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Principles and Practice of Emergency Neurology
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Book description

In this handbook, the emergency physician-neurologist editorial team from the acclaimed comprehensive text Emergency Neurology bring its expertise to a readily accessible reference tool for the emergency department. With a symptom-based emphasis, the text, tables, and illustrations guide the emergency physician in the recognition, diagnosis, and management of neurological disorders both common and complex. Integrating fundamental neurological concepts with the practical realities and demands of emergency care, this handbook features management algorithms for dozens of conditions, and a list of 'pearls and pitfalls' at the conclusion of each of the 38 chapters. This survey of best practices in emergency neurology provides succinct and crucial clinical information for all emergency physicians who diagnose and manage neurologic disorders such as headache, seizure, and spinal cord injury. Emphasizing efficient neurological examination techniques, this is an essential handbook for emergency physicians, internists, and residents.

Reviews

‘This is a carefully edited and carefully written multiauthored book … ER physicians will enjoy reading this book - and learn much from it too. 4 stars.’

Source: Doody’s Reviews (refers to textbook version)

‘I recommend Emergency Neurology for inclusion in the libraries of emergency physicians and as a teaching reference for emergency medicine residents and out-of-hospital care providers.’

Source: Annals of Emergency Medicine (refers to textbook version)

‘This book will hopefully help to demystify and simplify what is actually a logical and interesting aspect to the Emergency Department caseload.’

Source: Resuscitation (refers to textbook version)

'Principles and Practice of Emergency Neurology incorporates major neurological concepts from prehospital management through to final outcome in a pragmatic approach … Reflecting the central role of neurological assessment and management in the daily practice of emergency medicine, this book will undoubtedly become a reference for clinicians thanks to its systematic reviews of the main interventions in emergency neurology.'

Source: The Lancet

'As an aid to the assessment of an individual patient, or to understand more about specific neurological conditions, this text is invaluable … I am sure it will be used widely.'

Source: Accident & Emergency Nursing

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Contents


Page 1 of 2


  • SECTION I - NEUROLOGICAL EXAMINATION AND NEURODIAGNOSTIC TESTING
    • By Sid M. Shah, Assistant Clinical Professor Michigan State University; Faculty member of Sparrow/MSU Emergency Medicine Residency Program Lansing, Michigan, Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine
  • View abstract

    Summary

    A detailed neurological history allows one to focus on important components of the neurological examination and for saving time and resources. The important elements of a focused neurological examination include onset of symptoms, temporal relationships of symptoms, progression of symptoms, associated symptoms, exacerbating and alleviating factors, symptoms that indicate involvement of a particular region of central nervous system (CNS), history of similar event and history of medication use. This chapter describes the examination of mental status, cranial nerve function, motor function, deep tendon reflexes, cutaneous reflexes, and miscellaneous signs, sensory modalities, and pathological reflexes. The Glasgow Coma Scale is often used as a method of briefly quantitating neurological dysfunction. A simple method to remember the anatomic basis of neurological examination is to focus on five levels of the CNS, which are the brain, the brainstem, the spinal cord, the peripheral nerves, and the muscles.
  • 2 - Neuroradiology
    pp 12-29
    • By Andrew L. Goldberg, Director Westside imaging Center Brook Brook Park, Ohio, Sid M. Shah, Assistant Clinical Professor Michigan State University; Faculty member of Sparrow/MSU Emergency Medicine Residency Program Lansing, Michigan
  • View abstract

    Summary

    Magnetic resonance imaging (MRI) with or without contrast is the study of choice when cerebellar, brainstem, or internal auditory meatus pathology is suspected. Similarly, the yield of computed tomography (CT) brain scans is minimal in patients with syncope or near syncope. Suspected spinal cord compression is best defined by MRI. Traumatic or atraumatic myelopathy should be investigated with emergent MRI. In case of nontraumatic myelopathy, the entire spine must be evaluated by MRI. Ready access to CT and its accurate interpretation is essential in evaluating the patient presenting with a new ischemic neurological deficit. Epidural hematomas are often associated with skull fractures, which should be evaluated with CT bone settings and the plain radiography. Most of epidural hematomas result from laceration of the meningeal arteries and/or dural venous sinuses. MRI is particularly sensitive in demonstrating subacute subdural hematomas because of its inherent soft tissue contrast characteristics and its multiplanar capability.
  • 3 - Electroencephalography
    pp 30-34
    • By Ivo Drury, Department of Neurology Henry ford Hospital Detroit, Michigan
  • View abstract

    Summary

    The appearance of the normal electroencephalogram (EEG) changes significantly from birth through the teenage years and remains relatively unchanged until at least age 80. Epileptiform abnormalities on the EEG may be either interictal or ictal. Status epilepticus (SE) is defined as a continuous seizure lasting 30 minutes or more, or the occurrence of two or more seizures without full recovery of the baseline level of consciousness. EEG abnormalities that are slower than expected for the age and behavioral state of the patient are referred to as slow-wave abnormalities. Focal slow-wave abnormalities imply a local disturbance of cortical and sometimes adjacent subcortical structures. Generalized intermittent slowing occurs most commonly in diverse encephalopathies. EEG is useful in establishing a diagnosis of brain death; it should be used only when the patient has met all clinical criteria for the absence of any brain or brainstem function due to a known and irreversible cause.
  • 4 - Lumbar Puncture
    pp 35-42
    • By James Valeriano, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania, Daniel Ammons, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The only absolute contraindication to performance of a lumbar puncture (LP) is the presence of infection over the puncture site. Potential side effects of lumbar puncture range from minor to life threatening. Even in the absence of infection in the region of the puncture site, there is a risk of introducing an infection into the spinal canal. Strict sterile precautions must therefore be maintained to minimize this risk. Meningitis can develop following LP in a bacteremic patient. D. W. Teele reported that 7 of 46 bacteremic patients developed meningitis following an (initially negative) diagnostic LP. In a patient with equivocal test results and a negative Gram stain, empiric antibiotics therapy is begun until culture results are available. In cases where the examiner has a high pretest probability of bacterial meningitis, the patient should receive appropriate antibiotics before or immediately after LP is performed, without waiting for results to become available.
  • SECTION II - COMMON NEUROLOGICAL PRESENTATIONS
    • By Sid M. Shah, Assistant Clinical Professor Michigan State University; Faculty member of Sparrow/MSU Emergency Medicine Residency Program Lansing, Michigan, Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine
  • View abstract

    Summary

    Altered mental status is due to neuronal dysfunction on a cellular level due primarily to inadequate oxygenation or glucose delivery to the cell. Abnormal vital signs are noted. Arrhythmias, especially atrial fibrillation and ventricular tachycardias, suggest an ischemic, toxic, or multifocal embolic etiology but also occur in dehydration or stress. Hypertension when extreme (diastolic greater than 120 mm Hg) can cause coma in hypertensive encephalopathy. A nonfocal neurological exam directs the work-up toward an etiology affecting the cortex diffusely, causing encephalopathy. Initial laboratory testing includes basic chemistries, glucose, creatinine, blood urea nitrogen, urinalysis and urine culture, and arterial blood gases. Administration of dextrose and thiamine is warranted in those patients in whom the etiology of the mental status change is unclear and the neurological examination is non-focal. The Glasgow Coma Scale has been shown to help prognosticate recovery in coma resulting both from trauma and out-of-hospital cardiac arrest.
  • 6 - Headache
    pp 52-61
  • View abstract

    Summary

    The typical evaluations of headache include vital signs, palpation of the sinuses, temporomandibular joint and cervical musculature, and auscultation of the carotids in addition to neurological examinations. Although plain films of the sinuses, temporomandibular joint, or cervical spine are occasionally helpful, brain computerized tomography (CT) or magnetic resonance imaging (MRI) are the imaging studies of choice for headache. Subarachnoid hemorrhage (SAH) afflicts nearly 30,000 Americans each year, the majority suffering a ruptured intracranial aneurysm. The primary headache syndromes include: tension-type headache, cluster headache and migraine headache. Given the wide array of newer treatment options for acute migraine, the role of narcotics has become more limited. However, it is compassionate and necessary to treat occasional patients who have failed all reasonable options with potent narcotic analgesics. Most migraine headaches may be aborted with parenteral sumatriptan, dihydroergotamine, or neuroleptic agents.
  • 7 - Weakness
    pp 62-67
    • By George A. Small, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania, David M. Chuirazzi, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The inability to perform a specific normal activity suggests weakness, which can be readily distinguished from loss of stamina or endurance. Pain, cramping, and gastrointestinal complaints frequently accompany weakness. The collagen-vascular diseases and inflammatory myopathies are likely to produce myalgia and muscle tenderness. The degree of weakness is assessed for each muscle group; serial examinations can provide evidence of improvement or worsening in the condition. This chapter provides differential diagnosis for specific conditions such as cerebral hemispheric lesions, spinal cord disorders, anterior horn cell disorders, nerve root disorders, neuromuscular junction disorders, and myopathies. In the emergency department, the most serious presentation of severe muscle weakness is acute respiratory failure. The three most common primary neurological causes of acute respiratory failure are previously unrecognized amyotrophic lateral sclerosis (ALS), myasthenia gravis, and Guillain-Barré syndrome. Respiratory failure due to a neuromuscular cause is a form of restrictive pulmonary disease.
  • 8 - Dizziness
    pp 68-91
    • By Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine, Steven A. Tellan, Department of Otolaryngology University of Michigan Ann Arbor, Michigan, Moises A. Arriaga, Department of Neuro–otology Allegheny General Hospital Pittsburgh, Pennsylvania, Thomas M. Stein, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    Dizziness or vertigo is frequently caused by a disorder of the vestibular system. The central vestibular system includes the vestibular nuclei and their central nervous system (CNS) connections. A carefully obtained history is critical in the evaluation of a patient's complaint of dizziness or vertigo. This is important diagnostically because vertigo usually results from vestibular system disorders, whereas nonvertiginous dizziness usually results from nonvestibular system disorders. The differential diagnosis of dizziness or vertigo can be approached by determining whether the disorder is due to an abnormality of the vestibular system or of nonvestibular systems. Imaging studies of the skull and brain may be indicated in the evaluation of a patient with dizziness or vertigo. A patient who presents to the emergency department (ED) acutely ill with vertigo accompanied by severe nausea and vomiting requires immediate stabilization. Benzodiazepines can be used acutely to treat moderately severe anxiety syndromes that cause dizziness.
  • 9 - Seizures
    pp 92-108
    • By Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine, Nick E. Colovos, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The epileptic seizures are internationally classified into simple partial seizures, complex partial seizures, partial seizures evolving to secondarily generalized seizures, generalized seizures (convulsive or nonconvulsive), myoclonic seizures, clonic seizures, tonic seizures, tonic-clonic seizures and atonic seizures (astatic seizures). The emergency department (ED) management of a patient with a seizure is commonly determined by the cause, type, severity, and frequency of the seizure. Status epilepticus (SE) can be nonconvulsive or convulsive. Convulsive SE is a medical emergency requiring prompt and focused treatment. A benzodiazepine is the first class of drug to be administered in treating SE. Alcohol withdrawal seizures are generalized tonic-clonic convulsions that usually occur within 48 hours after cessation of ethanol ingestion, with a peak incidence between 13 and 24 hours. It is important that the emergency physician knows the state's law regarding restriction of driving privileges for patients who have experienced a seizure.
  • 10 - Gait Disturbances
    pp 109-112
    • By Jon Brillman, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The gait abnormalities are indicative of some disorder of the nervous system. This chapter describes different types of gait disturbance with regard to localization and specific neurological disorders. The different gait disturbances are: senescent gait or early gait apraxia, advanced senescent gait (late gait apraxia), hemiparetic gait, spastic gait, ataxic gait, staggering gait, steppage gait, waddling gait, hysterical gait and antalgic gait. Antalgic gait results from a shortened stance phase or a painful limb. Osteoarthritis is a common cause. The gait of patients with Parkinson's disease and related disorders is stereotyped but may be confused with senescent gait. There is usually a flexion of all limbs and trunk and a tendency to lean forward and accelerate with walking, a disturbance referred to as festination. Tremor commonly accompanies the gait disturbance. Universal flexion is typically associated with the gait of Parkinson's disease.
  • SECTION III - SPECIFIC NEUROLOGICAL CONDITIONS
    • By Sid M. Shah, Assistant Clinical Professor Michigan State University; Faculty member of Sparrow/MSU Emergency Medicine Residency Program Lansing, Michigan, Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine
  • View abstract

    Summary

    Central nervous system (CNS) infections range from rapidly fatal bacterial meningitis to slowly progressive infectious processes from mycobacterial, fungal, or viral agents. The diagnosis of acute bacterial meningitis is made by the examination of cerebrospinal fluid (CSF). Brain abscess is a suppurative infection involving brain parenchyma. Although the CNS infections most commonly associated with HIV infection are toxoplasmosis and cytomegalovirus (CMV), such patients are susceptible to many other infections including aseptic meningitis, neurosyphilis, and M. tuberculosis. The term aseptic meningitis has been used to describe conditions of acute meningeal irritation that prove to be benign and self-limiting. The incidence of tuberculosis (TB) is on the rise, due to an increase in numbers of HIV-infected persons, numbers of homeless individuals, and immigrants from developing countries. Cryptococcus neoformans, a common fungal pathogen, commonly affects HIV infected patients. Viral encephalitis is an infectious and inflammatory process involving the brain.
  • 12 - Cerebrovascular Disease
    pp 131-145
    • By Michael R. Frankel, Department of Neurology Grady Memorial Hospital Atlanta, Georgia, Marc Chimowitz, Department of Neurology Grady Memorial Hospital Atlanta, Georgia, Sam Josvai, Kalamazoo Center for Medical Studies/MSU Emergency Medicine Residency Program Kalamazoo, Michigan, Rashmi U. Kothari, Kalamazoo Center for Medical Studies/MSU Emergency Medicine Residency Program Kalamazoo, Michigan, Sid M. Shah, M.D. Ingham Regional Medical Center Sparrow Hospital/MSU, Emergency Medicine Residency Program Lansing, Michigan
  • View abstract

    Summary

    Cerebrovascular disease encountered in the emergency department (ED) includes transient ischemic attacks (TIAs) and infarcts (strokes). The purpose of the initial evaluation is to determine whether there is evidence of a stroke, what part of the brain is affected, and whether the patient is a candidate for urgent intervention such as thrombolytic therapy. A chemistry profile, complete blood count (CBC) with platelets, and coagulation profile are essential after completion of brief examination. Attention to adequate airway protection, oxygenation, and circulatory function is essential for management of patients with acute stroke. The use of anticoagulants (heparin or low molecular heparins) remains the most controversial subject in the management of acute stroke. Patients with acute or hemorrhagic strokes need to be admitted to the hospital for further evaluation and management. A neurosurgeon should participate in the care of most patients with intracerebral hemorrhages (ICH) and all patients with subarachnoid hemorrhages (SAH).
  • 13 - Movement Disorders
    pp 146-160
    • By Sid M. Shah, Assistant Clinical Professor Michigan State University, Roger Albin, Department of Neurology University of Michigan Ann Arbor, Michigan, Susan Baser, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    Movement disorders (MD) encountered in the emergency department (ED) range from the familiar Parkinsonism and drug-induced dystonias to rare disabling hemiballism secondary to a stroke. Movement disorders can be classified into four broad categories based on phenomenological features, clinical pharmacology, and neuropathology. It includes hypokinetic disorders identical to Parkinsonism's syndrome, hyperkinetic/choreic movement disorders, tremors, and myoclonus. The cause-and-effect relationship between the drug and the movement disorder is poorly understood, but preexisting central nervous system (CNS) pathology likely predisposes to the development of movement disorders. Commonly prescribed medications that result in movement disorders include antiepileptics, neuroleptics, stimulants, oral contraceptives, antihistaminics and anticholinergics, and antidepressants. The use of monoamine oxidase (MAO) inhibitors is associated with tremors and less often with myoclonic jerks. Tricyclic antidepressants such as amitriptyline, imipramine, and nortriptyline cause choreiform movements infrequently, particularly orofacial dyskinesia.
  • 14 - Peripheral Nervous System and Neuromuscular Disorders
    pp 161-174
    • By John J. Wald, Department of Neurology University of Michigan Ann Arbor, Michigan, James W. Albers, Department of Neurology University of Michigan Ann Arbor, Michigan
  • View abstract

    Summary

    The hallmarks of peripheral nervous system (PNS) disorders and neuromuscular diseases are weakness, numbness, or pain. Acute exacerbation of a neuromuscular disorder can have a rapid transition from unlabored breathing to decompensation and hypoventilation because of muscular fatigue or with aspiration of oral secretions in patients with marginal ventilatory function. Strength testing is performed by assessing the power of several proximal and distal muscle groups and by noting patterns of weakness and asymmetry. Numbness indicates the need for sensory testing to determine the patient's ability to perceive sensory stimuli. Deep tendon reflex (DTR) loss that is asymmetrical or focal in the distribution of one or several nerve root(s) or specific nerve(s) suggests localized disease. This chapter discusses disorders involving nerve roots, mixed nerves, peripheral nerves, disorders of neuromuscular transmission, disorders involving muscle and muscle function and motor neuron disease.
  • 15 - Guillain-Barré Syndrome
    pp 175-179
    • By Sandeep Rana, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania, Sid M. Shah, Assistant Clinical Professor Michigan State University
  • View abstract

    Summary

    Guillain-Barré syndrome (GBS) is a form of acute inflammatory (demyelinating) polyneuropathy. It causes rapidly ascending numbness and weakness. In the early phase, a high index of suspicion for GBS is essential in the presence of ascending numbness and weakness because ancillary tests may not help. A normal cerebrospinal fluid (CSF) protein level in the early phase or a finding of numerous lymphocytes does not exclude the diagnosis of GBS. By end of first week of illness, CSF analysis usually reveals normal CSF pressure and elevated protein without leukocytosis termed albuminocytological dissociation. Despite advances in the treatment of GBS, good supportive care is still the most important determinant of favorable outcome. Cardiac monitoring is routine for patients with severe findings. Respiratory status is assessed with periodic vital capacities. Elective endotracheal intubation for ventilatory support is considered when the vital capacity is below 15 ml/kg.
  • 16 - Myasthenia Gravis
    pp 180-185
    • By George A. Small, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania, Mara Aloi, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    Myasthenia gravis is caused by antibodies that bind to postsynaptic acetylcholine receptors of the neuromuscular junction of skeletal muscle. The majority of patients with myasthenia gravis present to the emergency department (ED) with an exacerbation of the disease or complications of their medications. Brainstem stroke can present with altered mental status, ptosis, diplopia, and pupillary abnormalities. MRI with diffusion-weighted imaging can reliably distinguish acute brainstem stroke from myasthenia gravis. One reliable diagnostic tool for myasthenia gravis is the edrophonium (Tensilon) test, which may help to differentiate a cholinergic crisis (that is, overmedication of cholinesterase inhibitors) from a myasthenic crisis, and guide subsequent therapy. Careful attention to airway support is of primary importance in the myasthenic patient. Immunosuppressive agents are useful for long-term suppression of the disease. All patients with airway compromise require intensive case unit (ICU) admission.
  • 17 - Musculoskeletal and Neurogenic Pain
    pp 186-196
    • By Robert G. Kaniecki, Department of Neurology University of Pittsburgh Pittsburgh, Pennsylvania, L. R. Searls, Ingham Regional Medical Center Sparrow Hospital/MSU Emergency Medicine Residency Program Lansing, Michigan
  • View abstract

    Summary

    Although the most common sources of pain in the neck and upper extremities are musculoskeletal or neurogenic, referred pain from ischemic processes of visceral organs is often confounding. The most common cause of neck pain is cervical strain, characterized by transient cervical pain, stiffness, and posterior cervical muscle spasm. Local application of heat and anti-inflammatory analgesics are generally effective. Lesions of the cervical spinal cord generally result in deep segmental pain that is poorly localized and infrequently influenced by positional changes or Valsalva maneuvers. Tumors of the axial skeleton are commonly metastatic in origin. The thoracic region is the most common spinal location for metastatic disease, and 70% of spinal cord compression cases arise from thoracic cord involvement. Lumbar strain or sprain is the most common source of benign backache. The treatment for spinal stenosis involves analgesics, adjuvant analgesics (antidepressants or antiepileptics), physical therapy, and surgery in appropriate cases.
  • 18 - Neuro-Ophthalmological Emergencies
    pp 197-209
    • By Dennis Hanlon, Department of Emergency Medicine Allegheny General Hospital Pittsburgh, Pennsylvania, Eric R. Eggenberger, Michigan State University East Lansing, Michigan
  • View abstract

    Summary

    Diplopia, visual loss, and pupillary asymmetry are important presentations of neuroophthalmologic emergencies. When evaluating a patient with diplopia, the most important initial step is to determine whether the diplopia is monocular or binocular. Binocular diplopia resolves when either eye is covered. Monocular diplopia usually results from ophthalmologic causes or refractive errors. Binocular diplopia results from ocular misalignment. Diplopia is most pronounced when looking in the direction of the limited extraocular movement regardless of cause. Neuro-ophthalmologic visual loss is divided into prechiasmal, chiasmal, or postchiasmal etiologies. Monocular visual loss indicates a lesion anterior to the chiasm. Pupils are evaluated for reactivity and size in light and dark environments. Anisocoria is defined as unequal pupil size. A significant percent (approximately 20%) of the population has minimal anisocoria without pathology, termed physiological or simple anisocoria. Only physiological anisocoria or Horner's syndrome produce anisocoria with normally reactive pupils.
  • 19 - Multiple Sclerosis
    pp 210-217
    • By Thomas F. Scott, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The primary pathological event in multiple sclerosis (MS) lesion development is an immune-mediated destruction of the neuronal myelin sheath. The inflammatory lesions of MS can affect any part of the central nervous system and optic nerves, resulting in a wide variety of presenting symptoms. The first symptoms of MS are commonly weakness, paresthesias, visual loss, incoordination, vertigo, and sphincter impairment. Focused testing of cranial nerve function, strength, coordination, gait, and sensation, and an evaluation for pathological reflexes are important. The onset of MS is heralded by a bout of optic neuritis in about 20% of patients with MS, and more than 50% of patients with optic neuritis eventually develop the disease. Neuroimaging assists in differentiating MS from mass lesions, infections, or strokes. Patients with relapsing-remitting multiple sclerosis (RRMS) who experience an acute exacerbation of their illness present with either recurrence or worsening of old symptoms, or entirely new neurological symptoms.
  • 20 - Dementia
    pp 218-225
  • View abstract

    Summary

    Dementia is a syndrome, not a specific diagnosis. There are more than 70 recognized disorders that cause dementia and the ultimate responsibility of determining the precise cause of dementia lies with a multidisciplinary team or dementia clinic. Mild dementia, however, is often missed unless mental status is formally assessed. Transient global amnesia (TGA) is a rare, but dramatic entity with a benign prognosis. TGA is characterized by abrupt, temporary inability to form new memories (anterograde amnesia) and variable impairment of recent and remote memory. TGA spares nonmemory functions, such as language and visuospatial skills. The diagnostic evaluation of dementia is best done in the outpatient setting. Common complications, such as pneumonia and urinary tract infection, are considered in demented patients with a precipitous decline in cognition. Infectious precautions are required when evaluating patients with rapidly progressive dementia.
  • 21 - Brain Tumors and Other Neuro-Oncological Emergencies
    pp 226-235
  • View abstract

    Summary

    Neuro-oncologic emergencies are a diverse group of disorders that occur frequently in patients with brain tumors and other types of cancer. The most common structural alterations that cause mental status changes are the presence of primary or metastatic brain tumors. Seizures are common in patients with primary and metastatic brain tumors. In patients with a diagnosed brain tumor, the most common cause for seizure activity is nontherapeutic or inadequate anticonvulsant levels. The most important predisposing factors for cerebrovascular disease in cancer patients are direct effects of tumors on blood vessels, tumor-induced coagulation disorders (hemorrhagic and thrombotic), and treatment-related injury to blood vessels. Focal neurological signs and symptoms are common in patients with brain tumors and other forms of neuro-oncologic disease. In patients with systemic or central nervous system cancer, back pain is often the first sign of a more virulent underlying neurological process.
  • 22 - Neuropsychiatry
    pp 236-241
    • By Craig A. Taylor, Southwood Psychiatric Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    Neuropsychiatric patients with underlying central nervous system (CNS) disturbance can present to the emergency department because of a change in behavior. A detailed and accurate history is obtained from anyone who presents with a cognitive, behavioral, emotional, or other neuropsychiatric disturbance. In neuropsychiatric evaluation, the mental status examination is of paramount importance. The possibility of alcohol or illicit drug use is investigated thoroughly in any patient who presents with acute mental status or behavioral changes. Acute symptoms may be caused by worsening of a neurological or medical condition or by another underlying neuropsychiatric condition. Chronic neuropsychiatric symptoms that worsen are commonly associated with psychosocial stressors and a related adjustment disorder. Certain conditions of a psychiatric nature, including destructiveness, disorganization, depression, disorientation due to severe organic mental disturbances, and conditions requiring detoxification, require psychiatric hospitalization, whether or not the patient has an underlying CNS disturbance.
  • 23 - Increased Intracranial Pressure and Herniation Syndromes
    pp 242-251
    • By Amy Blasen, Sparrow Healthcare System Sparrow Hospital/MSU Emergency Medicine Residency Program Lansing, Michigan, Sid M. Shah, Assistant Clinical Professor Michigan State University
  • View abstract

    Summary

    Primary survey of a patient suspected of having an increased intracranial pressure (ICP) consists of a brief neurological examination and establishment of a Glasgow Coma Scale (GCS) score. Brain herniation, an end-stage manifestation of increased ICP, refers to displacement of brain tissue from one intracranial compartment to another through an opening in the dural sheath. A herniation syndrome is a neurosurgical emergency; if immediate intervention is not taken, death can ensue rapidly. Initial therapy is aimed at lowering ICP while determining and treating the underlying cause. Common conditions resulting in increased ICP include traumatic brain injury (TBI), cerebrovascular events, hydrocephalus, brain tumor, central nervous system infections, metabolic and hypoxic encephalopathies, and status epilepticus. Mannitol, an osmotic diuretic, is currently the diuretic of choice for treating increased ICP. Barbiturate therapy is effective in lowering ICP in a select subset of patients such as those with persistently high ICP despite aggressive management.

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