NONCONVULSIVE STATUS EPILEPTICUS

There are two scenarios where you might see non-convulsive status epilepticus (NCSE):

-Presentation of coma

-Failure to rouse after seemingly successful treatment of a seizure (one article said up to 20% of status epilepticus generates NCSE after resolution of the convulsion)

 

The gold standard is 48 hours of continuous EEG monitoring. Unfortunately at many EDs we rarely can get EEG monitoring at all. Thus we need to be mindful of some subtle clinical signs.

 

Clinical signs or triggers that might prompt you to consider non-convulsive status epilepticus:

-***history of epilepsy in someone in an unexplained coma***

-volatile vital signs

-dilated pupils

-twitching (disrobe patients. May especially notice this around the eyes, where it is easier to see)

 

TAKE HOME POINTS

-failure to rouse after seizure could indicate non-convulsive status epilepticus

-unexplained coma in someone with a history of epilepsy should trigger this possibility

-Disrobe the patient and look for subtle signs of twitching

-Consider autonomic signs – vital signs, pupils

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BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?

 

In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.

 

The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.

 

Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.

 

Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex

 

Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.

USE THE SWALLOW PROVOCATION TEST TO ASSESS AIRWAY PROTECTION

A patient presents obtunded. You wonder about airway protection and consider intubation. Is there any way at the bedside to gather more information before choosing to intubate?

 

This has not been well studied in the ED population mentioned above, but if you are wondering whether the patient is going to aspirate oropharyngeal liquids, you could consider a safe trial of seeing how they handle liquids.

 

Called the “swallow provocation test” it is done by injecting a “swallowful,” (ie 10 cc) of water into the mouth of the patient.

 

I have had patients leave the secretions there (so I suctioned them out) and proceeded to intubation. I recall one severely alcohol intoxicated patient swish it around in his mouth like he was seeing what it was, then lean over and spit it on the floor (I wondered what he would have done if it were a drink more of his choosing). He did not get intubated, needless to say.

 

While this approach is not validated, neither is your current approach! So consider using this in situations where you are not sure what they need.

 

Take home points:

-If you are wondering how the patient will handle liquids in the mouth, inject water and find out.

LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.

 

MOTOR

Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5

 

SENSORY

Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area

 

REFLEXES

 

Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1

DELIRIUM: COUNTING MONTHS BACKWARD

An elderly patient is brought by family for confusion. You wonder whether this is delirium, or whether dementia may have developed. As covered in a previous post, dementia is defined by a deficit in memory as well as one other cognitive function. You can easily test for 3 item recall and clock drawing. But for those tests to be valid at all you have to exclude delirium. The hallmark of delirium is inattention.

Have them count the months backward, starting with December, to see if they can maintain attention. This is 83% sensitive and 90% specific for delirium.(O’Regan JNNP 2014) Interestingly, the addition of confirmatory tests (CAM) to improve specificity worsened sensitivity to 62%. Of course, delirium is not a binary event but exists across a spectrum. So some of the deviation from perfection could merely indicate a different location on the spectrum of illness severity. In light of its simplicity and ease of use, I recommend using months backward in your ED delirium screening. This is not a gold standard but does contribute value in raising or lowering the probability.

You assess months backward and the patient goes no further than November. You suspect delirium, and are relieved when you discover a UTI. You give the family assurance that the confusion will improve, though she will need to see the family physician in follow-up to confirm cognitive function.

Take Home Points

-Delirum, in the ED, is identified by inattention

-Have the patient count the months backward as a fast bedside screening test

GAIT ASSESSMENT: WALK THE WALK  

A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.

 

The last time I tried really hard to analyze gait and make recommendations, it was so complicated that no one could remember it. I now have a more simple approach. An abnormal gait is either neurologic or orthopedic. If there is pain, it tends to be orthopedic. No pain suggests neurologic.

 

Next, don’t just watch the gait. Imitate it. Follow the child. This allows your proprioceptive neurons to do the thinking for you.

 

When you do that on this child you see she is splinting her hip. You examine the calmed child and get good range of motion of the ankle and knee. Internal and external rotation of the hip seems to cause discomfort. Now your differential is transient synovitis vs septic arthritis and you proceed from there.

 

Take Home Points:

Painful gait abnormalities are usually orthopedic. Painless are usually neurologic.

Walk the walk: imitate the gait so you can feel what they are doing with their gait

DEMENTIA: MEMORY + ONE MORE DOMAIN

An elderly patient presents brought by family for confusion. After a full but negative workup, you wonder whether this could represent dementia.

The main differential for confusion in this age group is delirium vs dementia.

Is the problem chronically progressive?

Dementia should have been slowly developing for months or years. If the problem is acute, consider delirium. The family states they are not sure about the time course, though you note that sometimes respect for the elderly expresses itself in overlooking the minor infirmities of aging.

Is the patient attentive?

Inattention is the hallmark of delirium. Have them count months backward to demonstrate attentiveness. If they can’t do that, they may be in a delirium and further testing for dementia is not valid. She can count months backward.

The definition of dementia according to DSM-IV is a chronic deficit in memory plus one more cognitive domain (mainly language, praxis, and executive function) not explainable by another condition.

A bedside examination can quickly assess this using 3 item recall at 5 minutes as well as clock-drawing. Patients with dementia usually have impairment in both modalities. When this examination is formalized as the “mini-Cog” it has been shown to have good sensitivity and specificity. It tests short-term memory and executive function as well as spatial awareness. I like to additionally test long-term memory, usually by asking about the previous three presidents.

She recalls one item at 5 minutes and can not draw a legible clock. She is able to describe but not name the current president. You suspect dementia and refer her to a neurologist for futher evaluation.

Take Home Points:

-Diagnosing dementia is invalid in delirium (acute, inattentive)

-Dementia: deficits in memory and at least one other cognitive domain

-3-item recall and clock-drawing assesses memory and executive/spatial functioning

HOW TO ELICIT REFLEXES

You are seeing a patient for possible stroke, and find no reflexes, on either side, upper or lower limb. Does that mean you didn’t do it right?

 

First of all, finding absent reflexes bilaterally in at least one pair of muscles is quite common. It happens in up to half of the ankles of normal elderly patients.(McGee, Evidence-Based Physical Diagnosis) Of course, some neurology texts, such as DeJong’s, state that one should be able to obtain reflexes, and that 97% of reflexes are obtainable. Perhaps it varies with the population. I have seen neurologists go to great lengths to find occult reflexes, such as whacking the tendon really hard, or using 4 foot long collapsable reflex hammers.

 

In the ED, it is probably sufficient to apply a consistent strike and document findings.

 

MUSCLE STRETCH

The muscle should be extended enough that there is no slack, but not overextended.

 

KEEP THE WRISTS LOOSE

For the swing, let gravity do the work, and like golf, make sure you have follow through. When you swing hard there isn’t much bounce. Your arm and shoulder absorbs some of the effect. That is why I suggest letting gravity do the work. What I am really saying here is to let it bounce. Don’t cushion it at all. If you swing hard, sometimes you inadvertently cushion. If you have ever split firewood you will know what I mean. The hard grip is not as effective as the loose grip.

PATIENT MUST NOT HAVE MUSCLE TONE

The patient should be relaxed. If they have muscle tone it blunts the reflex

 

ACCENTUATION MANEUVERS

The Jendrassik maneuver of clasping hands and pulling apart can accentuate lower extremity reflexes. Clenching teeth accentuates upper extremity reflexes.

 

Take home points:

Extend the limb to remove slack

Let gravity do the swing

Use accentuation maneuvers (Jendrassik/teeth clench) when needed

HORNER’S SYNDROME: FINDINGS ARE SUBTLE

Ptosis, miosis, and anhidrosis. The pathological term for the disease is “oculosympathetic paresis.” The term explains some of the other findings, including ipsilateral conjunctival injection, ipsilateral nasal congestion, upside down ptosis, and harlequin sign. It also explains why the presentation is subtle.

 

Unlike third nerve palsy, it is not the levator palpebrae superioris that is affected. Instead, it is the sympathetically-innervated Mueller’s muscle, which causes only 1-2mm of lid droop. Do an online images search of Horner’s syndrome, and you will see how subtle this can appear. Probably the best we can do is notice slight asymmetries and investigate further.

 

The miosis is easily missed too. If we typically examined patients in the dark, the miosis would stand out. But we see them in bright lights, where both eyes show a relative degree of miosis. If you notice anisocoria, turn the lights out. The Horner’s pupil will remain small. Even if it does eventually dilate, a delay to dilation is characteristic.

 

In summary, Horner’s syndrome is subtle. The ptosis is only 1-2mm, unlike the more dramatic ptosis of third nerve palsy. Miosis is less noticeable in the bright lights of the emergency department.

 

Take Home Points:

-Due to the sympathetically-innervated Mueller’s muscle, the ptosis of Horner’s syndrome is 1-2mm

-Miosis of Horner’s syndrome is best appreciated in the dark

LOCALIZE VERTIGO: LIKE IN A HEAD TURN, THE VOR PULLS THE EYE TO THE UNDERACTIVE SIDE

You are seeing a patient with suspected vestibular neuritis. The resident is having trouble with the physical examination. Will localization help her comprehend the bedside findings?

 

We understand neurolgical disease by localizing it. We can often localize vertigo, though it is more difficult for 3 reasons:

– the signal is tonic (there is always a basal tone which can then go up or down)

– it is bilateral

– Its sensory representation is space, which is not just within the body but includes the external world.

 

To localize vertigo, one only needs to know 2 physiological principles:

1) A head turn activates the ipsilateral labyrinth and suppresses the contralateral labyrinth.

2) The vestibulo-ocular reflex (VOR) makes the eyes move opposite the head turn.

 

Now let’s localize this patient’s vertigo.

 

Attending: “What direction is the spinning?”

Patient: “It is spinning to the left”

 

Attending (to the resident): “Now turn your head to figure out what induces a perception of ‘spinning to the left.’ (resident turns head to the right). Correct. A right head turn does this. So the patient has a more active right ear than left ear. Thus, the left ear is the suppressed ear. Let’s confirm that at the bedside with physical findings.”

 

Attending: “If the left ear is pathological, where will we see nystagmus, on right or left gaze?”

Resident: “Well the mnemonic of eyes to the ice would say left? Wait, no, to the right?”

Attending: “Forget about the mnemonic right now and use the head turn again. The VOR makes the eyes move opposite the head turn. So the eyes want to go to the pathologic side. When they look away from that you get nystagmus as the eyes try to overcome the pull, and then fatigue. So where do you see nystagmus?”

Resident: “When the eyes look away from the pull. So you get right beating nystagmus on right gaze.”

Attending: “Exactly. Nystagmus is the conscious mind overcoming the pull. We use nystagmus in cold calorics to confirm consciousness.”

Resident: (after testing the patient) “But there is no nystagmus either side.”

Attending: Ah, but you just got another localizing finding.

Resident: The hard blinking?

Attending: Yes, that is gaze aversion. It tells you the same thing nystagmus tells you. The eye doesn’t want to look that way. You can even ask the patient which side is harder to look at. That picks up subtler deficits.

Resident: So the lesson here is that the VOR makes the ear want to go to the pathologic side.

Attending: Exactly. The fast phase of nystagmus and gaze aversion on the right mean that the eye wanted to go to the left. Now we can confirm left pathology through one more test.

Resident: Head impulse test?

Attending: Exactly (this is performed and is equivocal to the left, normal to the right)

Resident: So do we need to get an MRI?

Attending: No. The studies you are thinking of were done on a select population with severe deficits. The patients were so sick they needed to consult neuro. This patient has a very mild presentation and we would not expect a definitive catch-up saccade. Future studies will catch up with this concept.

 

Take home points:

-You will forget these rules, but do not forget that turning your head to one side activates that ear and inactivates the opposite ear

-The VOR pulls the ear to the less active (pathologic) side, so the eye has trouble looking opposite that (fast phase nystagmus, gaze aversion on looking away from pathologic side)

The world spins toward the pathologic side

Head impulse test is positive to the pathologic side