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Paucis Verbis: Acute vestibular syndrome and HINTS exam

Dizziness HINTS exam acute vestibular examWhat is your diagnostic approach to the acutely vertiginous patient?

The bottom-line question is: Is the cause peripheral or central in etiology?

In this great 2011 systematic review article in CMAJ on Acute Vestibular Syndrome (AVS), the authors review how (un)predictive elements of the history and physical exam are. By definition of AVS, symptoms must be continuous for at least 24 hours and have no focal neurologic deficits.

Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught!

The take home point is to learn and incorporate the 3-part HINTS exam into your diagnostic approach (see bottom box on card). It is reported to be as good as a diffusion-weighted MRI for diagnosing a posterior stroke. The steps are:

  1. Do the horizontal head impulse test. (Normal = central cause)
  2. Check for directionally-alternating nystagmus movement on left and right gaze.
  3. Do the alternate cover test.

PV Card: Acute Vestibular Syndrome vs Stroke | The HINTS Exam


Adapted from [1]
Go to ALiEM Cards for more resources.

There is a helpful 10-minute video showing normal and abnormal HINT findings:

  • Head impulse testing
  • Nystagmus testing
  • Testing of skew

VIDEO LINK: http://emcrit.org/misc/posterior-stroke-video/

Thanks to Dr. Brian Resler (UCSF-SFGH EM resident) for giving me the heads up about this at Followup Conference!

Reference

  1. Tarnutzer A, Berkowitz A, Robinson K, Hsieh Y, Newman-Toker D. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571-92. [PubMed]
By |2021-10-11T15:40:21-07:00Dec 2, 2011|ALiEM Cards, Neurology|
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Trick of the Trade: Securing a peripheral IV on sweaty skin


IVcathetherTapePatients can become extremely diaphoretic with high fevers or if under the influence of PCP or a stimulant. Slippery, sweaty skin can pose a problem when securing peripheral IV’s. Adhesive tapes that are typically designed for securing these IV’s often slip off… immediately followed by the IV falling out.

How can you secure the IV … without using staples and sutures? 

By |2016-11-11T18:51:44-08:00Nov 29, 2011|Tricks of the Trade|
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Paucis Verbis: aVR Lead on ECG

ECG leads aVR lead

What lead is the most overlooked on the ECG?

 Answer: aVR Lead

This lead can provide some unique insight into 5 different conditions:

  1. Acute MI
  2. Pericarditis
  3. Tricyclic antidepressant (TCA) and TCA-like overdose
  4. AVRT in narrow complex tachycardias
  5. Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)

PV Card: The aVR Lead on ECG


Adapted from [1-4]
Go to ALiEM (PV) Cards for more resources.

See also:

References

  1. Williamson K, Mattu A, Plautz C, Binder A, Brady W. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006;24(7):864-874. [PubMed]
  2. Vereckei A, Duray G, Szénási G, Altemose G, Miller J. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. [PubMed]
  3. Kireyev D, Arkhipov M, Zador S, Paris J, Boden W. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-180. [PubMed]
  4. Riera A, Ferreira C, Ferreira F, et al. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011;16(3):295-302. [PubMed]
By |2021-10-11T15:47:33-07:00Nov 18, 2011|ALiEM Cards, Cardiovascular, ECG|
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Paucis Verbis: Methotrexate for ectopic pregnancy

Ectopic pregnancy methotrexate

Ectopic pregnancies account for as many as 18% of patients who present with first-trimester bleeding or abdominal pain in the Emergency Department. This Paucis Verbis card summarizes the 2008 American College of Obstetricians and Gynecologists (ACOG) guidelines on the use of methotrexate (MTX) for ectopic pregnancies. Not all ectopic pregnancies require operative management.

What are the indications and contraindications to MTX? When should they follow up with their obstetrician?

Answer: In 4 days for a repeat b-HCG and possible second dose of MTX

Note that one of the eligibility criteria is that the patient must have an “unruptured ectopic pregnancy”. Many would consider that any ultrasonographic evidence of free fluid may be a sign of an early rupture. It is left up to clinician judgment in how “unruptured” is interpreted.

PV Card: Methotrexate for Ectopic Pregnancy


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy. Obstetrics & Gynecology. 2008;111(6):1479-1485. doi: 10.1097/aog.0b013e31817d201e
By |2021-10-11T15:53:39-07:00Nov 11, 2011|ALiEM Cards, Ob/Gyn|
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Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

ShoulderDislocation

Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?

(more…)

By |2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|
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Paucis Verbis: Acetaminophen toxicity

acetaminophen toxicityDid you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That’s a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient’s risk for hepatotoxicity.

In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).

Rule of 150

  • The toxic ingestion dose of acetaminophen is 150 mg/kg.
  • The serum acetaminophen level when N-acetylcysteine treatment should be started is 150 mcg/mL (see Rumack Matthew nomogram)
  • The starting IV dose of N-acetylcysteine is 150 mg/kg over 15 minutes.

PV Card: Acetaminophen Toxicity


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Larson A. Acetaminophen hepatotoxicity. Clin Liver Dis. 2007;11(3):525-48, vi. [PubMed]
By |2021-10-11T15:53:18-07:00Nov 4, 2011|ALiEM Cards, Tox & Medications|
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