ER HA readings Flashcards
How common are benign HAs?
VERY
96%
Red flags of HAs
Sudden
Trauma
Exertion
AMS
Seizure
Fever
Neuro complaints
Vision changes
Medications (AC, AB, immunosuppressants)
No HAs in past
Change in quality or progressive
worsening over weeks or months
also
substance abuse
How often is a thunderclap HA associated with a high risk etiology
only about 10-14 %, but still need to r/o!
when are erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) useful?
Temporal arteritis
When might you order an MRI for a HA?
Sus of cerebral venous thrombosis after negative CT
When would you order an LP for HA?
Negative CT and worried about meningitis, encephalitis, or SAH
What two etiologies is concerning in elderly patients, blood thinner patients, alcoholics, and substance use patients
subdural hematoma or intracerbral hemorrhage
If HA is paired with vestibular symptoms, what might be the cause?
cerebral hemorrhage causing loss of BF to vestibulochoclear nerves
might need surgery to remove clot
Classic s/s of brain tumors?
Nothing specific about location or onset but:
Worsen upon wakening, valsava (coughing), positional, and associated w/ N/V
also risky if FH, seizures, or AMS
RF for cerebral venous thrombosis
hypercoaguable state (oral contraceptives, preggo, clot abnormalities, polycythemia)
What might the PE be for cerebral venous thrombosis?
papilledema may be present (increased venous pressure), and neurological findings can wax and wane
What would a LP for cerebral venous thrombosis show?
Elevated opening pressure
Most useful imaging for cerebral venous thrombosis
MR venography
What is temporal arteritis aka?
Giant cell arteritis
What is temporal arteritis?
systemic vasculitis that can cause a PAINLESS ischemic optic neuropathy.
What patient demographic is concerning for temporal arteritis?
women 50+ and increases with age
think that as you get older, you are more likely to get inflammation
Temporal arteritis s/s (non-artery related)
Fatigue
Fever
Jaw claudication (pain with chewing)
Vision changes
Sore throat (near the throat)
URI symptoms (near the UR system)
anorexia (d/t difficulty w/ eating)
Temporal arteritis temporal artery s/s
Tender
Non-pulsatile
Diminished pulse
(think lack of blood flow from inflammation)
unilateral (typically)
Can also be normal :)
what are the eye findings of temporal arteritis?
Afferent pupillary defect (eye constricts with consensual but NOT direct light)
Flame hemorrhages from vasculature inflammation
6th CN palsy (difficulty looking laterally)
why is temporal arteritis especially concerning?
One-third of the cases are associated with neurologic events such as transient ischemic attacks or stroke.
What is the most useful way to support diagnosis of Temporal arteritis? What is the definitive diagnosis?
ESR and CRP (remember) both are elevated
CRP is more sensitive
Temporal artery biopsy
apart from neurological events, what is a concern of untreated temporal arteritis?
bilateral vision loss
Temporal arteritis w/out suspected vision loss treatment
Stop inflammation with oral prednisone DAILY
Consult with an ophthalmologist or other appropriate specialist to arrange a temporal artery biopsy to confirm the diagnosis and for appropriate follow-up and continued treatment.
Temporal arteritis w/ suspected vision loss treatment
methylprednisolone
DO NOT DELAY TREATMENT
trigeminal neuralgia (TN) symptoms
facial pain along the CN V distribution
How is pain characterized with trigeminal neuralgia? Length?
paroxysms of SEVERE pain lasting SECONDS
What is the PE of trigeminal neuralgia?
normal
treatment of trigeminal neuralgia
Carbamazepine
MC benign cause of HAs in the ER?
Migraines
tension is the MC in the office
Are migraines more constant or pulsatile?
Pulsatile
but constant baseline pain
Idiopathic intracranial HTN is AKA? What patient population is this MC in?
pseudotumor cerebri
obese women 20-44 yo
s/s of idiopathic intracranial HTN?
Think of not getting too much BF
HA
transient vision loss/ disturbance
back pain
pulsatile tinnitus
What is the main concern of untreated idiopathic intracranial HTN?
Permanent vision loss
How to dx idiopathic intracranial HTN
Papilledema
Elevated LP opening pressure
NORMAL NEURO EXAM
When does intracranial HYPOtension occur and what are the s/s?
LP or epidural anesthesia interrupting the dura
HA worsens with upright posture and improves when lying down (d/t gravity)
What is the s/s of cluster HAs and are they common?
Not common
Severe unilateral pain around the eye
lacrimation, nasal congestion, rhinorrhea, conjunctival injection, and pacing in the exam room (increased autonomic NS)
First step of ED care of HA
Assess patients with an initial history and physical examination. When indicated, utilize appropriate diagnostic testing and/or neuroimaging based on risk factors, patient history, and physical findings. Disease- specific treatment and specialty consultation are indicated in the appropriate clinical circumstances.
What to consider before discharging a patient
WHERE
Consult with appropriate specialists based on the suspected underlying cause of headache, if symptom control is not adequately achieved in the ED, or if admission for further diagnostic testing or treatment may be needed.
when patients are discharged home, what should you discuss?
discuss indications for return and reassessment such as worsening of symptoms, failure to improve, or the development of new symptoms such as fever, neck stiffness, vision changes, or neurological abnormalities. Advise patients about expected side effects of medications prescribed or given in the ED. Recommend appropriate follow-up and outpatient management instructions based on the suspected diagnosis.
What is meningitis?
Meningitis is inflammation of the membranes surrounding the brain and spinal cord.
What is aseptic meningitis?
A = not
septic = bacteria
Not from bacteria: drug reactions, rheumatologic conditions, or nonbacterial infections such as fungi or viruses
MC cause of aseptic meningitis
Enteroviruses and echoviruses
classic meningitis triad
fever
neck stiffness
AMS
(often don’t have all three)
HA is also common
What populations is meningitis especially hard to diagnose?
Very young
Very old
Are kernigs and brudisnkis good indicator of menignitis?
They have poor sensitivity (high # of false negatives) but good specificity (if you have it, you likely have the disease)
What to look for on a skin exam for meningitis?
petechiae, splinter hemorrhages, or other findings concerning for sys- temic infection
MCC of encephalitis and what it presents as
Viral
an infection of the brain parenchyma that causes inflam- mation within the CNS
Most treatable cause of encephalitis
HSV
herpes
What is the presentation of viral encephalitis and how it differs from bacterial meningitis?
Very similar:
fever, stiff neck, or headache
but encephalitis has more emphasis typically on psych effects - altered mental status, cognitive deficits, psychiatric symptoms, or seizures.
What is the first-line test for encephalitis and bacterial meningitis? When might you hold off on this test?
LP: to obtain cerebrospinal fluid (CSF)
Consider a CT scan of the brain before the procedure when altered mental status, new onset seizures, immunocompromise, focal neurologic signs, or papilledema are present.
The goal for imaging in this circumstance is to identify possible contraindications to LP such as an occult mass or signs of brain shift or herniation (see Fig. 148-1).
What do you use the CSF for when doing an LP for encephalitis/bacterial meningitis?
Send CSF for cell count and differential, protein and glucose levels, and a Gram’s stain and bacterial culture.
3rd vile is for suspected underlying etiology (HSV or enterovirus PCR, bacterial antigen testing, or specialized fungal testing can be considered as additional testing in appropriate clinical situations.)
apart from LP, what might you order for meningitis/encephalitis?
CBC
CMP
BUN/Cr
Blood culture
What suggests a bacterial vs viral CSF?
Bacterial:
elevated opening pressure
cloudy
increased WBC
decreased glucose (eats glucose)
increased protein (poops out protein)
viral:
Normal OP
clear or bloody
decreased WBC
normal glucose
normal protein
When do you treat bacterial meningitis?
immediately after LP
treatment of bacterial meningitis in adults <50 yo
ceftriaxone
vanc
dexamethasone for inflammation
what do you add to the typical AB regimen for bacterial meningitis and when do you do it?
Ampicillin (to amp it up)
Patients at risk for Listeria monocytogenes infection (e.g., age 50 years or older, pregnant women, alcoholics, immunocompromised patients)
so:
ceftriaxone
vanc
ampicillin
dexamethasone for inflammation added before meds
treatment of typical encephalitis with possible HSV or VZV
Acyclovir
(because viral)
treatment of CMV encephalitis
ganciclovir
treatment of viral encephalitis that is not HSV, VZV, or CMV
No specific treatment and transitory
supportive care
after receiving AB regimen, Patients with suspected bacterial meningitis or encephalitis should be ___
admitted to the hospital for intravenous antimicrobial agents and further care.
What is a brain abscess?
A brain abscess is caused by a bacterial infection of the brain parenchyma and is composed of a CENTRAL PURULENT CAVITY ringed by a layer of granula- tion tissue and an outer fibrous capsule.
s/s of brain abscess? Do these differ from meningitis/encephalitis
NONSPECIFIC
headache, neck stiffness, fever, vomit- ing, confusion, or changes in mental status. Patient symptoms may reflect the origin of the infection (e.g., ear or sinus pain), and symptoms may be present for 1 to 8 weeks before the diagnosis is made.
Preferred imaging of choice for a brain abscess
CT w/ contrast more likely to accu- rately identify an abscess with thin rings of enhancement surrounding a
low-density center.
MRI also is good!
What should you avoid for a brain abscess?
Performing a LP
If possible, what should you do during the workup of a brain abscess other than imaging?
When possible, obtain blood cultures or cultures of other sites of infection to guide future management.
How to treat brain abscess?
empiric AB therapy based on the most likely source of infection
Consult with a neurosurgeon for admission to the hospital as many pa- tients will require surgery for diagnosis, pathogen identification, and definitive treatment.
What is a spinal epidural abscess?
rare infection consisting of pyogenic material that accumulates in the epidural space. Up to half of these infections originate from hematogenous spread of bacteria from soft tissue, urine, or respiratory sources.
What anatomical location do most spinal epidural abscesses originate?
Thoracic and lumbar spin (lower down)
Classic triad of spinal epidural abscess
back pain, fever, and neurological symptoms
seen in a minority of patients though
MC complaint of a spinal epidural abscess
Back pain
What are the 4 stages of symptoms for a spinal epidural abscess?
(1) back pain, fever, and localized spinal tenderness
(2) spinal irritation with radicular pain, hyperreflexia, and nuchal rigidity
(3) fecal or urinary incontinence plus focal neurological deficits; and
(4) motor paralysis of the lower extremities.
What are the RF for epidural abscess?
Immunocompromised states, intravenous drug abuse, spinal surgery, or recent procedures such as lumbar puncture or epidural anesthesia.
things that could cause infection of the epidural space!
Apart from assessing for midline spine tenderness to palpation or percussion and addressing neuro complaints, what are you really worried of with epidural abscess?
cauda equina syndrome. For example, decreased rectal tone has a reported sensitivity of 60% to 80%, while decreased perineal sensation has a sensitivity of 75%.
what labs should you order for epidural abscess and why is it difficult to diagnose?
nonspecific present- ing symptoms and the rarity of this condition.
Laboratory studies such as CBC, erythrocyte sedimentation rate, and C-reactive protein may be help- ful. Blood cultures are positive in 40% of cases and can be helpful to guide treatment after admission to the hospital.
Preferred imaging of epidural abscess? 2ndary?
MRI w/ gadolinium
CT scan with myelography may be helpful if an MRI is not possible.
1st line treatment epidural abscess
Spine surgeon referral for surgical debridement + AB
When do you initiate empiric AB for epidural abscess?
neurological dysfunction, signs of sepsis or systemic illness, or if immediate surgery is not available
typical Empiric AB therapy for epidural abscess
Vanc + ceftazidime or cefepime
When do you add an additional AB for an epidural abscess and what is it?
gentamycin 5 mg/kg IV in a patient with a recent neurosurgical procedure
SO:
Vanc + gentamycin + ceftazidime or cefepime
when receiving surgery from a gentleman, get gentamycin
