Category: Neurological Emergencies

Seizure: Lethal Dissection

Lethal Dissection Seizure
~ Naveen Paila, India ~ 1 Comment

Case Presentation

A 49-year old female without any co-morbidities presented to the emergency department (ED) with seizures. On arrival, she was in a postictal state.

She had recently visited a local hospital with complaints of severe dysmenorrhea and low back pain. The attenders informed us that she was very sleepy and weak at that time, was treated for pain and given tranexamic acid, and sent home. The next day, she had one episode of Generalized Tonic-Clonic Seizure, and she arrived in our ED in a postictal phase. She vomited twice in the ED.

Her vitals were as follows: 

  • Blood pressure (BP): 160/100 mmHg.
  • Heart rate (HR): 22/min
  • Peripheral capillary oxygen saturation (SPO2): 98% on room air
  • General Random Blood Sugar (GRBS): 233 mg/dl
  • Glasgow Coma Scale (GCS): E2V5M6

Her examination was as follows:

  • The patient was drowsy but arousable. 
  • Pupils bilateral reacting to light. No anisocoria.
  • CNS examination could not be completed as the patient was drowsy.
  • A normal pattern of breathing. The respiratory examination was normal.
  • The abdomen was soft, symmetric, and non-tender without distention.

Point-of-care ultrasound (POCUS) showed a flap in the abdominal aorta. (See Figure 1 and 2 for transverse and longitudinal views of the aorta, respectively) Upon this finding, cardiac surgery and neurology consultations were sought.

Transverse section of the abdominal aorta showing a flap.
https://ibb.co/N6VyMD8

Image shows transverse section of the abdominal aorta showing a flap.

Abdominal aorta showing a flap
https://ibb.co/wwkYHJY

Image shows abdominal aorta showing a flap.

The laboratory results were as follows:

  • D-dimer: 1192 ng/ml
  • Haemoglobin (Hb): 10 g/dl
  • The international normalized ratio (INR): 1.25
  • Platelets: 260000 per mcL
  • Total leucocyte count (TLC): 22000 cells/mm3
  • Creatinine :1.6 mg/dl.

Meanwhile, the patient was suffering multiple seizure-like episodes, characterized by staring, deviation of the mouth, and irregular limb movements, but these episodes lasted for few minutes and ended without the postictal phase. The patient was drowsy but obeyed commands and did not have any recollection of those few minutes.

Head computed tomography (CT) showed no infarct or bleeding. It was normal.

CT angiogram and aortogram revealed that the patient had Stanford Type A aortic dissection with the flap extending to the entire left subclavian artery, with severely occluding filling defects and thrombosis of the false lumen into bilateral common carotid arteries (See Figure 3, 4 and 5). On the other end, the dissection extended to the common iliac arteries (See Figure 6).

CT Aortogram showing bilateral common carotid artery filling defects
https://ibb.co/M6TMqpq

Image shows CT Aortogram showing bilateral common carotid artery filling defects

And on the other loose of the string the dissection was extending till the common iliac arteries.
Ascending and descending aortic dissection
https://ibb.co/n8Rbdvm

Image shows ascending and descending aortic dissection

Dissection of the common iliac artery before bifurcation
https://ibb.co/jVjL0qJ

Image shows dissection of the common iliac artery before bifurcation.

 

Management

Initially, the patient was treated symptomatically by anti-epileptics and analgesics. After the cardio-thoracic and vascular surgeon consultations, we decided to airlift the patient to a higher centre as our hospital was tertiary care and there were no grafts for the urgent repair of the extensive aortic dissection. We intubated the patient for secure transportation. However, we learned that the patient expired in the higher centre before reaching the operating room.

Discussion

Before I shed light on the important part of this discussion, I know that the outcome of this case was unfortunately grave. However, I chose this case because of it.

In this case, the patient had low back pain in her previous hospital visit. However, she was sent home with symptomatic management, implying that it could have been addressed more carefully. She visited our ED one day later, and POCUS let us diagnose the dissection in 15 minutes, which was confirmed by a CT aortogram within 40 minutes. After consultations and finding the available facility, we airlifted the patient to a higher centre for urgent repair, but the patient could not make it to the operating room.     

We all know acute aortic dissection is the most common life-threatening disorder affecting the aorta. Over the first several hours, the mortality rate increase up to 1% per hour; therefore, early intervention is critical (1). In our case, the involvement of bilateral carotid arteries caused seizure-like episodes and altered mental status. Also, studies show that patients with similarly located dissections may experience neck pain, transient ischemic attacks (TIA), cerebral ischemia, transient monocular blindness and subarachnoid haemorrhage (SAH) but not seizure(2). In our case, the global hypo-perfusion caused recurrent TIAs, which resembled seizure-like clinical episodes. That’s why emergency physicians should be vigilant about the underlying causes of seizure-like activities, even if altered mental status similar to postictal state is present, especially if the patient does not have a history of seizures and the complaints are unclear. Keep the aortic dissection in mind as a differential. Also, I cannot stress the use of POCUS in the ED enough. It is a game-changer, and in our case, it detected a lethal disease successfully.

Learning Points

  1. Never ignore back pain that does not subside after adequate pain management.
  2. POCUS is always a game-changer. It saves a lot of time and lives, as in my case.
  3. Seizures or not, you must keep a high suspicion for lethal vascular diseases. Remember the basics: If unclear, go back to history.
  4. Once you confirm an aortic dissection, never delay treatment because time = life.
  5. Never ever send a patient back home unless you are completely sure about the cause of the presenting symptom. Over investigating is ok when compared to under investigating, when it might cost a life.

References and Further Reading

  1. Braverman AC. Acute aortic dissection: clinician update. Circulation. 2010;122(2):184-188. doi:10.1161/CIRCULATIONAHA.110.958975
  2. Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011;77(12):1174-1181. doi:10.1212/WNL.0b013e31822f03fc
Cite this article as: Naveen Paila, India, "Seizure: Lethal Dissection," in International Emergency Medicine Education Project, November 15, 2021, https://iem-student.org/2021/11/15/seizure-lethal-dissection/, date accessed: April 25, 2024

Question Of The Day #53

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause for this patient’s condition?

  • A) Increased systemic vascular resistance (SVR)
  • B) Occult hemorrhage
  • C) Damage to the sympathetic nervous system
  • D) Tension pneumothorax

This patient endured a high-speed motor vehicle accident, arrives with hypotension and bradycardia, and has a C6 vertebral body fracture on imaging.  These details support a diagnosis of neurogenic shock, a type of distributive shock.

Shock is an emergency medical state characterized by cardiovascular or circulatory failure.  Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure.  Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic.  The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap.  The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam.  Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management.  The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

Neurogenic shock is caused by spinal cord damage above the T6 level.  Unlike other types of shock, neurogenic shock is characterized by hypotension and bradycardia (not tachycardia).  These vital sign abnormalities are caused by damage to sympathetic nervous system (Choice C).  Neurogenic shock has decreased systemic vascular resistance (warm extremities), not increased systemic vascular resistance (cool extremities) (Choice A).  Occult hemorrhage (Choice B) is always a concern in a trauma patient.  However, this would present with findings of hypovolemic/hemorrhagic shock (tachycardia, hypotension, cool extremities).  Tension pneumothorax (Choice D) is also unlikely as the patient has clear bilateral lung sounds on exam.  The best answer is Choice C.

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #53," in International Emergency Medicine Education Project, September 3, 2021, https://iem-student.org/2021/09/03/question-of-the-day-53/, date accessed: April 25, 2024

Question Of The Day #50

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) IV Physostigmine
  • B) IV Potassium iodide
  • C) IV Propranolol
  • D) PO Propylthiouracil (PTU)

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient arrives hyperthermic, tachycardic in atrial fibrillation, diaphoretic, and altered with psychotic behavior.  Thyroid storm, the most severe manifestation of hyperthyroidism, should always be on the differential diagnosis in patients with fever and altered mental status.  Other considerations are sepsis, sympathomimetic overdose, anticholinergic overdose, serotonin syndrome, and pheochromocytoma. 

This patient has thyroid storm, a life-threatening endocrine emergency that requires prompt recognition and treatment.  Symptoms of thyroid storm include altered mental status, psychosis, seizures, coma, tachycardia, atrial fibrillation, high-output heart failure, dyspnea, vomiting, diarrhea, weight loss, and anterior neck enlargement.  Severe hyperthyroidism should have a low-undetectable TSH level with elevated T3/T4 levels, but in acute illness these levels may be unreliable.  For this reason, the diagnosis and treatment of thyroid storm should be based on clinical grounds.

An anticholinergic toxidrome can appear similar to this patient with tachycardia, hypertension, agitation, and altered mental status.  A key differentiating factor is diaphoresis.  Patients with anticholinergic ingestions should have dry skin, not wet skin. The treatment for anticholinergic toxicity is benzodiazepines and IV physostigmine (Choice A) if symptoms are unresponsive to benzodiazepines.  Physostigmine is not the best next step in this scenario. 

Treatment of thyroid storm is algorithmic.  First, beta blockade (Choice C) should be given to control the heart rate and block T4 to T3 conversion, next anti-thyroid medications (Methimazole or Propylthiouracil (Choice D)) should be given to block thyroid hormone synthesis, and lastly corticosteroids and inorganic iodine (Choice B) can be given to block release of stored thyroid hormone.  The best next step in managing this patient with thyroid storm is administration of IV Propranolol (Choice C).  Propranolol helps manage the tachycardia, systemic symptoms, and also inhibits conversion of T4 to T3. 

 Correct Answer: C

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #50," in International Emergency Medicine Education Project, August 13, 2021, https://iem-student.org/2021/08/13/question-of-the-day-50/, date accessed: April 25, 2024

Question Of The Day #49

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause of this patient’s condition?
  • A) Sympathomimetic toxicity
  • B) Heat exhaustion
  • C) Heat stroke
  • D) Thyroid storm

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

Hyperthermia (or hypothermia) can cause altered mental status.  This patient arrives with altered mental status, severe hyperthermia, tachycardia, tachypnea, and hypotension.  The history of the patient running outside for exercise should raise concern for hyperthermia related to excess heat production due to overexertion.  This should narrow the differential diagnoses to heat exhaustion (Choice B) and heat stroke (Choice C).  Both heat exhaustion and heat stroke are marked by hyperthermia with temperatures often over 40ᵒC. Additional symptoms include weakness, nausea, vomiting, myalgias, syncope, and headache.  The differentiating factor between heat exhaustion and heat stroke is altered mental status and sweating.  Patients with heat exhaustion lack altered mental status and should still be able to thermoregulate through sweating.  On the contrary, heat stroke patients are more severely ill as they have altered mental status and can no longer thermoregulate with sweating.  The treatment in both conditions should be early and aggressive cooling measures.  This includes full body immersion in an ice bath, removal of clothes, and cold IV fluids.  Internal cooling with gastric, bladder, pleural, or peritoneal lavage with cold fluids can be done on more sick patients.  Antipyretic medications, like NSAIDs and paracetamol, have no benefit in patients with severe hyperthermia.  Evaluation for rhabdomyolysis, kidney failure, liver failure, sepsis, or other organ dysfunction should also be a part of the evaluation of hyperthermic patients.

Sympathomimetic toxicity (Choice A) is possible, but less likely as the skin is dry and the history of exercise outdoors.  Sympathomimetic toxicity manifests as diaphoresis, tachycardia, hypertension, hyperthermia, and sometimes altered mental status.  Thyroid storm (Choice D) is another possibility.  This diagnosis can also present with similar vital signs, hyperthermia, and altered mental status.  Again, the history of outdoor exercise should point more towards heat exhaustion vs heat stroke.

The diagnosis of this patient is heat stroke (Choice C) as he has altered mental status and lacks wet skin.

Correct Answer: C

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #49," in International Emergency Medicine Education Project, August 6, 2021, https://iem-student.org/2021/08/06/question-of-the-day-49/, date accessed: April 25, 2024

Cerebral Venous Sinus Thrombosis

~ Sumaiya Hafiz, UAE ~ Leave a comment

One of the most frequent presentations in the ED is a patient complaining of headache. There is a wide range of differentials, such as mental illnesses to life threatening causes. Cavernous sinus thrombosis is amongst them, thus making it one of the main causes that need to be ruled in or out when a patient first presents to the ED with complaints of headache.

The most common presentation you may encounter or a presentation frequently asked in exams would be of a young female on oral contraceptive pills who presents with a headache and limb weakness. Although the list of differentials is long, cerebral venous thrombosis should definitely be kept amongst the top 3, as early diagnosis is key.

What is Cerebral Venous Thrombosis (CVT)?

CVT is the formation of a clot in the cerebral veins and the dural sinuses. The dural sinuses consist of the superior sagittal sinus, straight sinus, and transverse sinus. These are the sites commonly affected by clot formation. Rarely, it may present in cortical veins and jugular veins.

It is considered a type of stroke and is divided into three types: acute, subacute, and chronic.

Epidemiology and Risk Factors

Young patients between the ages of 20-50 years are most commonly affected, especially women of the age group are affected more compared to men.

People with factors contributing to Virchow’s Triad (stasis, endothelial injury, and hypercoagulability) are at a higher risk of getting affected. Other factors include – genetic disorders such as thrombophilia, APS – antiphospholipid syndrome, autoimmune disorders, malignancies, pregnant women, recent surgery, use of oral contraceptive pills, infections (most commonly sinusitis and meningitis), patients who recently underwent lumbar puncture, and catheterization of the jugular vein.

Anatomy

Cerebral veins are compromised of a deep and superficial system. The veins do not have valves. There are several connections between the veins of both systems and the sinuses.

Venous blood from cerebral veins drains into the major dural sinuses and the internal jugular vein. The superficial system mainly drains into the superior sagittal sinus and the lateral sinus.

https://radiologyassistant.nl/neuroradiology/sinus-thrombosis/cerebral-venous-thrombosis

Pathophysiology

How does it happen? The exact mechanism is unknown; however several studies propose the following theory: Thrombus formation in veins causes obstruction as the blood pools and raises pressure within the blood vessels and decreases CSF drainage. This CSF collection gives rise to intracranial hypertension and hydrocephalus, leading to the most common symptom patients present with – headache and stroke-like symptoms. Almost half of the cases have hemorrhagic transformation prior to treatment.

History and Physical Examination

The presentation is non-specific and may mimic other illnesses, making it one of the hardest to diagnose.

The history and physical examination findings depend on the extent of the thrombosis.

Some of the most common complaints in patients with CVT include-

  • Headache is the most common presentation – in the case of a patient complaining of sudden onset headache typical of subarachnoid hemorrhage, CVT should always be kept in mind as an uncommon yet possible cause.
  • Nausea, vomiting may also be present.
  • Seizures
  • Papilledema
  • Focal neurological deficits – weakness, gait, and visual abnormalities have all been reported
  • If the thrombosis extends to the jugular vein, there will be signs of multiple cranial nerve involvement :

Lesions in the superior sagittal sinus can present with seizures and motor dysfunction

Lesions in the left transverse sinus may cause patients to be aphasic

Lesions in the cavernous sinus could present with periorbital pain and visual changes

Lesions in deep venous sinuses may present with altered mental status

Differentials

  • Infections – meningitis, encephalitis
  • Trauma
  • Benign intracranial hypertension
  • 6th Cranial Nerve Palsy
  • Stroke
  • Cavernous sinus thrombosis

Investigations and Imaging

  • Full blood count – increased hemoglobin due to polycythemia, decreased platelet count, and increased white blood cell count are all important factors
  • In patients suspected to have hereditary hypercoagulable states, appropriate diagnostic tests may be done such as protein c and S deficiency, antiphospholipid syndrome, factor V Leiden
  • Lumbar puncture may be done if meningitis or encephalitis is suspected to be the cause
  • D-dimer level

Various imaging modalities are used to diagnose CVT, or the conditions leading to it. 

  • CT Scan- hyperdensity in the lumen- dense clot sign & Empty delta sign (filling defect in the dural sinus)
  • CT Angio 
  • MRI
  • Magnetic Resonance Venogram (MRV)- Gold standard

1) Empty delta sign

https://radiopaedia.org/articles/empty-delta-sign-dural-venous-sinus-thrombosis

2) Dense clot sign

https://radiologyassistant.nl/neuroradiology/sinus-thrombosis/cerebral-venous-thrombosis

3) MRV of the Cerebral Venous System (Saposnik 2011)

https://coreem.net/core/cerebral-venous-thrombosis/

Treatment and Management

t is important to treat CVT, including its cause and complications. CVT treatment is quite similar to the treatment of stroke with the use of thrombolysis and anticoagulation. The treatment modalities have been controversial due to the risk of bleeding, but several studies conducted showed a much greater benefit of anticoagulation and thrombolysis in patients with CVT. Parenteral administration of Heparin or the use of Enoxaparin is preferred in the acute phase.

In patients who do not improve by anticoagulation treatment, thrombolytics are administered systemically or catheter directed. Common thrombolytics used are Tenecteplase and alteplase. After acute management, patients are prescribed warfarin for 3-6 months duration.

Treating the cause includes appropriate antibiotic coverage for infections, methods of lowering intracranial pressure, anticonvulsants for seizure control and care must be taken to prevent aspiration in patients with focal neurological deficits.

Prognosis

Death due to herniation is common, and decompressive surgery to prevent this has greatly reduced morbidity and mortality. The mortality associated with CVT is 5%.

Things To Consider

As the emergency physicians are the first ones to evaluate the patient, any patient who presents with stroke-like symptoms, headache – especially first occurrence and extremely painful, with a significant history of blood disorders or oral contraceptive use, CVT should be considered, and the appropriate tests must be ordered in order to make a timely diagnosis and begin management to prevent morbidity and mortality.

References and Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Cerebral Venous Sinus Thrombosis," in International Emergency Medicine Education Project, August 2, 2021, https://iem-student.org/2021/08/02/cerebral-venous-sinus-thrombosis/, date accessed: April 25, 2024

Recent Blog Posts By Sumaiya Hafiz

Question Of The Day #48

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

  • A) Hypercarbic respiratory failure
  • B) Hypoxic respiratory failure
  • C) Opioid overdose
  • D) Sepsis

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The first step in managing this patient should be to treat the hypoxia with supplemental oxygen.  Prolonged hypoxia is dangerous and if left untreated, can cause brain damage.  Hypoxia can cause altered mental status, however, when this patient’s hypoxia is resolved, she remains somnolent and altered.  This should raise concern over an alternative etiology for the patient’s condition.      

The arterial blood gas demonstrates a low pH (acidosis), normal paO2, elevated paCO2 (hypercarbia), and a normal HCO3 (no metabolic compensation for acidosis).  The final interpretation of the ABG would be an acute respiratory acidosis without metabolic compensation.  Acute elevations of pCO2 can manifest as somnolence and altered mental status as seen in this patient.  This is known as hypercarbic or hypercapnic respiratory failure (Choice A).  This condition is caused by the inability to exhale CO2.  Risk factors include obstructive lung diseases (i.e., COPD), obesity, and obstructive sleep apnea.  Treatment involves treatment of hypoxia with supplemental oxygen, non-invasive positive pressure ventilation (i.e., BIPAP, CPAP, High Flow Nasal Cannula), and treatment of the underlying cause.

The patient’s arterial blood gas does not show hypoxic respiratory failure (Choice B).  Since treatment of the patient’s hypoxia does not improve the patient’s mental status, hypercarbic respiratory failure is more likely the underlying cause of the patient’s condition.  Opioid overdose (Choice C) can cause a similar ABG and patient presentation.  The normal size pupils and absent history of drug abuse makes this diagnosis less likely. Sepsis (Choice D) can trigger changes in mental status and cause respiratory failure, however, the absence of infectious symptoms and the presence of obesity and COPD support hypercarbic respiratory failure as the more likely underlying cause. 

Correct Answer: A

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #48," in International Emergency Medicine Education Project, July 30, 2021, https://iem-student.org/2021/07/30/question-of-the-day-48/, date accessed: April 25, 2024

Question Of The Day #47

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) 1000mL bolus of 0.9% NaCl
  • B) 25g of IV dextrose
  • C) 1mg of IV naloxone
  • D) 100mg of IV thiamine

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The initial approach to all Emergency Department patients, especially those with abnormal vital signs, should include a primary survey (“ABCs”, or Airway, Breathing, Circulation).  This patient is breathing independently but at a significantly reduced rate and is hypoxic.  Hypoxia should prompt the administration of supplemental oxygen to the patient and reassessment of the SpO2.  The patient’s reduced respiratory rate, lethargy, and bilateral miosis (constricted pupils) should strongly hint at the possibility of opioid overdose.  Although the patient is lethargic and hypoxic, establishing a definitive airway (endotracheal intubation) should be avoided until after the antidote to opioid overdose is administered.  Naloxone is a mu-opioid receptor antagonist and functions as the antidote to opioid overdose.

 

Administration of 1000mL of 0.9% NaCl (Choice A) is unlikely to fix the patient’s clinical condition.  The patient needs naloxone to improve respiratory status.  25g of IV dextrose (Choice B) would be helpful if this patient’s altered mental status was from hypoglycemia.  A normal glucose level is provided in the question stem.  100mg of IV thiamine (Choice D) may be helpful in the case of Wernicke-Korsakoff Syndrome, a state of thiamine deficiency often associated with malnutrition and alcohol abuse.  Wernicke-Korsakoff Syndrome presents with vision disturbances, ataxia, and confusion.  Typically, this syndrome does not present with severe lethargy or depressed mental status as is seen in this patient.

The best next step in management is 1mg of IV naloxone (Choice C).  If given appropriately, naloxone can prevent the need for intubation.  Naloxone has a very short onset to action (~1min).  If suspicion for opioid overdose is high and there is an inadequate respiratory response after a single naloxone dose, repeat doses of naloxone are appropriate.  Naloxone can be administered in repeat boluses every 3-minutes to a total dose of 10mg IV.  Patients who respond appropriately to naloxone should be observed for recurrent respiratory depression as naloxone is cleared.  Need for repeat doses of naloxone indicates the need for a continuous naloxone infusion and hospital admission.  The typical infusion dose is 2/3 the “wake-up” dose given over 1 hour as a continuous infusion.  For example, if the patient responded to 1mg IV initially, the continuous infusion dose would be 0.6mg/hour of IV naloxone.

Correct Answer: C

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #47," in International Emergency Medicine Education Project, July 23, 2021, https://iem-student.org/2021/07/23/question-of-the-day-47/, date accessed: April 25, 2024

Question Of The Day #46

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) 1000mL of IV 0.9% NaCl
  • B) Noncontrast CT scan of head
  • C) 25g of IV dextrose
  • D) 150mL of 3% NaCl

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The serum chemistry results provided show elevated BUN and Creatinine with a BUN/Cr ratio of 21.3.  A BUN/Cr ratio greater than 20 indicates decreased perfusion to the kidneys, also known as pre-renal azotemia, which can indicate dehydration, hypovolemia, or shock.  The serum chemistry also shows a severely low sodium level.  Hyponatremia can present with a variety of symptoms, including weakness, fatigue, myalgias, nausea, vomiting, headaches, altered mental status, focal neurologic deficits, seizures, or coma.  Hyponatremia can be acute or chronic, asymptomatic or symptomatic, and mild or severe.  Sodium levels below 120 mEq/L are severely low.  Neurologic symptoms, such as seizures, altered mental status, and focal neurologic deficits, are also considered severe.  Treatment should be based on patient symptoms, rather than the sodium level, as it can be difficult to assess how acute or chronic the hyponatremia state is on initial evaluation.  The presence of any severe neurologic symptoms as is seen in this scenario should prompt administration of hypertonic saline (3% NaCl).  This allows for rapid correction of serum sodium levels, which should in turn relieve the neurologic symptoms.  A 100-150mL IV bolus of 3% NaCl can be given a second time if symptoms continue after 5-10 minutes.  

Typically, hyponatremia should be corrected slowly to avoid central pontine myelinolysis.  Increases in sodium greater than 8mEq/L per 24hours should be avoided for this reason.  However, in the case of neurologic symptoms, rapid correction of sodium is opted for to prevent further damage.

Administration of “normal saline”, or 1000mL of IV 0.9% NaCl (Choice A), can increase the sodium level.  However, normal saline is not concentrated enough to rapidly increase the serum sodium to terminate neurologic symptoms.  A noncontrast CT scan of the head (Choice B) is a reasonable investigation for this altered patient, but hypertonic saline should be administered first if hyponatremia is known.  Administration of 25mg IV dextrose (Choice C), also known as “D50”, would be helpful in a patient with hypoglycemia and altered mental status. However, this patient is not hypoglycemic.

Administration of hypertonic saline (Choice D) is the best next step in this patient with severe hyponatremia and neurologic symptoms.

Correct Answer: D

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #46," in International Emergency Medicine Education Project, July 16, 2021, https://iem-student.org/2021/07/16/question-of-the-day-46/, date accessed: April 25, 2024

Question Of The Day #45

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Administer IM haloperidol
  • B) Endotracheal intubation
  • C) Roll patient to lateral decubitus position and suction the airway
  • D) Obtain a 12-lead EKG

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient’s altered mental status is likely due to a post-ictal state after a first-time seizure.  A seizure occurs when the brain is in a state of neuronal hyperactivity.  First time seizures can be caused by a variety of factors, such as hypoxia, hyperthermia, hypoglycemia, traumatic brain injury, brain tumors, meningitis, encephalitis, hyponatremia, or alcohol withdrawal.  It can sometimes be difficult to differentiate a seizure from a syncopal episode.  Both conditions cause loss of consciousness and both may include body convulsions.  Details that support a diagnosis of seizure over syncope include bowel or bowel incontinence, tongue biting, and confusion after regaining consciousness (post-ictal state).

Management of a patient having a seizure should focus initially on the ABCs (Airway-Breathing-Circulation) and terminating the seizure.  This involves first repositioning the patient to prevent aspiration.  A common maneuver is rolling the patient in the lateral decubitus position, performing a jaw thrust, and suctioning the airway (Choice C).  Administration of IM haloperidol (Choice A) is unlikely to terminate the seizure as it is an antipsychotic, not an antiepileptic medication.  Obtaining a 12-lead EKG (Choice D) is an important aspect of evaluating a patient with a potential seizure, however, the next best step in this seizing patient should focus on the ABCs and terminating the seizure.  Endotracheal intubation (Choice B) may be necessary in this patient to protect the airway, but patient repositioning (Choice C) and antiepileptic (i.e., benzodiazepines) administration are important initial steps prior to considering intubation.  The best next step in this scenario is Choice C.

 Correct Answer: C

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #45," in International Emergency Medicine Education Project, July 9, 2021, https://iem-student.org/2021/07/09/question-of-the-day-45/, date accessed: April 25, 2024

Question Of The Day #44

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next investigation to confirm this patient’s diagnosis?

  • A) Lumbar puncture
  • B) 12-lead EKG
  • C) MRI of brain
  • D) Noncontrast CT scan of head

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The information provided indicates that the patient’s headache was maximal at onset, severe, associated with vomiting, and led to a deteriorating mental status ultimately requiring intubation.  This history is very concerning for intracranial bleeding, especially subarachnoid hemorrhage (SAH).  The majority of atraumatic SAHs are caused by the rupture of a saccular aneurysm.  This causes the leakage of blood into the subarachnoid space.  Symptoms of a SAH are sudden onset headache that is maximal intensity at onset (“thunderclap headache”), syncope, vomiting, seizures, and any neurological deficits.  Risk factors for SAH are age over 50years-old, family history of SAH, alcohol abuse, tobacco smoking, Marfan Syndrome, Ehlers-Danlos Syndrome, and Polycystic Kidney Disease.  Diagnosis of SAH takes into account the patient’s history, physical exam, and risk factors. 

Patients that arrive in the Emergency Department under 6hours since symptom onset should initially get a noncontrast CT scan of the head (Choice D).  When a noncontrast head CT is performed in this time window, its sensitivity reaches 98-100%.  Noncontrast head CTs performed within the first 24hrs since headache onset have a sensitivity of about 90%.  Patients with signs and symptoms concerning for SAH who have a negative CT head should get a lumbar puncture (Choice A) to evaluate for xanthochromia.  This is especially important if the patient’s symptoms have been for over 6 hours.  A 12-lead EKG (Choice B) can show ST and T wave changes, but an EKG alone cannot be used to make a diagnosis of SAH.  A brain MRI (Choice C) can make the diagnosis of SAH, but a CT scan would be preferred due to greater CT scan accessibility, cost, and the shorter time of this imaging test.  The best next investigation would be a noncontrast CT of the head (Choice D).

Correct Answer: D

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #44," in International Emergency Medicine Education Project, July 2, 2021, https://iem-student.org/2021/07/02/question-of-the-day-44/, date accessed: April 25, 2024

Question Of The Day #43

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause for this patient’s altered mental status?

  • A) Diabetic ketoacidosis
  • B) Sepsis
  • C) Intracerebral hemorrhage
  • D) Hypothyroidism

This patient presents to the Emergency Department with altered mental status and fever.  Altered mental status can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient has confusion, fever, lower abdominal pain, dysuria, and no focal neurological deficits on exam.  Diabetic ketoacidosis (Choice A) is unlikely as the patient does not have marked hyperglycemia (>250mg/dL (13.8mmol/L)), polyuria, or polydipsia.  Intracranial hemorrhage (Choice C) is unlikely as the patient has no headache, history of trauma, focal neurologic deficits, or coma.  Severe hypothyroidism (Choice D), known as myxedema coma, can cause altered mental status.  This condition is marked by somnolence or coma, hypothermia, nonpitting edema on the hands and feet, dry skin, macroglossia (enlarged tongue), and hair loss.  This patient does not have symptoms consistent with severe hypothyroidism. 

Sepsis (Choice B), especially in elderly individuals, can cause altered mental status.  The patient’s fever, confusion, lower abdominal pain, and dysuria all point to a likely diagnosis of urosepsis.  Sepsis is the most likely cause of this patient’s disoriented state.  Treatment with early IV hydration and antibiotics will help remedy the patient’s altered mental status.  Correct Answer: B

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #43," in International Emergency Medicine Education Project, June 25, 2021, https://iem-student.org/2021/06/25/question-of-the-day-43/, date accessed: April 25, 2024

Question Of The Day #42

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) IV insulin continuous infusion
  • B) IV hypertonic 3% NaCl
  • C) IV 0.9% NaCl bolus
  • D) IV insulin bolus

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient has a markedly elevated glucose level.  All patients with altered mental status should have a point of care glucose test as both hypoglycemia and severe hyperglycemia can cause altered mental status.  Some diagnoses to consider in this patient are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).  Both of these diagnoses can present with hyperglycemia and altered mental status, but HHS more often presents with higher glucose levels (greater than 600mg/dL (33mmol/L)) and more pronounced Central Nervous System depression.  Patients with HHS may have severe somnolence to the point of coma and may require intubation for airway protection.  In both DKA and HHS, patients are severely dehydrated by osmotic diuresis.  High glucose levels in the serum create an osmotic gradient that causes increased urination and fluid loss.  The first step in treatment for DKA and HHS is volume resuscitation. 

IV fluids (Choice C) should be given prior to the initiation of insulin therapy (Choices A and D).  After adequate IV hydration and correction of electrolyte derangements, insulin can be started to normalize glucose levels.  Bolus doses of IV insulin (Choice D) are harmful in both DKA and HHS and increase the risk of cerebral edema development.  For this reason, an IV insulin continuous infusion (Choice A) is always preferred over an insulin bolus (Choice D).  IV hypertonic 3% NaCl (Choice B) is the treatment for severe hyponatremia causing altered mental status or seizure.  Severe hyperglycemia can cause pseudohyponatremia, but this can be corrected for using the standard sodium correction formula (see references below).  The question stem provides an explanation for this patient’s altered mental status (hyperglycemia), so hypertonic saline should not be given with the information provided.  IV fluid administration (Choice C) is the next best step. Correct Answer: C

Want Another Question?

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #42," in International Emergency Medicine Education Project, June 18, 2021, https://iem-student.org/2021/06/18/question-of-the-day-42/, date accessed: April 25, 2024