Delirium

Definition

•  Acute state of temporary or fluctuating disturbance of consciousness (eg, impaired cognition, perception disturbances, reduced attention, hypo- or hyperactivity) that is caused by an organic medical condition or medication/drug (ie, not psychiatric)

•  Progressive, unremitting decline in cognitive function is dementia

Pearl

•  Organic etiology (as opposed to functional/psychiatric) is more likely if age <12 or >40, having visual hallucinations (as opposed to auditory), acute onset, or any abnl exam

Dementia

Definition

•  Chronic steady decline in short- & eventual long-term memory

•  Stuttering course may point to vascular (multi-infarct) dementia due to lacunar infarcts

VERTIGO

Definition

•  The sensation of disorientation in space combined w/ sensation of motion/spinning

Approach

•  Onset, duration & severity of sxs, exacerbating & alleviating factors, associated sxs

•  Ask about trauma & risk for vertebral artery injury (torsional neck injury, chiropractic)

•  Careful history: Distinguish b/w vertigo & presyncope or lightheadedness

•  Consider ECG to r/o arrhythmia/MI, glucose to r/o hypoglycemia, CBC to r/o anemia

•  Exam should include carotid bruits, otoscopy, cerebellar exam, gait, nystagmus ± Hallpike

•  Vertigo is broadly classified as peripheral or central in etiology

•  Peripheral etiologies are usually nonemergent

•  Central etiologies are generally emergent diagnoses, account for 10% of cases

•  RFs for central vertigo: Older age, males, HTN, CAD, DM, AF, h/o CVA/TIA

Central Vertigo

History

•  See tables above. Consider RFs when determining w/u.

Evaluation

•  Head CT useful as initial exam for hemorrhage but limited utility for cerebellum/brainstem

•  MRI, when available, is diagnostic modality of choice for cerebellar process

•  Consider CTA or MRA to evaluate for vascular dz (carotid, vertebrobasilar)

Treatment

•  Symptomatic relief (antiemetics, benzodiazepines). Neurology consult.

Disposition

•  Depends on findings, severity of sxs. Admit if high risk for vascular etiology.

Peripheral Vertigo

Treatment

•  Usually supportive care w/ antivertigo medications:

•  Diazepam 2–4 mg IV/5–10 mg PO, meclizine 25 mg PO, diphenhydramine, promethazine

•  For BPPV, consider trying Epley maneuver (or modified self-Epley maneuver at home)

•  For acute bacterial labyrinthitis: ENT consult, IV abx, usually need admission

•  For Ménière’s: Supportive medications, encourage decreased salt intake, close ENT f/u

Disposition

•  Home once sxs improve w/ PCP/ENT f/u

•  Admit if vertigo refractory to ED tx or acute bacterial labyrinthitis

FACIAL DROOP

Approach

•  Quickly distinguish UMN (central) from LMN (peripheral) lesion by testing strength of eye closure & eyebrow elevation

•  Central etiology spares forehead due to bilateral innervation → w/u for stroke

•  Bedside fingerstick blood glucose early b/c hypoglycemia can cause this

BELL’S PALSY

History

•  Acute (over hours) onset painless unilateral facial droop; no other neuro signs or sxs

•  RFs: Adult, diabetics, pregnancy. Recent hiking in endemic area suggests Lyme dz.

•  Accounts for ∼50% of all facial palsies. Can be bilateral, but this requires further w/u.

Findings

•  Paralysis must include forehead. Inability to smile or close eye, drooling, hyperacusis.

•  No other neuro findings, but speech affected due to weakness

•  Look for findings of spec etiology; eg, erythema migrans (Lyme), vesicles (HSV)

Evaluation

•  Full neuro exam, pay special attention to CNs. No labs if typical presentation.

•  If atypical presentation, other signs, systemic sxs: Neuroimaging & neuro consult

Treatment (Neurology 2012;79(22):2209)

•  Artificial tears, tape eyelid before sleeping to prevent corneal injury (cannot close lids)

•  Prednisone 60 mg QD × 5, then slow taper (10–14 d)

•  No empiric abx, but consider if concerned or severe: Acyclovir (HSV), doxycycline (Lyme)

Disposition

•  Home w/ reassurance, neuro f/u if paralysis persists for months

•  Prognosis: 80–90% complete recovery in 2–3 mo. 10% permanent. 14% recurrence.

HEADACHE

Approach

•  Must differentiate life-threatening HA from vast majority of benign HAs

•  Evaluate associated sxs: Photophobia, vomiting, visual changes, eye pain, focal neuro sxs

•  Assess for head or neck trauma, medications, substance abuse

•  Red flags requiring neuroimaging: Sudden/rapid onset (<1 h to peak), exertional onset, worst of life, AMS, 1st severe HA >age 35, fever, neck stiffness, immune compromise, daily HA, no similar prior HAs, abnl neuro exam, meningismus, papilledema

PRIMARY HEADACHE SYNDROMES

Migraine

History

•  Slow in onset, unilateral throbbing or pulsatile, often w/ N/V, photophobia

•  Usually lasts 4–72 h, visual aura or prodrome may precede HA (15%)

Findings

•  nl neuro exam or stereotypical neuro deficit that may last hours (complex)

Evaluation

•  No studies or consults indicated unless need to exclude other cause w/ CT/LP

Treatment

•  Prophylaxis: TCAs, BB, anticonvulsants

•  Abortive: “Migraine cocktail” of dopamine antagonist (eg, prochlorperazine, metoclopramide) w/ diphenhydramine (↓ extrapyramidal sxs), IVF, NSAIDs, or APAP

•  Other options include triptans, dihydroergotamine (DHE), & dexamethasone

•  DHE, sumatriptan contraindicated in pregnancy & pts w/ CAD

Disposition

•  Home if migraine improved, admit if HA unresponsive to tx

Pearl

•  Be wary of diagnosing a 1st-time migraine in pts of age >35

Tension Headache

History: Dull, aching pressure HA a/w muscle tension in neck or lower head, sometimes a/w depression, anxiety, worsens at end of the day

Findings: nl neuro exam

Evaluation: No studies or consults indicated unless need to exclude other cause w/ CT/LP

Treatment: NSAIDs or APAP, neck massage & heat, relaxation techniques, not narcotics

Disposition: Home once HA improved, admit if HA unchanged w/ meds

Pearl: Most common cause of benign HA

Cluster

History: Sudden onset unilateral, paroxysmal, sharp, stabbing eye pain that may awaken from sleep; clusters of several episodes/week for up to 6–8 wk, more common in men

Findings: ± ipsilateral lacrimation, flushing, rhinorrhea or nasal congestion, conjunctival injection or Horner syndrome (30% of pts)

Evaluation: No studies indicated unless need to r/o other cause (eg, 1st time worst HA)

Treatment: High-flow O₂ (7–10 L/min) by mask, sumatriptan (avoid in pregnancy or CAD), intranasal lidocaine, NSAIDs. Prophylaxis: Prednisone 60 mg ×10 d then taper, ± verapamil or valproic acid.

Pearl: Make sure to distinguish from acute angle-closure glaucoma

VASCULAR

Subarachnoid Hemorrhage (Nontraumatic)

Approach

•  This is considered one of the most difficult diagnoses in Emergency Medicine.

•  Note that ruptured aneurysms are generally not subtle, present like a hemorrhagic stroke

•  Goal of working up “worst HA of life” is actually to identify sentinel bleed (leak), which occurs in 30–50% of pts, so that we can look for an aneurysm in hopes that it is amenable to intervention.

•  20% of SAH are nonaneurysmal (eg, AVM) & these have good prognosis

•  Low threshold to work this up. Know that even SAH HA often improves w/ meds.

Presentation

•  Classically sudden “thunderclap” HA, maximal pain <1 h, “worst HA of life”

•  Additional historical red flags for SAH: Onset w/ exertion/Valsalva, neck stiffness, arrival by ambulance, LOC, vomiting

•  RFs: Age >60, FH (4× risk), HTN, smoking, alcohol, cocaine, amphetamine use, PCKD, collagen/connective tissue disorders

•  Neuro exam is often nl. May have ocular motor palsy 2/2 aneurysm compression.

Evaluation

•  CTH: In pts who are low risk by hx & nl neuro exam, sens 100% w/i 6 h, 86% after 6 h (BMJ 2011;343:d4277).

•  Some sources recommend no LP in this pt population w/ negative CTH <6 h after onset

•  LP (gold standard for bleed): Xanthochromia is 100% sens after 12 h

•  No established “lower limit” for RBCs

•  CTA: Reaches sens of 98% for bleed, but is improving & will likely play greater role

•  Conventional angiography is the gold standard for identifying an actual aneurysm, if LP +

Management

•  If LP +, consult neurosurgery/IR & see Hemorrhagic Stroke section below

Disposition

•  Admit

Hypertensive Headache

History

•  Untreated HTN or other precipitants (pregnancy, drug use, serotonin syndrome)

Findings

•  BP often >240/140 (unlikely w/ DBP <120)

•  Papilledema, encephalopathy, ± focal neuro abnormalities or sz

Evaluation

•  Head CT to eval for edema or ICH; consider A-line for frequent & accurate BP checks

•  Look for other end-organ damage (hypertensive emergency): EKG for AMI, signs of aortic dissection, pulmonary edema, renal failure

Treatment

•  Goal is ↓ MAP by 25% over 1 h (↓ BP too quickly could lead to ischemia)

•  May use nitroprusside (except in pregnancy) 0.5 μg/kg/min or Labetalol 1–2 mg/min

Venous Sinus Thrombosis

History

•  Hypercoagulable state, (eg, 73% are pregnant/postpartum)

•  Gradual onset HA (average time to Dx is 7 d), visual changes, nausea, vomiting

Findings

•  Papilledema, leg weakness, focal neuro deficits

•  Cavernous sinus: CN III, IV, & VI compromise

•  Lateral sinus thrombosis: Middle ear infection sxs

Evaluation

•  Commonly start w/ CTH/CTV, but MRV is most sens

Treatment

•  Anticoagulation (heparin) ± direct infusion of thrombolytics

Pearl

•  Results from the occlusion of venous sinus causing congestion & then ischemia

CNS INFECTIONS

Meningitis

History

•  HA, fever, neck stiffness, lethargy, AMS; ask about recent illness, travel, immunosuppressive medications, head trauma, or surgery

•  Bacterial: Typically acute (<1 d), high-grade fever, HA, nuchal rigidity, ill appearing

•  Viral: Typically subacute (1–7 d), also w/ HA, fever, photophobia

•  Fungal/TB: Subacute (>1 wk), HA, low-grade fever, weight loss, night sweats

Findings

•  Fever (very sens), HA, nuchal rigidity (in 50%), often photophobia, AMS

•  Brudzinski sign (hip flexion elicited by passive neck flexion) & Kernig sign (inability or reluctance to extend knee when hip is flexed to 90) are only 5% sens

•  Petechial rash suggests meningococcus

•  Expect subtle presentation in elderly or immunocompromised pts; may be AMS only

Evaluation

•  If bacterial etiology suspected by hx/exam, abx should be given immediately, before LP

•  Blood cultures, full infectious w/u (CBC, CXR, UA). ↓ PLT suggests meningococcus.

•  See table below for indications for CT prior to LP

•  LP tubes: (1 & 4) cell count & diff, (2) glucose & protein, (3) Gram stain, cx ± HSV PCR

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