Trick of the Trade: Corneal reflex test

CornealreflexThe corneal reflex test (blink test) examines the reflex pathway involving cranial nerves V and VII. Classically the provider lightly touches a wisp of cotton on the patient’s cornea. This foreign body sensation should cause the patient to reflexively blink.

This maneuver always makes me a little worried about causing a corneal abrasion, especially if you are examining a very somnolent patient. You are wondering — Is there no blinking because you’re not touching the cornea hard enough? You apply harder pressure but still no blink. You repeat the test and now the patient finally blinks. That’s 3 times you’ve just scraped against the cornea.

What’s an alternative approach?

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2016-11-11T18:58:00-07:00

Paucis Verbis card: Generalized Convulsive Status Epilepticus

StatusEpilepticusHow do you manage patients who present in status epilepticus, knowing that “time is CNS function”? The longer patients remain seizing, the greater their morbidity and mortality.

Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That’s scary.

Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of positive tricyclic tox screens.

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2019-01-28T23:06:29-07:00

Paucis Verbis card: Workup for first-time seizure

StatusEpilepticusHow do you workup adult patients who present with a new-onset seizure and now neurologically back to normal?

There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches.

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2019-01-28T23:00:09-07:00

Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics

SAHIn Wednesday’s post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada.

We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it’s difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don’t miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache.

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2019-01-28T23:15:47-07:00

Trick of the Trade: OKN drum to test psychogenic coma

3D Character and Question MarkOccasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren’t sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)?

What test can you do to reassure yourself that this may indeed be psychogenic coma?

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2019-01-28T23:37:29-07:00

PV Card: Dermatomal and Myotomal Maps

Forget
There are some things in life which I just can’t memorize and dermatomal/myotomal maps are one of them. Weird cases of peripheral neurologic symptoms have presented to the ED in the setting of trauma and no trauma. So purely for selfish reasons, I’m making my own map to have on file.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Sensory and Motor Function Testing by Levels.

Testing Sensory Function by Level

dermatomes

Testing Motor Function by Level

  • C1-C4 Spontaneous breathing
  • C5 Shoulder abduction (deltoid)
  • C6 Wrist extension (carpi radialis longus and brevis)
  • C7 Elbow extension (triceps)
  • C8 Finger flexion (flexor digitorum superficialis/profundis, lumbricals)
  • T1 Finger adduction & abduction (dorsal/palmar interossei, abductor digiti quinti)
  • T1-T12 Intercostal and abdominal muscles
  • T12-L3 Hip flexion (iliopsoas)
  • L2-L4 Hip flexion, knee extension (quadriceps), hip adduction
  • L4 Ankle dorsiflexion and inversion (anterior tibialis)
  • L5 Big toe extension (ext hallucis longus), heel walk (ext digitorum), hip abduction (gluteus medius)
  • S1 Ankle plantarflexion and eversion (peroneus longus), toe walk (peroneus brevis), hip extension (gluteus maximus)
  • S2-S4 Rectal sphincter tone

Go to the ALiEM Cards site for more resources.
2019-01-28T23:40:22-07:00