Neurologic

Rapid Review

• Background
  • Also known as “trepanning”. Involves drilling or scraping a hole into the skull to provide drainage for expanding intracranial hematoma
• Indications
  • Epidural or subdural hematoma w/ midline shift on imaging.
• Contraindications
  • Lack of imaging, reasonable access to neurosurgery, GCS > 8
• Complications
  • Damage to brain parenchyma, infection, bleeding.

Pearls

• The optimal location for this procedure will be based on the location of the hemorrhage on CT scan. When in doubt though, utilize the temporal site. 
• If a trephination tool is not available, there are case studies supporting the use of a 25-mm EZ-IO needle with an electric driver.

Deep Dive

• Crackin’ the Cranium: A Review of Cranial Burr Hole Decompression (emDocs)

Rapid Review

• Background
  • Physical exam technique utilized as a screening tool to distinguish central causes of vertigo (ex. Posterior stroke) from peripheral causes (ex. Vestibular neuritis)
• Indications
  • Patients with acute onset, continuous vertigo. 
• Contraindications
  • Chronic or episodic vertigo, C-spine injury
• Complications
  • Cervical injury from head impulse test.

Pearls

• The patient’s neck must be fully relaxed in order to perform the test correctly. Avoid being too gentle withe the head impulse, as this may cause a false negative. 
• Any positive finding from one of the 3 components (Head Impulse, Nystagmus, or Test of Skew) warrants further diagnostic imaging for posterior circulation stroke.

Deep Dive

• Take a HINT on Central Vertigo in the Emergency Department (EMResident)

Rapid Review

• Background
  • Insertion of a needle into the lumbar subarachnoid space for the purposes of measuring CSF pressure, administering therapeutic agents, or collecting CSF for laboratory testing
• Indications
  • Suspected subarachnoid hemorrhage, meningitis, or GBS. May also provide relief for pseudotumor cerebri.
• Contraindications
  • Trauma or overlying skin infection at insertion site. Suspected spinal epidural abscess. 
• Complications
  • Post-lumbar puncture headache, spinal epidural hematoma

Pearls

• Ultrasound can be useful for identifying the intervetebral spaces, especially in obese patients.
• There are no differences in complications or success rates between the sitting position and the lateral decubitus, so do whatever works best for you!

Deep Dive

• Lumbar Puncture (Taming The SRU)

Rapid Review

• Background
  • Aspirating fluid from a ventriculoperitoneal (VP) shunt may be diagnostic (evaluate for infection or blockage), as well as therapeutic (alleviates symptoms of blocked shunt). 
• Indications
  • Suspected VP shunt infection, meningitis, or blockage
• Contraindications
  • Infection over entry site. Relative contraindications include coagulopathy, lack of shunt imaging/information.
• Complications
  • Infection (low risk), bleeding, CSF leak, ventricular collapse, or misplaced tap.

Pearls

• It is always best to consult neurosurgery prior to attempting any ventricular shunt taps.
• No fluid return or abrupt stop in flow = proximal obstruction. Opening pressure > 20 = distal obstruction

Deep Dive

• Tapping a VP Shunt (Pediatric EM Morsels)