Robust and comprehensive studies now support specific management guidelines for patients presenting with different intracranial hemorrhages (ICH). From the Emergency Department perspective, the primary dilemmas involve specific blood pressure goals and whether seizure prophylaxis with phenytoin is necessary. The Brain Trauma Foundation provides an excellent summary of the current guidelines.1
The NIH Stroke Scale is used to assess the severity of a suspected stroke. It includes 11 neurologic exam components that can be quickly performed at the bedside. The second component of the NIH Stroke Scale is testing of voluntary horizontal eye movements, a.k.a., “best gaze”.1 Gaze is usually tested by instructing the patient to follow the examiner’s hand or pointer finger in a horizontal plane from side to side. This assessment assumes that the patient can comprehend instructions and actively participate in the physical exam.
But… how do you test gaze if your patient is aphasic or unable to follow commands?
Congratulations, you’ve made it! On July 1, thousands of medical students across the country made the transition to becoming Emergency Medicine residents. It was a particularly competitive year for Emergency Medicine, with 99.7% of first-year spots filled despite a whopping 2,047 positions being offered in 2017 (up by 152 spots compared to last year).1 Now begins the most crucial 3 or 4 years of your medical training that will prepare you for the rest of your career in Emergency Medicine.
It is thought that the autonomic nervous system is likely involved in migraines and other primary headache disorders given commonly associated symptoms such as nausea, lacrimation, emesis, and rhinorrhea. The sphenopalatine ganglion (SPG) is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. It has therefore been hypothesized that blockade of the sphenopalatine ganglion may produce relief from primary headaches by modulating the autonomic fibers involved in headache disorders.1
While in our anecdotal experience with SPG blocks has been overall very positive, thus far there have been only a few small studies that have investigated it’s use in the Emergency Department. The currently available evidence has been mixed.
In Emergency Medicine, we are like Goldilocks when it comes to many things: We don’t like a patient’s PaO2 to be too high or too low. We don’t like the bed too high or too low when we intubate. We get concerned when we see a potassium that is too high or too low. The Goldilocks principle is also true of opening pressures on a lumbar puncture (LP). This post will discuss what the opening pressure means, and a differential diagnosis for when it is too high or too low and even when it is in the normal range.
The lumbar puncture (LP) procedure is commonly performed in the Emergency Department (ED). While minor complications of LP such as post-procedure headache or back pain occur somewhat regularly, significant complications such as post-procedural spinal hematomas, are rare.1 Despite their low incidence, these spinal hematomas are associated with a significant amount of morbidity for the patient and increased medicolegal risk for the provider.
Case vignette: A 42-year-old female presents at 10 pm with a throbbing right frontal headache associated with nausea, vomiting, photophobia, and phonophobia. The headache is severe, rated as “10” on a 0 to 10 triage pain scale. The headache began gradually while the patient was at work at 2 pm. Since 2 pm, she has taken 2 tablets of naproxen 500 mg and 2 tablets of sumatriptan 100 mg without relief.
The patient has a diagnosis of migraine without aura. She reports 12 attacks per month. The headache is similar to her previous migraine headaches. She is forced to present to an Emergency Department (ED) on average 2 times per month for management of migraine refractory to oral therapy. She reports a history of dystonic reactions and akathisia after receiving IV dopamine antagonists during a previous ED visit. The physical exam is non-contributory including a normal neurological exam, normal visual fields and fundoscopic exam, and no signs of a head or face infection. When you are done evaluating her, the patient reports that she usually gets relief with 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM, and asks that you administer her usual treatment. What do you do?