Neurologic Emergencies: How to Do a Fast, Focused Evaluation of Any Neurologic Complaint

322 Pages·2018·7.83 MB·English

by  Latha Ganti

Neurologic
Emergencies
How to Do a Fast,
Focused Evaluation
of Any Neurologic
Complaint
Latha Ganti
Joshua N. Goldstein
Editors
123
Neurologic Emergencies
Latha Ganti • Joshua N. Goldstein
Editors
Neurologic Emergencies
How to Do a Fast, Focused Evaluation
of Any Neurologic Complaint
Editors
Latha Ganti Joshua N. Goldstein
Orlando, Florida Boston, Massachusetts
USA USA
Disclaimer: The American College of Emergency Physicians (ACEP) makes every effort to
ensure that contributors to its publications are knowledgeable subject matter experts. Readers
are nevertheless advised that the statements and opinions expressed in this publication are
provided as the contributors’ recommendations at the time of publication and should not be
construed as official College policy. ACEP recognizes the complexity of emergency medicine
and makes no representation that this publication serves as an authoritative resource for the
prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be
the basis for the definition of, or standard of care that should be practiced by all health care
providers at any particular time or place. To the fullest extent permitted by law, and without
limitation, ACEP expressly disclaims all liability for errors or omissions contained within
this publication, and for damages of any kind or nature, arising out of use, reference to,
reliance on, or performance of such information.
ISBN 978-3-319-64521-6 ISBN 978-3-319-64523-0 (eBook)
https://doi.org/10.1007/978-3-319-64523-0
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My co-faculty, residents, nurses, and paramedics at
UCF/Osceola Regional Medical Center who lead by
example, and make my job super fun.
My dad Dr. Ganti L. Rao and late mother Prabha
Ganti for always pushing me to pursue my dream of
being a doctor and a writer. I wouldn’t have the
amazing career I do without you.
My children Thor, Tej, Trilok, Karthik & Vaishnavi for
their patience, resilience and grace – I may have
taught you to read and ace algebra, but you taught me
how to live life.
—LG
My teachers, mentors, and colleagues at
Massachusetts General Hospital for helping me build
an academic career that is interesting, fulfilling, and
fun.
My parents, brother, sisters, friends, and so many
family members that are immediate, extended, and
“other” – they taught me, raised me, and gave my life
meaning.
My wife Erica for her love and support all these years
(22 years so far!) even though I spent too many hours
over the laptop.
My children, Alexa and Lindsey, for filling my life with
joy, love, and (of course) dance. And for just being
awesome.
—JNG
This book was only possible thanks to the hard work
of so many people.
Our authors who put their time and effort into these
chapters, and their families who helped them do it!
Our team at Springer- Margaret, Gayathri &
Rajeshwari for keeping us on track and seeing us
through seamless production.
Marta Foster at the American College of Emergency
Physicians for encouraging us to co-publish this text
with ACEP.
—Latha Ganti & Joshua Goldstein
Foreword
Neurologic emergencies are not only some of the most common conditions seen
in the emergency department, but are also among the most devastating conditions
that we treat. The toll of severe neurological conditions not only involves life or
death but also impacts the lives of its victims even more profoundly. The long-
term sequelae from neurological emergencies include paralysis, loss of sensation,
loss of intellectual capacity, and personality change, all of which can be often life
changing.
Between 5 and 8% of all patients seen in emergency departments across the
United States will have neurological issues. These conditions range from neu-
rotrauma such as traumatic brain and spinal cord injury to ischemic and hemor-
rhagic stroke, status epilepticus, central nervous system infections, anoxic brain
injury, headache, and others. These conditions have a very high burden of dis-
ease. Acute ischemic stroke affects about 200/100,000 people in the United
States and has a mortality of 15–17% at 30 days. Intracerebral hemorrhage
affects about 15/100,000 people but has a mortality rate as high as 50% at 30
days. Status epilepticus affects 40/100,000 people in the United States with a
mortality rate of 22% at 30 days and subarachnoid hemorrhage affects 6/100,000
people with a mortality of 50% at 30 days. Not only are these diseases devastat-
ing in terms of death and disability, but the healthcare costs from these condi-
tions are enormous.
For many neurological emergencies, patient outcomes can be significantly
affected by rapid recognition and appropriate treatment. Ischemic stroke outcomes
have been profoundly affected by the use of intravenous thrombolytic agents and
recently by the effective use of endovascular treatment for large vessel occlusions.
Outcomes from status epilepticus are improved by rapid cessation of seizures with
appropriate antiepileptic drugs. We also know that prompt recognition and effective
treatment of hypoxia and hypotension can have profound impacts on the outcome of
patients with traumatic brain and spinal cord injury.
For these reasons, it is implicit that all emergency physicians have appropriate
knowledge and training in recognition and treatment of neurological emergencies.
Latha Ganti, M.D., M.S., M.B.A., and Josh Goldstein, M.D., Ph.D., have put
together this outstanding book on Neurological Emergencies to address this need.
The book has been structured to cover the broad landscape of neurological emer-
gencies and provide the essential keys to rapid recognition and diagnosis. Drs. Ganti
vii
viii Foreword
and Goldstein are notable experts in neurological emergencies and they have
recruited an outstanding list of authors to put this book together.
I am hopeful that this text will help emergency physicians to better recognize and
treat neurological emergencies and lead to better patient outcomes.
William Barsan MD,
Professor of Emergency Medicine
University of Michigan
Ann Arbor, MI, USA
Disclaimer
The American College of Emergency Physicians (ACEP) makes every effort to
ensure that contributors to its publications are knowledgeable subject matter experts.
Readers are nevertheless advised that the statements and opinions expressed in this
publication are provided as the contributors’ recommendations at the time of publi-
cation and should not be construed as official College policy. ACEP recognizes the
complexity of emergency medicine and makes no representation that this publica-
tion serves as an authoritative resource for the prevention, diagnosis, treatment, or
intervention for any medical condition, nor should it be the basis for the definition
of, or standard of care that should be practiced by all health care providers at any
particular time or place. To the fullest extent permitted by law, and without limita-
tion, ACEP expressly disclaims all liability for errors or omissions contained within
this publication, and for damages of any kind or nature, arising out of use, reference
to, reliance on, or performance of such information.
ix
Contents
1 The Fast and Focused Neurological Examination . . . . . . . . . . . . . . . . 1
Matthew S. Siket
2 Rule Out Acute Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Aunali S. Khaku and Sayed K. Ali
3 Acute Head Injury: When to Image and When to Observe? . . . . . . . 39
Tracy MacIntosh and Adam Benzing
4 Seizure Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Claire S. Jacobs and Imoigele P. Aisiku
5 Syncope: Who Needs Imaging? Who Needs Admission? . . . . . . . . . . 85
Ellen Vollmers and Sean Kivlehan
6 Dizziness: An Evidence-Based Approach (Better than MRI?) . . . . . . 103
Jonathan A. Edlow
7 Acute Vision Loss and Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
David C. Lebowitz, Amninder Singh, and Amanda Webb
8 Headache: When to Image, When to Tap . . . . . . . . . . . . . . . . . . . . . . . 143
Perrin T. Considine, Levi Filler, and Murtaza Akhter
9 Atraumatic Acute Neck and Back Pain . . . . . . . . . . . . . . . . . . . . . . . . 175
John W. Martel and J. Brooks Motley
10 The Nonanatomic Exam: Psychogenic Syndromes and Malingering 195
Michael Hoffmann
11 Altered Mental Status in the Emergency Department . . . . . . . . . . . . 209
Austin T. Smith and Jin H. Han
12 Acute Generalized Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Latha Ganti and Vaibhav Rastogi
xi