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?

(more…)

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

Paucis Verbis card: Skipping the CT prior to LP for meningitis

LumbarPunctureWith increasing awareness of CT’s irradiation risk, I thought I would review a classic 2001 article from the New England Journal of Medicine. Head CT’s previously were commonly performed prior to all lumbar punctures (LP) to rule-out meningitis. When can you safely go straight to an LP without imaging?

Caveat: This review only applies to those patients in whom you suspect meningitis. This does not apply to those being worked up for subarachnoid hemorrhage.

(more…)

2019-01-28T23:41:24-07:00

Paucis Verbis card: NIH Stroke Scale

StrokePatients present with acute strokes to the Emergency Department. Time is of the essence to obtain a rapid neurologic exam, draw labs, get CT imaging, and consulting a neurologist especially if the patient presents within 3 hours of onset. To help the neurologist determine whether the patient should get thrombolytics, calculating a NIH Stroke Scale score is useful.w

(more…)

2019-01-28T23:48:10-07:00

Paucis Verbis Card: CNS Infections

PV Card: CNS Infections

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of CNS infections from EM Clinics of North America 2009.

 


Adapted from 1
Go to the ALiEM Cards site for more resources.

1.
Somand D, Meurer W. Central nervous system infections. Emerg Med Clin North Am. 2009;27(1):89-100, ix. [PubMed]
2019-01-28T23:52:20-07:00