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  1. Home
  2. Books
  3. Principles and Practice of Emergency Neurology
  • Cited by 5
Publisher:
Cambridge University Press
Online publication date:
August 2009
Print publication year:
2003
Online ISBN:
9780511547256
DOI:
https://doi.org/10.1017/CBO9780511547256
Subjects:
Emergency Medicine, Neurology and Clinical Neuroscience, Medicine
Information

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 2 of 2

Contents
  • 24 - Idiopathic Intracranial Hypertension
    pp 252-259
  • View abstract

    Summary

    Idiopathic intracranial hypertension (IIH) is considered when evaluating a young patient with symptoms such as headache, transient visual obscuration or finding of palliedema. Lumbar puncture (LP) with opening pressure recording and cerebrospinal fluid (CSF) examination are required in patients with suspected IIH. Patients with IIH can have large variations in intracranial pressure (ICP), but rarely a single measurement of ICP is normal. Pathological conditions that resemble IIH clinically include cerebral mass lesions, hypertensive encephalopathy, hydrocephalus, and dural sinus thrombosis. Chronic forms of meningitis such as cryptococcal meningitis can resemble IIH initially because of headache and papilledema. Changes in visual acuity or visual-evoked potentials are signs of end-stage IIH-related optic nerve injury. Hospitalization is required when rapid visual loss or serious complications of IIH are suspected. Consultation with a neurologist, ophthalmologist, and neurosurgeon is indicated according to the severity of symptoms and the current treatment.
  • 25 - Normal Pressure Hydrocephalus
    pp 260-262
    • By Oliver W. Hayes, Ingham Regional Medical Center Sparrow Hospital/MSU Emergency Medicine Residency Program Lansing, Michigan, Lara Kunschner, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    Normal pressure hydrocephalus (NPH) is clinical syndrome of dementia, gait disturbance, and urinary incontinence that progresses over a period of weeks to years. Urinary incontinence, a late symptom, occurs in less than 50% of patients. If untreated, NPH progresses resulting in an inability to stand, akinetic rigidity, and withdrawn behavior. The differential diagnosis includes Parkinson's disease, bifrontal brain disease due to tumor, metastases, cerebral infarction, aqueductal stenosis, metabolic encephalopathy, and Alzheimer's disease. When NPH is suspected clinically, computerized tomography (with contrast enhancement) reveals ventriculomegaly, minimal or absence of cortical atrophy, periventricular lucencies, and nearly normal-sized subarachnoid space. Magnetic resonance imaging (MRI) is the study of choice to evaluate ventriculomegaly and functional imaging of cerebrospinal fluid (CSF) flow. The role of the emergency physician is to consider the diagnosis of NPH in patients with dementia and gait disturbance and to initiate appropriate referral.
  • 26 - Nontraumatic Spinal Cord Emergencies
    pp 263-272
  • View abstract

    Summary

    Nontraumatic spinal emergencies can be caused by a wide spectrum of conditions including infection, hemorrhage, and neoplasm. The most common findings in patients with spinal emergencies are pain, motor deficits, sensory deficits, abnormal reflexes, and urinary dysfunction. Acute back pain is the only symptom of catastrophic spinal emergencies such as spinal hemorrhage or infection. Sudden paralysis can result from trauma, cord infarction, or hemorrhage. Even though a thorough sensory examination in the emergency department is often difficult and unreliable, complexes of sensory and motor abnormalities are helpful. As a result of the anatomical distribution of upper and lower motor neurons, acute spinal cord lesions almost always present with hyperreflexia. The mechanism of urinary incontinence depends on the type of lesion. Spinal cord emergencies frequently go unrecognized initially or are misdiagnosed even with such obvious symptoms as the inability to walk or bladder function failure.
  • 27 - Sleep Disorders
    pp 273-278
    • By A. Sinan Baran, Department of Psychiatry University of Mississippi Jackson, Mississippi
  • View abstract

    Summary

    The sleep disorders that predispose to trauma are: disorders associated with excessive daytime sleepiness, obstructive sleep apnea, upper airway resistance syndrome, periodic limb movement disorder, narcolepsy, cataplexy, sleep paralysis and hypnagogic hallucinations. The disorders associated with behaviors while asleep (parasomnias) are: sleep terrors and sleepwalking and REM sleep behavior disorder. Injury can result from behaviors that occur during sleep. The patient's ability to recall the episode depends partly on the type of the parasomnia (occurrence during non-REM versus REM sleep). The other sleep disorders are recurrent hypersomnia and insomnia. Insomnia can result from multiple causes including psychiatric or general medical disorders, medication effects, substance abuse, and other sleep disorders. Restless legs syndrome (RLS) is another important cause of insomnia. RLS is thought to be related to periodic limb movement disorder and is characterized by lower extremity dysesthesias that occur at rest.
  • SECTION IV - NEUROLOGICAL TRAUMA
    • 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

    Patients with mild traumatic brain injury (TBI) can have normal neurological and physical examinations. Mild traumatic brain injury is not always clinically apparent. The findings include: any period of loss of consciousness, amnesia of the event, and change in mental status such as feeling dizzy or disoriented. Focal motor findings in the unconscious patient with TBI can localize intracranial lesions or spinal cord injuries. Noncontrast computerized tomography (CT) provides useful anatomical and pathological information regarding the location, extent, and nature of the TBI within minutes. Although available evidence does not show that prevention of early posttraumatic seizures improves outcomes following TBI, anticonvulsants are an option in patients at high risk for seizures following head injury (Glasgow Coma Scale less than 9). TBI is the cause of death in approximately 40% of childhood injuries, and occurs more frequently in males and infants or adolescents.
  • 29 - Spinal Cord Injury
    pp 286-303
    • By Charles H. Bill, Sparrow Healthcare System Lansing, Michigan, Vanessa L. Harkins, Sparrow Helthcare System Sparrow Hospital/MSU Emergency Medicine residency Program Lansing, Michigan
  • View abstract

    Summary

    Spinal cord injuries at or above the C4 level can result in respiratory compromise. When the level of injury is just below the origins of the phrenic nerves, intercostal muscle function is lost, and the patient can be completely dependent on diaphragmatic contraction for respiration. Various degrees of transient neurological disability may occur as a result of a phenomenon known as spinal shock. Spinal shock results from physiological transection of the spinal cord, which commonly lasts 24-48 hours. Acute cervical strain is the most common injury following a vehicular accident. Injuries to the carotid and vertebral arteries and jugular veins are commonly associated with spinal cord injuries caused by gun shot wounds. The Third National Acute Spinal Cord Injury Randomized Controlled Trial (NASCIS III) concluded that high-dose methylprednisolone administration is associated with improved neurological outcome in spinal cord-injured patients. Spinal cord injuries are rare in patients under 17 years old.
  • 30 - Peripheral Nerve Injuries and Compression Neuropathies
    pp 304-312
    • By Patricia B. Jozefczyk, Department of Neurology Allegheny General Hospital Pittsburgh, Pennsylvania, Mark Baratz, Department of Orthopedic Suegery Allegheny General Hospital Pittusburgh, Pennsylvania
  • View abstract

    Summary

    Peripheral nerve injuries are one of three types: neuropraxia, axonotmesis and neurotmesis. Blunt trauma and traction injuries may cause nerve transection when associated with open fractures, but the majority result in neuropraxia or axonotmesis. High-energy trauma to an extremity with or without a fracture may produce a compartment syndrome. Nerve injury does not usually result from a direct electrical source. Typically, the energy is dissipated throughout the soft tissues and the nerve injury resolves more commonly from surrounding soft tissue swelling. Peripheral nerve compression may occur where the nerve passes through a tunnel and slides back and forth with joint flexion and extension. The upper extremity compression neuropathies are: pronator syndrome, anterior interosseous syndrome, carpal tunnel syndrome, thoracic outlet syndrome, cubital tunnel syndrome, Guyon's canal syndrome, posterior interosseous nerve syndrome, radial tunnel syndrome, and radial sensory nerve entrapment.
  • SECTION V - PEDIATRIC NEUROLOGICAL EMERGENCIES
    • 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

    Most children with cerebrospinal fluid (CSF) shunts who present with irritability, headache, vomiting, and fever are more likely to have a viral illness than a shunt malfunction. Almost all CSF shunt systems have intraventricular tubing, a valve apparatus, and distal tubing. Distended scalp veins or bulging of the fontanel or a craniotomy site indicates high intracranial pressure (ICP) in the process of inspection of the shunt system. A sunken fontanel and sunken craniotomy site indicate low ICP. Proximal obstruction of the ventricular catheter of the CSF shunt system occurs from cellular debris, fibrosis, infection, envelopment by the choroid plexus, and catheter migration. Furosemide (1 mg/kg per day) with or without mannitol is also used to lower elevated ICP. In addition to the shunt malfunction, the two commonly encountered complications of long-term CSF shunt systems are slit ventricle syndrome and ventriculitis.
  • 32 - Pediatric Infections of the Central Nervous System
    pp 325-329
  • View abstract

    Summary

    The presenting symptoms of CNS infections in children 2-24 months of age typically are nonspecific. Fever, seizures, poor feeding, and irritability are the most common symptoms. Patients with viral meningitis can also present with fever, headache, and stiff neck. In contrast to children with bacterial meningitis, children with viral CNS infection rarely appear toxic. CSF results usually confirm the diagnosis. Clinical stabilization is followed by administration of antibiotics and occasionally corticosteroids when bacterial meningitis is suspected. The use of Dexamethasone has been found to improve the outcome from bacterial meningitis in children in some studies. Neurological sequelae, specifically hearing impairment, occurred less often in children who received Dexamethasone early on. Children currently taking antibiotics at the time of presentation to the emergency department pose a unique challenge. Children with partially treated meningitis present differently and are more likely to have a history of vomiting with prolonged symptoms.
  • 33 - Pediatric Cerebrovascular Disorders
    pp 330-336
    • By Liza A. Squires, Devos Childrens Hospital Grand Rapids, Michigan, Imad Jarjour, Department of Pediatrics and Neurology Allegheny General Hospital Pittsburgh, Pennsylvania
  • View abstract

    Summary

    The childhood stroke is classified as either hemorrhagic or ischemic. Hemorrhagic infarctions are either subarachnoid or intraparenchymal. No historical feature distinguishes ischemic from hemorrhagic stroke. However, nausea, vomiting, headache, and a depressed level of consciousness are more common in hemorrhagic strokes. Subarachnoid hemorrhage (SAH) generally presents with a sudden onset of severe headache, nausea, vomiting, meningismus, and photophobia. Ischemic infarctions are thrombotic (arterial or venous) or embolic (arterial). Seizures are a presenting symptom of ischemic stroke in approximately 20% of patients. The sudden development of focal neurological deficits, headache, seizure, and altered consciousness are typical manifestations of childhood stroke. Selected historical information helps to determine the etiology of stroke. An emergent head computerized tomography (CT) scan may help to determine whether the stroke is hemorrhagic or ischemic and to guide further diagnostic evaluations. Aspirin is used especially in children who are at risk of developing recurrent stroke.
  • 34 - Pediatric Seizures
    pp 337-349
    • By Mont R. Roberts, Sparrow Healthcare System Sparow Hospital/MSU Emergency Medicine Residency Program Lansing, Michigan, Rae R. Hanson, Midelfort Clinic Eau Claire, Wisconsin
  • View abstract

    Summary

    The average age of childhood status epilepticus (SE) is under 3 years old. The acute management requires a planned treatment schedule and a specific time line. The duration of SE is the greatest risk to the patient; the longer SE lasts, the more difficult it is to treat. The three goals of treatment are to control seizures, to preserve vital functions, and to diagnose the underlying pathology. Absence SE, partial absence SE, or complex partial SE may present as nonconvulsive SE. Neonatal seizures occur in patients under 29 days old, and they are usually related to significant neurological disease. Pediatric patients are unique in that several characteristic epileptic syndromes have an age-dependent appearance, one or more characteristic seizure types, a natural history, and a prognosis. Some major syndromes include febrile seizures, infantile spasms, Lennox-Gastaut syndrome, and benign rolandic epilepsy (BRE).
  • 35 - Hypotonic Infant
    pp 350-358
  • View abstract

    Summary

    A focused history and a careful physical examination of a hypotonic infant distinguish hypotonia from weakness, essential to diagnosis and treatment. The differential diagnosis of infantile hypotonia can be generated by first determining whether hypotonia is associated with weakness. Global central nervous system (CNS) disorders are suggested by the loss of developmental milestones or evidence of mental retardation. The disorders associated with significant weakness and secondary hypotonia are: spinal muscular atrophy or Werdnig-Hoffmann syndrome, congenital muscular dystrophies, congenital myotonic dystrophy and Guillain-Barré syndrome. Hypotonia with weakness requires the use of electrophysiology and biopsy studies, interpreted in the context of the infant's age. Hospitalization is commonly required to observe a hypotonic infant and to continue with diagnostic evaluation. A pediatric neurologist is consulted to determine the need for further diagnostic procedures or to initiate treatment of an underlying neurological disorder.
  • SECTION VI - PREGNANCY-RELATED NEUROLOGICAL EMERGENCIES
    • 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

    When convulsions and altered sensorium occur in the pregnant patient past 20 weeks gestation or in the first 2 weeks postpartum, eclampsia is the prime suspect. Phenytoin can be used to control seizures that are resistant to magnesium. Phenytoin is also a good choice if a woman is identified as high risk for eclamptic seizures and needs treatment for a prolonged period of time. Adequate control of hypertension is essential for prevention of central nervous system (CNS) complications in these patients. All patients with eclampsia and many with preeclampsia need hospitalization. Seizures are one of the most frequent neurological disorders encountered in pregnancy and carry an increased risk to the fetus from trauma, hypoxia, and metabolic acidosis. Quite common during pregnancy, headache is generally benign, but it can occasionally herald serious pathology. Chorea gravidarum (CG) is chorea occurring during pregnancy. Myasthenia gravis (MG) worsens in 40% of women with pregnancy.
  • SECTION VII - NEUROTOXICOLOGY
    • 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

    Many poisonous substances produce their primary toxic effects by affecting neurotransmission. Recognition of several known toxidromes may narrow the diagnostic focus and aid in management. The various types of toxidromes include: cholinergic syndrome, aticholinergic syndrome, adrenergic syndrome, sedative hypnotic syndrome, opioid syndrome, and withdrawal syndromes. Although many drugs depress the level of consciousness and respiratory drive, the agents most frequently responsible for these effects include opioids or sedative/hypnotics. The toxicity from any of these agents can cause hypotension, hypothermia, pulmonary edema, and hyporeflexia. Electrical injuries can result in numerous immediate and delayed neurological complications. The most common cause of death by either alternating current or direct current (lightning strike) is cardiorespiratory arrest. The most common cause of death in persons with significant thermal injury is multiple organ failure and its complications. Alternating current typically induces ventricular fibrillation and lightning strike (direct current) commonly causes asystole.
  • SECTION VIII - BRAIN DEATH
    • 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

    The brain death criteria include assessment of the following: normothermia; cause of brain death; unresponsiveness; absence of brainstem reflexes; and apnea. The presence of withdrawal reflexes, typically seen in the lower extremities, do not preclude the diagnosis of brain death given that withdrawal reflexes can be spinally mediated. The absence of brainstem reflexes includes pupillary responses, eye movements, and lower brainstem reflexes such as response to tracheal stimulation. Apnea testing is performed to demonstrate lack of respiratory effort, even in the presence of elevated pCO2 levels. When no respiratory effort is made during the apnea test and the other criteria have been met, the patient may be pronounced dead. The diagnosis of brain death is not without controversy. For instance, thermoregulation is regarded as a brainstem function; therefore, some argue that those patients who maintain their body temperature cannot be declared brain dead.

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