UMEM Educational Pearls - By Danya Khoujah

Contrary to a popularly held belief that one can estimate the age of a bruise by its color, present day research found that the color of a bruise at the time of its initial appearance is unpredictable. It is also affected by medications.
Take Home: Do not assumptions about the age of the bruise based on the color.

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Category: Neurology

Title: Headache in the Bodybuilder

Keywords: headache, steroids, bleed (PubMed Search)

Posted: 2/28/2018 by Danya Khoujah, MBBS
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Benign headaches are common in bodybuilders. However, several less benign headaches are worth noting:

  • Low cerebrospinal fluid (CSF) pressure headache: caused by a small dural tear mostly at the thoracic level. Similar to postdural headache. Treated by recumbency, and blood patches if recalcitrant.
  • Subarachnoid hemorrhage (SAH)
  • Spontaneous intracranial hemorrhage
  • Ischemic stroke
  • Dural sinus thrombosis

All except the first two are exclusively reported in patients on anabolic steroids, growth hormone, and/or “energy” supplements. Make sure to ask your patient about these risk factors.

 

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Category: Geriatrics

Title: Geriatric Dizziness (Submitted by: Dr. Katherine Grundmann)

Keywords: dizziness, CT, MRI, Cerebellar (PubMed Search)

Posted: 2/5/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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15% of older adults presenting to ED for dizziness have serious etiologies; 4-6% are stroke-related and sensitivity of CT for identifying stroke or intracranial lesion in dizziness is poor (16%), so if CNS etiology suspected, seek neuro consult or MRI (83% sensitivity)

 

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Category: Neurology

Title: Brain Tumor Imaging 101

Keywords: edema, hemorrhage, tumor, CT, MRI, contrast (PubMed Search)

Posted: 1/24/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Although MRI is more sensitive for identifying tumors of the CNS, CT is usually the first line imaging modality in the ED. Some pearls:

  • Hyperattenuation = bright = dense (blood)
  • Hypoattenuation = dark = radiolucent (fluid, air, lipid, scar)
  • Masses that are darker + increased volume or mass effect = edema (image 1)
  • Masses that are darker + decreased volume = scar tissue or atrophy (image 2)
  • Masses that are bright + edema = hemorrhage (image 3)
  • Adding IV contrast improves detection of tumors: abnormal enhancement from disruption of blood brain barrier, necrosis or increased vascularity. (Image 4)

Image 1 Courtesy of Radiopedia.orgImage 2: courtesy of Dr Chris O'Donnell, Radiopaedia.orgImage 3: courtesy of Dr David Cuete, Radiopaedia.orgImage 4: Courtesy of David Kernick, and Stuart Williams Br J Gen Pract2011;61:409-411

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Takeaways

A recent study was undertaken to validate the 4A's Test for the assessment of delirium in the elderly, with particular focus on inpatient geriatric patients; it revealed that the tool had high sensitivity in detecting delirium, particularly in those with dementia or language barriers, in whom this diagnosis can often be difficult to make.  Further studies would be useful in a similar demographic of emergency department geriatric patients to confirm that this straightforward test is generalizable to the emergency department geriatric patient population.

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Category: Neurology

Title: Cerebral Venous Thrombosis (CVT)

Keywords: headache, seizure, stroke, neurological deficit, thrombogenic (PubMed Search)

Posted: 12/27/2017 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Cerebral venous thrombosis is a rare (but dangerous) cause of headaches and strokes in patients below the age of 50. It includes thrombosis of the cerebral veins and major dural sinuses. 
A d-dimer can NOT be used to rule it out, as it would be falsely negative in up to 40% of patients. A dry head CT is completely normal in 30% of patients, with nonspecific changes present in another 30%.

Take home: If you are considering the diagnosis, obtain a CT venography (95% sensitive) and don’t rely on a negative dimer or dry head CT.

 

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Asymptomatic bacteriuria is common and increases with age, with an incidence of up to 50% in women over the age of 70.  Asymptomatic bacteriuria does not carry an associated high morbidity or mortality if left untreated; it is usually transient and resolves spontaneously.  In order to decrease polypharmacy and possible drug interactions in our elderly patients, they should only be diagnosed with and treated for a UTI if they have laboratory evidence of a UTI (bacteriuria and pyuria) and have two of the following:

·      Fever

·      Worsened urinary urgency or frequency

·      Acute dysuria

·      Suprapubic tenderness

·      Costovertebral angle tenderness

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Category: Neurology

Title: Guillain-Barre's less evil twin - CDIP!

Keywords: GBS, weakness, intubation, CSF, LP (PubMed Search)

Posted: 11/22/2017 by Danya Khoujah, MBBS
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CDIP, or chronic inflammatory demyelinating polyradiculoneuropathy, is an immune-mediated polyneuropathy which presents similarly to Guillain-Barré Syndrome (GBS). However, it is not as dangerous as GBS. Patients present with symmetric proximal and distal weakness with reduced or absent deep tendon reflexes, just like GBS. The difference is that in typical CDIP, patients have prominent sensory signs, no autonomic dysfunction, no facial weakness, no preceding infectious illness, and most importantly no respiratory failure. It also continues to progress past 4 weeks.

CSF is not diagnostic, and may show albuminocytologic dissociation. The diagnostic test is nerve conduction studies. 

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Category: Geriatrics

Title: Suicidal Risk in Older Adults

Keywords: elderly, psychiatry, mental health, screening (PubMed Search)

Posted: 11/5/2017 by Danya Khoujah, MBBS
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A potential area of care improvement was identified in this recent study; how we address a positive suicide screening test in older adults. Although completed suicide is higher in this age group, older patients are less likely than their younger counterparts to receive mental health evaluation prior to ED discharge for suicidal ideation within the past 2 weeks or a suicidal attempt within the past 6 months, especially if their chief complaint was not of a psychiatric nature.

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Category: Neurology

Title: Guillain- Barr Syndrome

Keywords: weakness, infection, paralysis, intubation, influenza, vaccine (PubMed Search)

Posted: 10/25/2017 by Danya Khoujah, MBBS
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It's respiratory infection and flu vaccine season! Time to brush up on Guillain-Barré Syndrome..

- It is the most common cause of acute or subacute flaccid weakness worldwide

- 70% of cases are preceded by an infection in the past 10-14 days, but most are minimized or forgotten by the patient. 40% of these infections are by Campylobacter jejuni.

- 30% develop respiratory failure requiring intubation and ventilation

- Half of the patients will develop their maximum weakness by 2 weeks, most will develop it by 4 weeks.

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Takeaways

Providing consistent, quality emergency care to the elderly is critically important. The Geriatric Emergency Department (GED) guidelines, developed collaboratively, provide a standardized set of guidelines to help improve care of the geriatric population in the emergency department.

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Category: Neurology

Title: tPA Contraindications

Keywords: stroke, tPA, thrombolytics, ICH, hemorrhage, adverse events (PubMed Search)

Posted: 9/28/2017 by Danya Khoujah, MBBS
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Classically, the list of contraindications for tPA in stroke has been extensive and excludes a significant percentage of patients. This scientific statement from AHA clarifies the evidence behind these contraindications, and in short, expands the population of patients that should be considered for tPA.
The following is NOT considered a contraindication for tPA: 
- Age over 80 
- Severe stroke (NIHSS >25)
- Improving symptoms, if patient remains moderately impaired and potentially disabled
- A small (<10 mm) unruptured and unsecured intracranial aneurysm (NOT other vascular malformations)
- Extra-axial intracranial neoplasms (e.g. meningiomas, pituitary adenomas)
- Blood glucose of >400mg/dL that is subsequently normalized
- Seizure at onset of stroke if residual impairment is secondary to stroke not a postictal phenomenon 

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Category: Geriatrics

Title: Falls in the Elderly (Submitted by Amal Mattu, MD)

Keywords: arrhythmia, syncope, fall (PubMed Search)

Posted: 9/4/2017 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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20% of unexplained falls in the elderly can be attributed to an arrhythmia.

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Category: Neurology

Title: Pituitary Apoplexy

Keywords: pituitary apoplexy, subarachnoid hemorrhage, meningitis, headache, CT, MRI (PubMed Search)

Posted: 8/9/2017 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Pituitary apoplexy is a sudden hemorrhage or infarction of the pituitary.
  • It most commonly occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients with pituitary adenomas are unaware of their diagnosis.
  • Patients may acutely present with thunderclap headache, with or without visual field deficits or cranial nerve dysfunction. They may also have meningeal symptoms due to extravasation of blood into the subarachnoid space.
  • Endocrine dysfunction is common but not readily diagnosed in the ED.
  • Symptoms may be triggered by some hormonal treatments (e.g. GnRH agonists for prostate CA), head trauma, angiographic procedures, or anticoagulation therapy.
  • CT is diagnostic in only one-third of cases, but can reveal the intrasellar mass in 80% of cases, and therefore should be the initial test. Blood may be missed in subacute cases.
  • MRI is the test of choice, with a sensitivity of over 90%.  

Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI. 

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When you are working up an elderly patient for trauma  look for patterns such as circumferential bruising on the wrists that have the pattern of fingers the same way you would look at the injuries of a child. Remember that the person who is sitting next to them is frequently the person that is abusing them. Therefore, it is important to interview the patient alone. 

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Category: Neurology

Title: Autoimmune Neurological Disease

Keywords: autoimmune, cancer, encephalopathy (PubMed Search)

Posted: 6/28/2017 by Danya Khoujah, MBBS
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One of the differentials of a subacute neurological deficit (usually with a fluctuating course) is autoimmune neurologic disorders. This can encompass anything from neuropathic symptoms, to cerebellar pathology, to encephalitis-like picture. A personal or family history of autoimmune disease or malignancy should heighten suspicion, and the CSF is likely an inflammatory CSF profile as well (pleocytosis). Neural autoantibodies confirm the diagnosis, and are usually performed in both the serum and the CSF. Most laboratories perform a global screen for a number of potential antibodies that fit the concerning clinical picture, rather than one or two tests.
In addition, autoimmune CNS pathology is concerning for a paraneoplastic syndrome e.g. teratoma, lymphoma or small cell lung cancer.

Take Home Message: If suspecting an autoimmune pathology due to the risk factors and subacute nature of the disease, obtain some extra CSF to run the necessary tests after consulting with neurology. 

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Category: Geriatrics

Title: ACS in Elderly Patients (Submitted by Dr Katherine Grundmann)

Keywords: Geriatric, cardiology, symptoms, atypical, angina (PubMed Search)

Posted: 6/4/2017 by Danya Khoujah, MBBS
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Older patients with acute coronoary syndrome (ACS) are less likely to present with typical ischemic chest pain (pressure-like quality, substernal location, radiating to jaw, neck, left arm/shoulder and exertional component) compared with younger counterparts.

Typical angina symptoms predictive of acute myocardial infarction (AMI) in younger patients were less helpful in predicting AMI in the elderly population.

Autonomic symptoms such as dyspnea, diaphoresis, nausea and vomiting, pre-syncope or syncope are more common accompaniments to chest discomfort in elderly ACS patients.

Symptoms may also be less likely to be induced by physical exertion; instead, they are often precipitated by hemodynamic stressors such as infection or dehydration

Bottom Line: Keep a high index of suspicion for ACS in older patients as they present atypically.

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Category: Neurology

Title: Neurally Mediated Syncope - Part 2

Keywords: syncope, vasovagal, orthostatic, blood pressure (PubMed Search)

Posted: 5/24/2017 by Danya Khoujah, MBBS
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Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension. 

Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope. 

 
 

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Category: Neurology

Title: Neurally Mediated Syncope - Part 1

Keywords: syncope, vasovagal, seizures, orthostatic, blood pressure (PubMed Search)

Posted: 5/10/2017 by Danya Khoujah, MBBS
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"Neurally mediated syncope" is the most common cause of syncope in all age groups, and includes various overlapping entities, such as neurocardiogenic syncope, vasovagal syncope, and vasodepressor syncope. These are distinctly different from orthostatic hypotension and seizures. 
A careful history is the most important “test” to diagnose neurally mediated syncope. It is frequently preceded by a characteristic prodrome with symptoms such as nausea, dizziness, feelings of warmth or coldness, visual dimming or blurring, clammy skin, facial pallor, general weakness, decreased hearing, or fecal urgency. Symptoms last 30 seconds to several minutes prior to syncope. 
Differentiating syncope from seizures:
Brief, multifocal,arrhythmic, myoclonic jerks are observed in up to 90% of patients at the time of syncope. These are caused by brainstem hypoperfusion and may be mistaken for seizures. The jerks follow the LOC (rather than immediate) and the eyes deviate upward (rather than lateral). If tongue biting occurs, it’s the tip (rather than the side, which is what occurs with seizures).
 

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·       In the elderly, falling is the most common mechanism of injury
·       Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
·       Other factors: alcohol consumption, polypharmacy
·       Mechanisms of fall:  slipping, tripping, stumbling
·       Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
·       Must consider neglect/abuse, affects 10% of seniors per year
·       Evaluate for anticoagulant use due to increased risk of intracranial injury
·       Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative

 

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