Neuro

  • Altered Mental Status
  • Headache
  • Syncope
  • Dizziness
  • Seizure

Altered Mental Status

  • Differentials 
    • “AEIOU-TIPS”
      • Alcohol
      • Electrolytes, Endocrine, Encephalopathy
      • Infection
      • Overdose
      • Uremia
      • Trauma
      • Insulin
      • Poisons, Psychogenic
      • Stroke, Seizure, Space occupying lesion, Shock
  • History
    • Baseline mental status?
    • Last seen normal?
    • Recent trauma?
    • New medications/exposures?
    • Recent surgery/illness?
    • Additional symptoms?
  • Physical Exam
    • Signs of trauma?
      • Consider concussion, brain bleed
    • Pupil size?
      • Consider overdose, ICP
    • Neck stiffness?
      • Consider meningitis
    • Odor?
      • Consider DKA, alcohol
    • Neurological deficits? 
      • Consider stroke, seizure
    • Abnormal lung sounds?
      • Consider pneumonia, heart failure, COPD
    • Skin lesions?
      • Consider infection
  • Work-Up
    • Labs: 
      • CBC, CMP, UA, blood alcohol level. 
      • Consider: urine drug screen, TSH, lactate, ABG, blood cultures, lumbar puncture
    • Imaging:
      • CXR
      • Head CT
Video Credit: Anna Pickens

*Deep Dive: Approach to Altered Mental Status (SAEM)



Headache

  • Differentials 
    • Most serious
      • Meningitis
      • Subarachnoid hemorrhage
      • Temporal arteritis
      • CVA
      • Cervical artery dissection
      • Venous Sinus Thrombosis
    • Most Common
      • Tension headache
      • Migraine headache
      • Sinusitis
  • History
    • Worst headache of life?
      • Consider dissection, CVST, SAH
    • Neck stiffness?
      • Consider meningitis, brain abscess
    • Sick contacts?
      • Consider carbon monoxide poisoning, meningitis
    • Vertigo?
      • Consider stroke, vertebral artery dissection
    • Confusion?
      • Consider encephalitis, CVST, mass
    • Visual Changes?
      • Consider mass, glaucoma, temporal arteritis
    • Head Trauma?
      • Consider intracranial bleeding, concussion
  • Physical Exam
    • Head trauma?
      • Consider intracranial bleeding, concussion
    • Dilated pupil?
      • Consider acute glaucoma, brain injury
    • Photophobia?
      • Consider migraine, meningitis
    • Kernig/Brudzinski Sign?
      • Consider meningitis
    • Rashes/lesions?
      • Consider meningitis
    • Neurological deficits?
      • Consider cervical artery dissection, space-occupying lesion
  • Work-Up
    • Labs
      • CBC, BMP, ESR, blood cultures
      • Lumbar puncture for CSF analysis
    • Imaging
      • Head CT w/o contrast (if suspect cerebellar stroke
      • MRI brain w/o contrast (if CT negative)
      • CTA of head/neck (if suspect dissection)
Video Credit: EM in 5

*Deep Dive: Headache Management in the ED (emDocs)



Syncope

  • Differentials 
    • Cardiac 
      • Arrhythmias (WPW, Brugada, VF/VT, AV block)
      • Aortic stenosis
      • Aortic dissection
      • Pulmonary embolism
    • Reflex
      • Vasovagal 
      • Carotid sinus syndrome
      • Orthostatic hypotension
    • Neuro
      • Stroke
      • Seizure
    • Pulmonary
      • Pulmonary embolism
      • Pneumothorax
    • Genitourinary
      • Ectopic pregnancy
    • Gastrointestinal
      • Upper/lower GI bleed
  • History
    • Head trauma before or after episode?
      • Consider brain hemorrhage
    • Tonic/clonic movements? Tongue biting? Urinary incontinence?
      • Consider seizure
    • Recent emotional stress?
      • Consider vasovagal syncope
    • Associated with exertion?
      • Consider cardiac or vascular causes
    • Diabetic?
      • Consider hypoglycemia
    • Melena or hematochezia?
      • Consider GI bleed
  • Physical Exam
    • Head trauma?
      • Consider intracranial hemorrhage
    • Murmurs, Rubs, Gallops?
      • Consider aortic stenosis or heart failure
    • Capillary refill?
      • Consider dehydration
    • Rales/wheezing in lung fields?
      • Consider heart failure
    • Neurologic deficits?
      • Consider stroke
    • Tongue bite marks?
      • Consider seizure
  • Work-Up
    • EKG
      • Look for ischemia, arrhythmia, delta wave, long QT, etc.
    • Labs
      • CBC, BMP, hCG
    • Imaging
      • CXR 
      • Head CT w/o contrast
Video Credit: Anna Pickens

*Deep Dive: Syncope as Easy as 1-2-3 (ALiEM)



Dizziness

  • Differentials 
    • Vertigo
      • Benign Positional Peripheral Vertigo
      • Labrynthitis
      • Meniere Disease
      • Cerebellar stroke
      • Vertebral basilar artery insufficiency
      • Brain tumor
      • Multiple sclerosis
    • Lightheadedness
      • Anemia
      • Hypotension
      • Bradycardia
      • Dehydration
  • History
    • What do you mean by “dizzy”?
      • Differentiate between vertigo and lightheadedness
    • Positional?
      • Consider BPPV
    • Palpitations?
      • Consider arrhythmia
    • Chest pain/SOB?
      • Consider ACS/PE
    • Focal neurologic deficits? (diplopia, dysarthria, dysphagia, dystaxia)
      • Consider cerebellar dysfunction
  • Physical Exam
    • Head Impulse Test
      • Abnormality suggests peripheral lesion
    • Nystagmus
      • Horizontal/vertical/rotary nystagmus suggests central lesion
    • Test for Skew
      • If unable to remain focused on spot, specific for central lesion
  • Work-Up
    • EKG
      • Useful for work-up of lightheadedness/pre-syncope
    • Labs
      • CBC, BMP, hCG
    • Imaging
      • CT or MRI (if concern for central lesion)
Video Credit: The Center for Medical Education

*Deep Dive: A Simplified Approach to the Patient with Dizziness (emDocs)



Seizure

  • Differentials 
    • Metabolic/Endocrine
      • Hypoglycemia
      • Hyperglycemia
      • Hyponatremia
      • Uremia
    • Medications
      • Antispasmodics
      • Anticholinergics
      • Antipsychotics
      • Antibiotics (isoniazid, fluoroquinolones)
    • Substance use
      • Alcohol withdrawal
      • Stimulants
      • Organophosphates
    • Infection
      • Meningitis
      • Encephalitis
      • Brain abscess
    • Structural
      • Intracranial hemorrhage
      • Hydrocephalus
      • Neoplasm
  • History
    • Type of seizure?
      • Differentiate between generalized vs partial
    • Previous episodes?
      • Consider hx of epilepsy
    • Head trauma?
      • Consider intracranial hemorrhage
    • Drug/alcohol use?
      • Consider alcohol withdrawal or drug toxicity
    • Diabetic?
      • Consider hypoglycemia
  • Physical Exam
    • Head trauma?
      • Consider intracranial hemorrhage
    • Tongue biting?
      • Consider seizure vs syncopal episode
    • Rashes/lesions?
      • Consider infectious causes
    • Pregnancy?
      • Consider eclampsia
  • Work-Up
    • Labs
      • CBC, CMP, BAL, Urine drug screen
    • Imaging
      • CT head non contrast (if first seizure)
Video Credit: Details Medical

*Deep Dive: Emergency Approach to Resolved Seizures (EM Cases)


Brandon Simpson, PA-C
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