1. Neurology Evaluation in the ED Nicholas Cascone, PA-C

2. Components of Neuro Evaluation in ED Mental Status – emotional and intellectual function – Thought process – Mood – Insight – Sensorium – Attention – Memory, short and long-term

3. Components of Neuro Evaluation in ED Glasgow Coma Scale – measure of sensorium/consciousness – Eye opening: 4 = spontaneous 3 = opens to speech 2 = opens to pain 1 = none – Verbal response: 5 = alert, oriented 4 = disoriented but verbal 3 = nonsensical 2 = moans/unintelligible speech 1 = none

4. Components of Neuro Evaluation in ED Glasgow Coma Scale (cont’d) – Motor response 6 = follows commands 5 = localizes pain 4 = withdraws from pain 3 = decorticate – flexion 2 = decerebrate – extension 1 = none

5. Components of Neuro Evaluation in ED Higher cerebral function – Language Dysarthria – mechanical disorder of speech from weakness of facial/oral muscles Dysphasia – problem with language of cortical/subcortical origin – Fluent (Wernicke’s) or nonfluent (Broca’s) – Comprehension – tested by ability to follow commands

6. Components of Neuro Evaluation in ED Cranial nerves – I – rarely tested – II/III – direct/indirect pupillary response – III/IV/VI – extraocular muscle movements – V/VII – corneal reflex – VIII – hearing, balance – IX/X – gag reflex – XI – shoulder shrug – XII – tongue protrusion

7. Components of Neuro Evaluation in ED Sensory exam – Touch in all extremities – If negative, test proprioception or vibration sense – Further investigation involves testing individual dermatomes to localize lesions

8. Components of Neuro Evaluation in ED Motor system – Muscle tone – passive movement of muscle groups with patient not resisting – Muscle bulk – atrophy, wasting – Muscle strength – 0-4 scale, 0=complete paresis, 1=minimal contraction, 2=active movement when gravity counteracted, 3=movement against gravity only, 4=movement against resistance – Reflexes, Babinski response

9. Components of Neuro Evaluation in ED Cerebellar testing – Posture, truncal movements test central cerebellum – Appendicular movements test lateral cerebellum – Dysdiadokokinesis – inability to execute rapidly alternating movements

10. Components of Neuro Evaluation in ED Gait and station – Most important neurological test – Watch as patient sits upright, rises, stands, walks, turns, heel walks, toe walks – Gait disturbance examples Ataxic – wide-based, unsteady, irregular steps, inability to negotiate barriers; cerebellar lesions Apraxic – cannot initiate gait; nondominant hemispheric lesions Equine – high step present due to foot drop; peroneal muscle weakness Festination – narrow-based, shuffling; Parkinsonism Waddling – weakness of lower trunk/pelvic girdle

11. Introduction to Psychiatric Emergencies Nicholas Cascone, PA-C

12. Psychiatric Presentations in the ED Estimated that up to 1/3 of ED patients have a psychiatric diagnosis ED task: to evaluate patient’s risk of harm to self and/or others Psychiatric Dx accomplished through criteria defined in DSM-IV Psychiatric evaluation includes five axes

13. Axis I disorders in ED Cognitive disorders – Dementia Hallmark is cognitive deficit, including memory, abstraction, judgment, language, spatial ability – Delirium Hallmark is clouding of consciousness, reduction of awareness of external environment, loss of alertness

14. Axis I disorders in ED Substance-Induced Disorders – Intoxication Recent ingestion of exogenous substance producing maladaptive behavior, impairment of judgment, perception, attention, emotional control Usually Dx by laboratory tests – Withdrawal Syndromes vary according to substance of abuse Usually Dx by identification of withdrawal syndrome and evidence of recent use

15. Axis I disorders in ED Psychotic disorders present to the ED due to: Exacerbation of chronic psychosis from stress or noncompliance with medications Side effects of antipsychotic medications Suicidality Violence directed towards self or others Chronic psychosis leads to disregard for other medical conditions, precipitating need for emergency care

16. Axis I disorders in ED Mood disorders present in the ED due to: – Suicidality in depressive disorders – Mania in bipolar disorders causing erratic behavior or overt psychosis Anxiety disorders present in the ED due to: – Panic disorder mimicking angina/MI – Violent/impulsive behaviors in PTSD

17. Axis I disorders in ED Somatoform disorders present in the ED due to: – Conversion disorder presenting with sudden neurological deficit – Hypochondriasis presenting with somatic illusion of serious illness – Factitious disorders/malingerers presenting in ED with fake/self-created symptoms

18. Axis I disorders in ED Personality disorders frequently seen in ED: – Antisocial personality disorder Violence Criminality Substance abuse – Borderline personality disorder Suicidality Substance abuse

19. Emergency Psychiatric Evaluation History – obtain from patient and collaterals – Changes in behavior – Acute stressors – Previous psychiatric diagnoses/treatment Neurologic symptoms – Dizziness, syncope, disorientation, confusion, loss of consciousness, headaches, difficulty with speech/routine tasks

20. Emergency Psychiatric Evaluation Other medical comorbidities – Fever, head trauma, HIV, exposure/ingestion of toxins Medication history: benzodiazepines, stimulants, antipsychotics, anticonvulsants, anticholinergics, steroids, β-blockers, fluoroquinolones, opioids, salicylates, SSRIs, thiazide diuretics, antiparkinsonian agents Drug history: alcohol, PCP, LSD, amphetamines, cocaine, barbiturates

21. Emergency Psychiatric Evaluation Mini Mental Status Exam (MMSE) Complete physical exam – Abnormal vital signs should not be ascribed to stress/anxiety – Trauma signs – Neuro exam Laboratory investigations – Minimally, urine toxicology and blood alcohol

22. Altered Mental Status in the ED Nicholas Cascone, PA-C

23. Delerium Transient disorder of attention and cognition – Distortion of attention, perception, thinking, memory – Reduced alertness – Activity level may increase or decrease – Sleep/wake cycle disrupted – “sundowning” – Psychosis may be present; hallucinations tend to be visual

24. Delerium - Causes Infection: pneumonia, UTI, meningoencephalitis, sepsis Metabolic: hypoglycemia, electrolyte abnormalities, hepatic encephalopathy, thyroid disorder Neurological: stroke/TIA, seizure/post-ictal state, SAH, subdural hematoma, space-occupying lesion Cardiopulmonary: CHF, MI, PE, hypoxia Drug-related: drug/EtOH withdrawal, antihistamines, antiparkinson agents, antiemetics, antidepressants, antipsychotics, sedative-hypnotics, narcotic analgesics, antispasmodics/muscle relaxants, digoxin

25. Delerium – evaluation History from collaterals – Acute onset – Fluctuating severity – Exacerbation at night Medication history – Medication side effects/toxicity can be observed in elderly patients at normally safe doses Physical examination – Directed at discovering underlying process Labs – Electrolytes, LFTs, kidney function, urinalysis/tox,CXR

26. Delerium – Management Tx directed at underlying cause(s) – Environment: adequate lighting, psychosocial support, reduced stimulus – Sedation to relieve agitation – Majority of patients will be hospitalized

27. Dementia Memory and cognitive impairment of gradual onset – Early: memory loss, naming problems, forgetting items – Middle: loss of reading, loss of social skills, spatial/direction problems – Late: disorientation, loss of self-care, personality changes

28. Dementia – causes Degenerative – Alzheimer’s, Huntington’s, Parkinson’s Vascular – multiple infarcts, hypoperfusion, subdural hematoma, SAH Infectious – meningoencephalities, neurosyphilis Metabolic – B 12 /folate deficiency, thyroid disease, uremia Psychiatric – depression Inflammatory – SLE, demyelinating disease Neoplastic – primary tumors/metastasis, pareneoplastic syndromes Other – trauma,toxins (EtOH, medications), hydrocephalus

29. Dementia – evaluation History from patient and collaterals – Course of progression Acute onset of symptoms suggests reversible process Specific dates of worsening associated with vascular dementia – Family history: some causes of dementia are inherited (e.g., Huntington’s) Physical exam – Directed at associated causes – examples: Focal neurologic signs suggest vascular dementia or space-occupying lesion Extrapyramidal signs suggest Parkinson’s Labs – CBC, electrolytes, glucose, calcium, kidney function, LFTs, TFTs, B 12 – CT/MRI

30. Dementia – treatment in ED Environmental/psychosocial interventions Antipsychotic medications for those with persistent psychotic features or dangerous/extremely disruptive behaviors Admission: – Patients with superimposed delerium – Treatable causes of dementia – Comorbid medical problems – Rapid progression – Unsafe/uncertain home situation

31. Special Psychiatric Emergency Presentations Nicholas Cascone, PA-C

32. Emergencies related to psych medications Antipsychotics side effects – Akathisia responds to β-blocker therapy such as propranolol – Dystonia (torticollis, oculogyric crises, etc.) respond to anticholinergics (e.g. benztropine, diphenhydramine) – Parkinsonism requires dose reduction and anticholinergic therapy as above – Neuroleptic malignant syndrome: emergency presentation with rigidity, fever, tachycardia, BP lability, and altered mental status – discontinue antipsychotic and give dantrolene or bromocriptine, hydration, supportive treatment in intensive care setting

33. Emergencies related to psych medications Benzodiazepines – Used frequently in the ED for anxiolysis or sedation Anxiolytics: alprazolam (Xanax ® ), lorazepam (Ativan ® ), clonazepam (Klonopin ® ) Longer-acting anxiolytics/mild sedatives: diazepam (Valium ® ), chlordiazepoxide (Librium ® ) Sedative-hypnotics: temazepam (Restoril ® ), triazolam (Halcion ® ), flurazepam (Dalmane ® ) – Overdose is treated with flumazenil – Paradoxical response requires discontinuation

34. Anorexia nervosa Dx by usual signs and symptoms – BMI 16, < 85% of expected weight for height – Unexplained primary amenorrhea – Derangement of body image ED treatment: – Volume repletion – Correction of electrolytes – Aggressive refeeding leads to hypertonic dehydration, hypernatremia, pancreatitis

35. Anorexia nervosa Criteria for hospitalization: – Weight loss of 30% or more in 3 months – Severe metabolic disturbance – Suicidality – Failure to maintain outpatient weight contract – Family crisis or denial – Severe bingeing and purging – Need to initiate therapy (psychotherapy, family therapy, pharmacotherapy)

36. Panic attack Symptoms – Palpitations/tachycardia – Chest pain/pressure – SOB/smothering – Diaphoresis – Tremor – Choking sensation/globus – Nausea/abdominal complaints – Dizziness/lightheadedness/syncope – Paresthesia – Chills/hot flashes – Fear of: going crazy, loss of control, dying, syncope – Derealization/depersonalization

37. Panic attack – medical differential Cardiovascular: angina, MI, MVP, PACs Pulmonary: angina, PE, hyperventilation Endocrine: hyperthyroid, hypoglycemia, pheochromocytoma, Cushing’s Neurological: stroke/TIA, partial seizure, migraine, Ménière’s Drugs/medications: caffeine, cocaine, thyroid meds, SSRIs, cannabis, steroids, β-agonists, triptans, nicotine, hallucinogens, anticholinergics Withdrawal syndromes: alcohol, barbiturates, benzodiazepines, opiates

38. Panic attack – treatment In ED: benzodiazepines Referrals – Psychotherapy – cognitive-behavioral – Psychiatry SSRI Buspirone Short-term “bridging” benzodiazepines

39. Emergencies involving alcohol Trauma – assault, MVA, other injuries – 25% of assaults involve alcohol – 45% of fatal MVAs involve alcohol – Head trauma often overlooked when presenting with alcohol intoxication Obtain CT of head when: – History of head injury – No improvement in 3 hours – Worsening of mental status while under observation

40. Emergencies involving alcohol Withdrawal – Four steps of alcohol withdrawal 6 – 8 hours since last drink: autonomic hyperactivity – tachycardia, diaphoresis, tremor 24 hours since last drink: tactile and visual hallucinations 24 – 48 hours since last drink: motor seizures 3 – 5 days since last drink: delerium tremens – altered mental status, convulsive seizures, 5 – 15% mortality

41. Emergencies involving alcohol Treatment of alcohol withdrawal – Fluid resuscitation with D5NS or D5LR and thiamine (100 mg/L) – Patient placed in a quiet area with minimal stimulation – Lorazepam 2 – 4 mg IV q 15-30 minutes until light sedation is achieved – MgSO 4 : 4 g IV in 1 – 2 hours – For pts with seizures: CT indicated if head trauma, focal seizure, persistent post-ictal defect in consciousness

42. Emergencies involving alcohol Criteria for admission – Medical complications such as CHF, infection – More than 8 mg of lorazepam needed Referral for treatment of alcoholism

43. Tests for conversion disorder/ malingering Sensation – Yes/no test: pt closes eyes and responds yes/no to touch stimulus – “no” response favors conversion – Bowlus & Currier test: pt extends crossed arms, thumbs down, palms touching, interlocking fingers, arms then rotated towards chest False response to sensory stimulus difficult d/t distortion of position – “Strength” test: pt closes eyes and moves touched finger to assess “strength”. True sensory loss would not allow pt to determine which finger is being tested

44. Tests for conversion disorder/ malingering Pain – Gray test of abdominal pain With psychological pain, pt closes eyes during palpation With organic pain, pt watches palpation so they can guard tender areas Motor – Drop test: “paralyzed” extremity dropped from above the face will miss it – Thigh adductor test: examiner places hands against inner thighs of patient. Pt is told to adduct normal leg against resistance. In pseudoparalysis, other leg will also adduct – Hoover test: examiner cups both heels of patient. Pt is told to elevate normal leg. In pseudoparalysis, other leg will push downward. Pt is told to elevate weak leg. Absence of downward pressure indicates noncompliance.

45. Tests for conversion disorder/ malingering Coma – Corneal reflexes retained in awake patient Seizure – Resistance to covering of mouth & nose indicates pseudoseizure – Palpation of abdominal muscles reveals lack of contraction in pseudoseizure Blindness – Opticokinesis: tape with alternating black and white sections pulled laterally in front of patient’s open eyes induces nystagmus in patient with intact vision

46. Headache/Vertigo in the ED Nicholas Cascone, PA-C

47. Headache in the ED 4% of all ED visits are due to headache – 4% of these headache visits have serious or secondary pathology Objectives of evaluation: – Appropriately select patients for emergency investigation when critical secondary causes are present – Provide effective treatment for primary and benign secondary headaches

48. Evaluation of Headache in ED History – Pattern – worst ever, first severe, steady worsening, differences from prior headaches – Onset – sudden headaches that begin during exertion – up to 25% of such HA are SAH – Associated symptoms – dizziness, nausea, confusion, LOC, fever, neck pain/stiffness, visual changes, seizure

49. Evaluation of Headache in ED History (cont’d.) – Medical history – trauma, previous lumbar puncture, use of nitrates, MAOIs, exposure to toxics (e.g., CO) – Family history – migraines, SAH run in families

50. Evaluation of Headache in ED Physical examination – Temperature, blood pressure – Palpate sinuses, temporal artery, temporomandibular joint – Eye exam for acute glaucoma, fundoscopy for signs of hypertension, papilledema – Thorough neurological exam Labs – CT scan, lumbar puncture if indicated

51. Killer Headaches Subarachnoid hemorrhage – More common in women – Severe, constant occipitonuchal HA, “worst in my life” – Often presents suddenly, with vomiting and alteration of consciousness – History may indicate activities which raise blood pressure (e.g., intercourse, defecation, coughing)

52. Killer Headaches Subarachnoid hemorrhage (cont’d) – Dx: plain CT 93% sensitivity within 24 h of onset – If CT nondiagnostic, LP Xanthochromia on spectrophotometry nearly 100% sensitive Naked-eye detection only 50% sensitive – Tx: angiogram and surgery consult, nimodipine, prohylactic phenytoin, antiemetics, decrease BP if elevated

53. Killer Headaches Meningitis – Occipitonuchal headache with fever, meningeal signs, altered consciousness – Dx: immediate LP in pts without neurological signs, normal LOC and no papilledema If LP delayed and bacterial meningitis suspected, initiate empiric antibiotic tx

54. Killer Headaches Subdural hematoma – History of remote trauma with headache – High risk patients: Anticoagulation Chronic alcoholics Elderly patients – If plain CT nondiagnostic, contrast CT or MRI – Tx: surgery consult

55. Killer Headaches Brain tumor – Headache may be unilateral/bilateral, intermittent/continuous – Classic presentation is headache with vomiting, worse upon arising – Reliable pt with no neuro findings and no papilledema can follow-up as outpatient within 24 hours (worst at night and awakens pt)

56. Other Headaches Secondary headaches – Temporal arteritis – Acute glaucoma – Hypertensive headache – Sinusitis – Post-LP – Drug-related/toxic Primary headaches – Migraine – Cluster – Tension

57. Vertigo Sensation of movement where none exists Peripheral causes vs. central causes – peripheral causes usually benign, central causes can be urgent – Peripheral vertigo: sudden onset, intense, paroxysmal, aggravated by position/movement, associated with nausea or hearing loss/tinnitus, horizontal nystagmus, fatiguable, CNS signs absent – Central vertigo: any onset, ill-defined, constant, variable association with position/movement/nausea, not associated with hearing loss/tinnitus, vertical nystagmus, not fatiguable, CNS signs usually present

58. Vertigo – causes Peripheral causes – BPPV, Ménière’s disease, labrynthitis, ototoxicity, head injury Central causes – Cerebellar stroke, VBI, MS, migraine, epilepsy, neoplasm General causes – Anemia, EtOH intoxication, hypoglycemia, renal failure, thyroid disease

59. Vertigo - evaluation History – Description of sensation – vertigo, syncope/near-syncope, disequilibrium – Onset – Associated symptoms Peripheral associated with nausea/vomiting, tinnitus/hearing loss, photophobia Central associated with diplopia, dysarthria, visual abnormalities Headache suggests migraine or space-occupying lesion Head trauma, medications

60. Vertigo - evaluation Physical exam – Ear: otoscopy, hearing exam, Webber/Rinne – Eye: nystagmus, EOMs – Heart rate, rhythm, murmurs – Cranial nerves – Cerebellar testing – Proprioception/vibration – Test patients with near-syncope for orthostasis

61. Vertigo – evaluation Dix-Hallpike position testing: pt seated upright, head turned 45° to right, swiftly reclined with head tilted backward additional 45°; repeated with head turned to left – Warn pt that test may produce vertigo – Positive test indicated by nystagmus; positive side is side with lesion – Contraindicated in patients with carotid bruits, cervical spondylosis

62. Vertigo – evaluation Labs – Depend on suspected etiology Labrynthitis: CBC, blood culture Head injury: CT for bleeding Near-syncope: ECG, cardiac monitoring, CBC for anemia Electrolytes, glucose, kidney function, thyroid

63. Vertigo – symptomatic treatment Pharmacotherapy – Scopolamine – Antihistamines – diphenhydramine (Benadryl ® ), meclizine (Antivert ® ) – Neuroleptics – metoclopramide (Reglan ® ), promethazine (Phenergan ® ) – Benzodiazepines for anxiety – diazepam (Valium ® ), clonazepam (Klonopin ® )

64. Seizures in the ED Nicholas Cascone, PA-C

65. Seizures in the ED Episode of abnormal neurologic function caused by inappropriate electrical discharge of neurons 6 – 10% of individuals experience a seizure, 1 – 2% have recurrent seizures Peak incidence among age 60

66. Classification of seizure Classification – Partial: unilateral clonic/tonic movements, sensory hallucinations (tactile, olfactory, gustatory), visual symptoms Simple (no alteration of consciousness) vs. complex (loss of consciousness) – Generalized: loss of consciousness with or without motor manifestations Tonic-clonic Absence Myoclonus and others

67. Seizure – evaluation History – Aura, onset, duration, post-ictal condition – If known epileptic: precipitants, medication Hx, sleep Hx, infection – If no previous history: head injury, headache, drug/alcohol use/abuse Previous behaviors that may point to unrecognized seizures: enuresis, blank spells, unexplained injury, tongue biting

68. Seizure – evaluation Physical exam – Injuries to head/spine – Fractures, dislocations, bruising, tongue lacerations – Neuro exam Labs – Glucose, electrolytes, Ca, Mg, hCG, tox screen, UA for rhabodmyolisis – Wide anion gap metabolic (lactic) acidosis up to 1 hour after event – Anticonvulsant levels – First seizure: non-contrast CT to rule out structural lesion

69. Seizure – treatment in ED Seizing patient – expectant management – Clear area to prevent injury – Turn to side to prevent aspiration – After seizure, insure airway Patient with previous seizures: – Eliminate precipitants – Supplement anticonvulsant levels if necessary

70. Special cases Seizure in pregnancy – Epilepsy in pregnancy: antiepileptics are potentially teratogenic, but uncontrolled seizures also potentially dangerous Risk to fetus minimized with single-drug therapy, folate and vitamin K supplementation – Eclampsia: seziures beyond 20 weeks, with HTN, edema, proteinuria; may present with HA, blurry vision, epigastric pain, hyperreflexia Manage with MgSO 4, definitie treatment is delivery

71. Special cases Seizure associated with alcohol – Missed doses of anticonvulsant, sleep deprivation, propensity for head injury, toxic coingestions, electrolyte derangement – Seizures in alcohol withdrawal: No anticonvulsant if first seizure, benzodiazepines and referral for detoxification

72. Special cases Status epilepticus – More than 5 minutes of seizure activity – 2 or more seizure episodes without full recovery of consciousness between Management of SE – Large-bore IV, intubation, O 2 – Dextrose, thiamine, magnesium if needed – IV lorazepam, then IV phenytoin – IV phenobarbital if phenytoin fails – General anesthesia with midazolam/propofal/pentoparbital if phenobarbital fails

73. CNS Infection Nicholas Cascone, PA-C

74. Meningitis Infection in subarachnoid space – bacterial, viral, fungal – Noninfectious meningitis from neoplastic, toxic, autoimmune processes In ED, early suspicion and empiric treatment is critical Pt presents with fever, HA, neck pain/stiffness, photophobia, AMS

75. Meningitis – evaluation History – Living conditions: barracks, dormitories, day care centers – Head trauma/neurosurgery – Immunocompromise: asplenism, steroids, HIV Examination – Assess meningeal signs: Brudzinski, Kernig – Skin: petechial rash of N. meningitidis – Assess sinuses, ears for evidence of primary infection – Fundoscopy for papilledema – Neurological exam

76. Meningitis – evaluation Labs – Lumbar puncture when safe – CSF analysis: Bacterial: ↑↑ opening pressure, ↑↑ WBCs, ↑ PMNs, ↑ protein, ↓ glucose Viral: ↑ opening pressure, ↑ WBCs, normal PMNs, normal protein, normal glucose Fungal: ↑↑ opening pressure, ↑ WBCs, normal PMNs, ↑ protein, ↓ glucose

77. Meningitis – management Initiate empiric antibiotic treatment – does not affect results of LP if performed within 2 hours – Neonates: ceftriaxone for S. pneumoniae and E. coli – Infants, children, adults: ceftriaxone and vancomycin for S. pneumoniae and N. meningitidis – Immunocompromised patients, adults over 50: add ampicillin for L. monocytogenes

78. Meningitis – management Anti-inflammatory Antipyretic Monitor sodium to avoid SIADH Phenytoin loading for seizures Cerebral edema – elevate head, hyperventilate, administer mannitol Chemoprophylaxis for close contacts of patients with N. meningitidis or H. influenzae – Rifampin, ceftriaxone or ciprofloxacin

79. Encephalitis Viral infection of brain parenchyma – West Nile virus – Arboviruses – Rabies Presentation: meningeal signs with cognitive deficit, seizure, psych symptoms, movement disorder Patients should be admitted

80. Cerebrovascular Events in the ED Nicholas Cascone, PA-C

81. Cerebrovascular Events in the ED Stroke – Interruption of blood supply to focal region of the brain – 3 rd leading cause of death in US – 20% of stroke patients die within the first year – One-third of stroke patients are under the age of 65 – Early diagnosis and treatment of patients arriving at ED with stroke lessens impact of disease

82. Cerebrovascular Events in the ED Ischemic stroke syndromes – Anterior cerebral artery: LE > UE weakness, perseveration, motor slowing – Middle cerebral artery: face/UE>LE, aphasia if in dominant hemisphere, apraxia, homonymous hemianopia – Posterior cerebral artery: vision loss, paresthesia, sensory loss, dizziness, N/V – Cerebellar: “drop attack”, vertigo, HA, nausea, neck pain, cranial nerve abnormalities

83. Evaluation of Stroke in the ED History – Hx of HTN, CAD, DM suggests thrombotic stroke – Hx of A fib, mechanical/replacement valves, MI suggests embolic stroke – TIAs: prior TIA in same vascular distribution suggests thrombosis, multiple TIAs in different distributions suggest embolism

84. Evaluation of Stroke in the ED History (cont’d) – Onset: sudden (embolic or hemorrhagic) vs. stuttering/waxing and waning (thrombotic or hypoperfusion) – Onset during straining/coughing suggests rupture of aneurysm – Associated complaints: HA (hemorrhagic), N/V, trauma – Recent neck injury: MVA, chiropractic adjustment, sports- related suggests carotid dissection

85. Evaluation of Stroke in the ED Physical exam – Temperature – Skin signs of embolism (Janeway lesions, Osler nodes), bleeding dyscrasias (petechiae, ecchymosis) – Fundoscopy (papilledema, hypertensive retinopathy) – Cardiopulmonary auscultation (S3, rales, carotid bruits)

86. Evaluation of Stroke in the ED Labs – Emergent non-contrast CT distinguishes hemorrhagic stroke from ischemic – EKG – CBC, coagulation studies, type & screen, electrolytes, glucose, toxicology, cardiac enzymes

87. Management of Stroke in the ED O 2, elevate head, cardiac monitor, IV access Volume repletion, antipyretic Manage hypertension only if severe – higher pressure may help save penumbra of stroke Secondary prevention: antiplatelet agent, anticoagulation

88. Management of Stroke in the ED Thrombolytic treatment – Contraindications Absolute: previous hemorrhagic stroke, any other stroke in past year, suspected dissection, pericarditis, intracranial tumor Relative: BP over 180/110, chronic severe hypertension, age over 75, anticoagulation, trauma/internal bleeding within 4 weeks, surgery within 3 weeks, peptic ulcer, hemodynamically unstable, pregnant

89. Violence and Suicide in the ED Nicholas Cascone, PA-C

90. Violence in the ED 50% of all health care providers will be involved in violence during their careers ED patients/collaterals are frequently fatigued, hungry, frustrated, anxious, higher proportion of substance abuse 5% of patients presenting to the ED carry weapons Most perpetrators of violence in ED are males with Hx of substance abuse – Education, ethnicity, marital status, diagnosis are not reliable predictors Factors predisposing ED to violence: long waiting times, staff shortages, overcrowding, patient expectations, patient financial problems

91. Violence in the ED Prodrome of violence: – Phase 1: Anxiety Movement with no purpose other than to expend energy – Pacing, wringing of hands, clenching of fists, unwillingness to stay in waiting/treatment area Loud, pressured speech Appropriate response: develop rapport, listen to and address concerns

92. Violence in the ED – Phase 2: Defensiveness Verbal abuse, profanity – Directed towards staff or others in the department – Statements regarding age, weight, heritage, gender Body posturing Appropriate response: – Set simple, clear, enforceable and consistent limits – Offer patient reasonable choices – Isolate patient and provide show of force by uniformed security personnel

93. Violence in the ED – Phase 3: Physical Aggression Total loss of control Physical aggression directed towards staff or others in the department Aggressive patients must be confronted and controlled physically for the safety of themselves, other patients, visitors and staff – Requires personnel skilled in control techniques – Should never be attempted by unskilled personnel or single- handedly

94. Restraint in the ED Review your organization’s rules for restraint JCAHO policy: – Only licensed independent practitioner (LIPs) can order restraint Written order must include type of restraint, reason for restraint, time limit for restraint – If LIP is not available, restraint may be initiated by caregivers but LIP must perform face-to-face evaluation within 1 hour

95. Restraint in the ED – Restrained patients must be evaluated q15min, including examinations for: Injury Hydration/nutrition Circulation/ROM Vital signs Hygiene/elimination Comfort Psychological status Readiness for discontinuation of restraint

96. Restraint in the ED – Reason for restraint must be explained to the patient – Patient in restraint should never be abandoned – No patient who has been restrained should be allowed to leave the ED AMA – Patients brought to the ED in restraint should remain in restraint until thoroughly assessed for threat of violence and medical condition

97. Medical management of violent behavior Used when patients are too violent, even under restraint to perform adequate evaluation – Antipsychotics: haloperidol (Haldol ® ) 5 mg IM q30- 45min – Benzodiazepines: lorazepam (Ativan ® ) 2-4 mg IM q30min – More effective when used in combination; more rapid onset and fewer injections needed

98. Suicide Suicidality is associated with severe depression, isolation, loss, stressful life events Providers’ negative attitudes towards those who attempt suicide exacerbate patient risk

99. Risk of suicide High risk – Male – Separated/widowed divorced – Chaotic/conflictual family, FHx of suicide – Unemployed – Recent conflict or loss – Weak or no religious suicide taboo Low risk – Female – Married – Stable family – Employed – Stable relationships – Strong religious taboo against suicide

100. Risk of suicide High risk (cont’d) – Acute/chronic illness – Excessive drug/alcohol use – Depression/bipolar/ schizophrenia/panic – Disruptive behavior – Helplessness/ hopelessness – Frequent, intense, prolonged suicidal ideation Low risk (cont’d) – Stable health – Little or no drug/alcohol use – No axis I mental disorders – Directable – Hopeful, future-oriented – Infrequent, transient ideation

101. Risk of suicide High risk (con’td) – Prior suicide attempts – High-risk, dangerous attempts – Realistic plan – Guilt regarding suicide ideation – Lack of concern regarding attempts – Social isolation Low risk (cont’d) – No prior attempts – Attempts with high likelihood of rescue – No plan – Embarrassment regarding ideation – Insight regarding affect on others – Social integration

102. Markers for ongoing risk Psychosis Hopelessness/helplessness Exhaustion Lack of anger/remorse/embarassment History of prior attempts, especially high-risk attempts Continuing intention to die

103. Criteria for discharge Medically stable Pt agrees to return to ED if suicidal intent recurs Not intoxicated, delerious, demented Means of self-harm has been removed Treatment of psychiatric diagnoses has been arranged Acute precipitants of suicide have been addressed/resolved Patient and family agrees to follow-through on treatment Patient’s caregivers/family agrees to discharge plan “No harm” contract has been established Document all criteria If in doubt, obtain psychiatric consult or hospitalize