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18 05, 2016

Managing migraine headaches in complicated patients

2017-03-11T00:22:59+00:00

migraineCase 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?

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29 03, 2016

AIR Series: Neurology Module 2 – Headaches, Seizures, and Other

2018-10-28T21:25:27+00:00

Welcome to the Second Neurology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality neurology content relating to headaches, seizures, and other neurologic emergencies. Below we have listed our selection of the 17 highest quality blog posts within the past 12 months (as of December 2015) related to neurologic emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 9 AIRs and 8 Honorable Mentions.

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14 03, 2016

AIR Series: Neurology Module 1 – Bleeds and Strokes

2018-10-28T21:25:18+00:00

Welcome to the first Neurology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality neurology content relating to intracranial hemorrhage and stokes. Below we have listed our selection of the 17 highest quality blog posts within the past 12 months (as of November 2015) related to neurologic emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 5 AIRs and 12 Honorable Mentions.

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31 08, 2015

PEM Pearls: Migraine Treatment for Pediatric EM Patients

migraine treatment for pediatric em patients © Can Stock Photo / SergiyNYou are working your evening shift at the pediatrics emergency department, and you walk into a darkened patient room with a distressed mother and her otherwise healthy 10-year old son who is curled in a ball, holding his head and crying. Her mother tells you that the around-the-clock ibuprofen has barely touched his 2-day headache.

After determining that your patient has no neurologic deficits and that this is most likely a primary headache, what can you do to break his symptoms?

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27 07, 2015

Assessing and Managing Delirium in Older Adults

2018-10-28T21:23:40+00:00

© Can Stock Photo / focalpoint delirium in older adultsEvery day in the Emergency Department we see older adults with dementia who have developed delirium and are brought in because of worsening agitation, combativeness, or confusion. In order to care for them, we have to consider what the underlying cause of their agitation may be, but we also have to protect the patient and staff in case of violent outbursts. Older adults experience a phenomenon termed ‘homeostenosis’ in which their physiologic reserve and the degree to which they can compensate for stressors is narrowed, putting them at risk for delirium. This post will outline ways to prevent and de-escalate agitation in a patient with delirium, and how to treat it pharmacologically in a cautious manner to minimize side effects.

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18 05, 2015

Ketamine for Excited Delirium Syndrome

Delirium canstockphoto11866731Excited delirium syndrome is defined as “a syndrome of uncertain etiology characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction”.1 You may have encountered a patient like this in the ED or prehospital setting. Although the etiology is impossible to determine in many cases, stimulant abuse and other drugs are involved in a majority of cases. An 8% mortality has been ascribed to Excited Delirium Syndrome, resulting from hyperthermia, severe metabolic acidosis, and cardiovascular collapse.

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9 02, 2015

Trick of the Trade: L5 medial hamstring reflex

2019-01-28T21:44:46+00:00

Reflex HammerTraditionally in medical school, it is taught that lower extremity deep tendon reflexes for L4 and S1 nerve root levels can be elicited by tapping on the patella and Achilles tendons. It was just taught that L5 didn’t have a reflex to check. Knowing if an L5 radiculopathy existed would be especially helpful when assessing a patient for a potential lumbar disc herniation where a careful lower extremity neurologic exam is important. It turns out one can actually check for a L5 reflex.

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