Test.

What movement tests C6?

Wrist extension. "Up" in motorocycle test.

What movement tests C7?

Wrist flexion. "Down" in motorcycle test.

What movement tests C8?

Finger flexion. Lock hands and pull.

What movement tests T1?

Finger abduction/hand extensors. Keep fingers spread.

How to test lower extremity strength via physical exam?

"Bend at the hip" "Kick out / pull back"

🔴What does normal walking/squatting/standing suggest?

Gross L1-S1 motor function is intact.

What LE roots are tested by hip flexion aka "press your knees up"?

L1-L3.

What LE roots are tested by knee extension? "Kick out"

L3-L4.

What LE root is tested by dorsiflexion? "point toes up"

L5.

What LE root is tested by plantar flexion? "point toes down"

S1.

A note about checking sensation in a neuro exam?

Get adequate exposure if you are checking sensation

How to test coordination for neuro exam?

- cerebellar function (finger to nose, heel to shin

- balance & gait (Romberg)

Which reflexes are there to test?

C5-Biceps

C6- Brachioradialis

C7- Triceps

L4- Patellar

L4-5, S1-2- Babinski (toe extensor)

S1- Achilles

A positive Babinski test (toe extends up) would indicate:

If an upper motor neuron issue

If coordination/balance is abnormal, what emergency should you consider?

Posterior circulation stroke.

When are reflexes especially indicated?

🔴Suspected cauda equina or abnormal initial neuro screen.

What reflex finding is most concerning?

🔴Marked asymmetry. (probably more than 2+ difference)

What do hypo- vs hyperreflexia generally suggest?

Hypo = lower motor neuron/reflex arc; hyper = upper motor neuron (brain)

If patient has a headache - key questions to ask ?

- H/o migraine : when/where were you diagnosed? when did they start?

- If today's migraine different from baseline

- Red flag

- Describe headache

Suspecting subarachnoid hemorrhage - key questions to ask patient ? Meaning?

- "How long did it take to get to its worst point" (Fast = bad)

- "When was the last time you had a headache this bad?"

___ a benign HA that fits the picture of Migraine, Tension, or cluster.

Document.

In asking about HA in patient who has a history of headache, document the ___ between this HA and past ones.

Consistency.

What type of neurologic symptoms are classic for stroke?

Negative/ablative symptoms: loss of normal neurologic function.

What are "irritative" neuro sx?

Addition of new, atypical sensations.

What are "irritative" neurologic symptoms more suggestive of?

Stroke mimics such as migraine, radiculopathy, or focal/partial seizure.

What focal deficit is classic for stroke?

Sudden unilateral face/arm/leg weakness or numbness.

What other sudden symptoms suggest stroke?

Confusion, speech trouble, gait/balance problems, vision loss, or severe headache.

What is the single most important time question in suspected stroke?

When was the patient last known normal?

Why is last-known-normal time critical?

It determines eligibility for time-sensitive reperfusion therapy.

What should happen while an acute stroke patient is going to CT?

Interview and neuro assessment should occur without delaying imaging.