Ep-PAINE-nym



Wernicke’s Aphasia

Other Known Aliasesreceptive aphasia

Definitiondifficulty in understanding written or spoken language, but demonstrate fluent speech that lacks meaning

Clinical Significance this condition manifests due to damage to Wernicke’s area of the brain in Brodmann area 22. This region is located in the posterior section of the superior temporal gyrus of the dominant hemisphere.

HistoryNamed after Karl Wernicke (1848-1905), who was a German physician, anatomist, and neuropathologist and received his medical doctorate from the University of Breslau in 1870. He went on to study under Ostrid Foerster and Theodor Maynert after serving as an army surgeon during the Franco-Prussian War and had a modest career in both private and academic practice, culminating as head of the University Hospital’s Department of Neurology and Psychiatry at Breslau. A proponent of the same cerebral localization theory as Broca, he described his theory of “sensory aphasia” being different from Broca’s “motor phasia” in his book Der Aphasische Symptomencomplex in 1874.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Wernicke C. Der Aphasische Symptomencomplex. 1874.

PAINE #PANCE Pearl – Neurologic



Question

A 47yo man is being evaluated for a headaches that he describes as “someone jabbing my brain through my eye”. He reports these headaches occur several times a day for the past several weeks, lasting only for a minute, and only affecting his right side of this head. While speaking with him, he has another episode and you notice his eye becomes red and injected with significant tearing and nasal drainage present. On closer examination, he also notice his pupil on the affected side is constricted and he has a mild lid lag.

  1. What is the treatment protocol of choice for this patient?

Answer

This patient is suffering from a classic cluster headache due to hypothalmic activation of the trigeminal-autonomic reflex. Abortive treatment for this type of headache includes:

  • 100% oxygen via non-rebreather
  • Sumatriptan 6mg SQ
  • 4-10% Lidocaine 1mL IN
  • Dihydroergotamine 1mg IV

Verapamil 240mg daily with a prednisone 60-100mg daily bridge for 5 days can be used for prevention.

Ep-PAINE-nym



Broca’s Aphasia

Other Known Aliasesexpressive aphasia

Definitionpartial or full inability to produce language/communication in any form, with full preservation of language/communication comprehension

Clinical Significance this condition manifests due to damage to Broca’s area of the brain. This region is bounded by the pars opercularis and pars triangularis of the inferior frontal gyrus of the dominant hemisphere.

HistoryNamed after Pierre Paul Broca (1824-1880), who was a French physician and anatomist who received his medical doctorate from the University of Paris in 1844 at the age of 20. He went on to study under and assist Peirre Gerdy before becoming the youngest prosector for his alma mater in 1848. He went on to practice in various surgical and pathologic specialties culminating as Chair of Clinical Surgery in 1868 at the University of Paris. In 1861, in an effort to support the cerebral localization theory for speech, he dissected the brain of a patient with a 21-year progressive loss speech, after succumbing to a gangrenous infection of his paretic limb, where he found a frontal lobe lesion. He would go on to find similar localized lesions on 13 additional patients with expressive aphasia and called this region the “circonvolution du language”. He would later be given the posthumous eponym by David Ferrier who termed this area “Broca’s convolution”.

Other notable accomplishments include describing muscular dystrophy before Duchenne, rickets as a nutritional disease before Virchow, and the venous spread of cancer before von Rokitansky.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Broca, P.P. (1861) Loss of Speech, Chronic Softening, and Partial Destruction of the Anterior Left Lobe of the Brain. Bulletin de la Société Anthropologique, 2, 235-238.

#59 – Headaches



***LISTEN TO THE PODCAST HERE***



Classifications and Subtypes

  • 3rd Edition of the International Classification of Headache Disorders (ICHD-3)
    • Primary Headaches
    • Secondary Headaches
    • Neuropathies, Facial Pains, and Other Headaches
  • 90% of headaches fall into 3 primary headache categories

Migraines

Tension-Type

Trigeminal Autonomic Cephalgias


Approach to Evaluation

  • Malignancy of myeloid precursor cells
    • Multipotential hematopoietic stem cell –> common myeloid progenitor –> myeloblast

Signs and Symptoms

  • Environment
    • Turn off the lights
    • Speak quiet
    • Let the patient talk uninterrupted about what is going on
  • History
    • Age of onset
    • Past medical and family history
    • Medication history
    • Presence of absence of aura
    • Characteristics
      • Frequency
      • Intensity
      • Duration
      • Onset
      • Quality
      • Location
      • Radiation
    • Number of headaches per month
    • Associated symptoms
      • Fever, nausea, vomiting, visual disturbances, dizziness, syncope
    • Precipitating, exacerbating or relieving factors
      • Positional changes, exertional
      • Photophobia, phonophobia
      • Relationship to food or alcohol
    • Women
      • Contraception
      • Associated with menstrual cycle
  • Physical Examination
    • Review of vital signs
    • Auscultate for bruits (evaluation for AVM)
      • Neck, eyes, head
    • Palpate head, neck, and shoulder regions
    • Palpate neck and head arteries
    • Palpate neck muscles for spasms or tightness
    • Neurologic examination
      • Mental status
      • Cranial nerve evaluation
      • Fundoscopy
      • Motor and sensory examination
      • Cerebellar exam, including gait, Romberg

Concerning History and Physical Examination Findings

  • SNNOOP10 Red Flag List
    • Systemic symptoms
      • Fever
    • Neoplasm history
    • Neurologic deficits
      • Focal or general
    • Onset
      • Sudden or abrupt
    • Older age
      • Age > 50 years
    • Pattern change or recent new headache
    • Positional
    • Precipitation
      • Sneezing, coughing, exercise, exertional
    • Papilledema
    • Progressive headache and atypical presentations
    • Pregnancy or postpartum
    • Painful eye with autonomic features
    • Post-traumatic
    • Pathology of the immune system
    • Painkiller overuse
  • Presence of ANY of the SNNOOP10 require further investigation
  • Low-Risk Documentation Pearls
    • Age < 50 years
    • Features typical of primary headache
    • History of similar headache
    • No abnormal neurological findings
    • No concerning change in usual headache pattern
    • No high-risk comorbid conditions
    • No new or concerning findings on physical examination

Serious and/or Life-Threatening Headaches

  • “Thunderclap”
    • sudden onset, maximal intensity
  • Neck pain with Horner’s Syndrome and/or neurologic deficit
    • Cervical artery dissection
  • Fever, AMS, and/or nuchal rigidity
    • Meningitis, encephalitis
  • Neurologic deficit and/or papilledema
    • Increased intracranial pressure
      • Pseudotumor cerebri, mass effect lesion
  • Orbital or periorbital symptoms
    • Acute angle closure glaucoma, cavernous sinus thrombosis/fistula

Imaging Recommendations

  • Criteria for imaging in Headaches
    • Any of the SNNOOP10 findings
  • Emergency Setting
    • CT is generally the study of choice because:
      • Widely available
      • Most life-threatening conditions are seen on CT
      • Safer for unstable patients
    • MRI is an option if:
      • New headache with optic disc edema
      • Chronic headache with new features
      • Known or suspected cancer
      • Patient is pregnant
  • Outpatient Setting
    • American Academy of Neurology recommend imaging for:
      • Patients with unexplained abnormal finding on neurologic examination
      • Patients with atypical headache features or headaches that don’t fulfill strict definition of other primary headache disorder
    • Choosing Wisely Campaign – MRI is recommended over CT
    • Consult radiology for recommendations of type of study
      • Imaging vessels, facial structures, orbits

Indications for Lumbar Puncture

  • Suspicion of SAH with a negative CT
  • Suspicion of infectious or inflammatory pathology
  • Suspicion of pseudotumor cerebri


Tension-Type Headache

Epidemiology

  • Most common headache subtype
  • 2nd most prevalent disorder in the world
  • Slightly more prevalent in women
  • Least distinct of the primary subtypes
  • Least studied

Classifications

  • Episodic
    • Infrequent – < 1 episode per month
    • Frequent – 1-14 episodes per month
  • Chronic – 15 or more episodes per month

Pathophysiology

  • Peripheral activation or sensitization of the myofascial nociceptors leading to heightened sensitivity of the pain pathways in the central nervous system
    • Central factors
      • Increased pain sensitivity
      • Altered brainstem and limbic-controlled descending pain systems
    • Peripheral factors
      • Muscular abnormalities
        • Trigger points, postural, mobility

Clinical Features

  • History
    • Quality
      • Dull, pressure, fullness, band-like, weight on shoulders
    • Increased stress and mental tension
    • Pericranial muscular tenderness
      • Masseter, temporalis, sternocleidomastoid, trapezius

Diagnostic Criteria

  • Two of the following:
    • Bilateral location
    • Pressing/tightening, non-pulsatile quality
    • Mild/moderate intensity
    • Not aggravated by routine physical activity
  • Both of the following
    • No more than one of photophobia or phonophobia
    • No moderate/severe nausea or vomiting
  • Episodic
    • At least 10 episodes lasting 30 minutes to 7 days
  • Chronic
    • At least 15 episodes per month for at least 3 months lasting for hours to days

Treatment

  • Acute/Abortive
    • NSAID Analgesia
      1. Ibuprofen, acetaminophen, aspirin
      1. Can be combined with caffeine
    • Triptans can be used if NSAIDs fail
  • Preventative
    • Antidepressants
      • Tricyclic antidepressants
        • Amitriptyline has the best evidence
          • Start 10mg and increased 10mg every 2-3 weeks until:
            • Improvement of headaches
            • Max dose of 125mg/day
      • Mirtazapine and venlafazine has some limited data
    • Anticonvulsants
      • Topiramate and gabapentin can also be helpful
    • Trigger point injections
    • Botulinum toxin injections
    • Behavioral treatments
      • Cognitive-behavioral therapy
      • Relaxation techniques
      • Biofeedback
    • Acupuncture and physical therapy has limited evidence of success

Migraines

Epidemiology

  • Affects up to 12% of the population
  • More frequent in women
  • Most common age range is 30-40 years
Up-to-Date. 2020

Pathophysiology

  • Cortical spreading depression
    • Self-propagating wave of neuronal and glial depolarization that spreads across the cerebral cortex
    • This then causes:
      • Aura
      • Activation of the trigeminovascular system
        • Causes inflammatory changes in the pain-sensitive meninges
        • Increase pain sensitization
      • Alters blood-brain barrier permeability

Clinical Features

  • Cascade of four events over a course of hours to days:
    • Prodrome
      • 24-48 before headache
      • Yawning, euphoria, depression, irritability, food cravings
    • Aura
      • 25% of patient experience focal neurologic symptom
        • Visual
          • Positive
            • Lines, shapes, objects
          • Negative
            • Scintillating scotomas, vision loss
        • Sensory
          • Positive
            • Burning, paresthesias
          • Negative
            • numbness
        • Auditory
          • Positive
            • Tinnitus, noises
          • Negative
            • Hearing loss
    • Headache
      • Unilateral
      • Throbbing, pulsatile quality
      • Nausea or vomiting common
      • Photophobia and phonophobia common
    • Prodrome
      • Feeling of exhaustion, elation, euphoria
Scintillating Scotoma

Precipitating Factors or Triggers

Common Migraine Triggers

Diagnostic Criteria

  • Without an Aura
    • ≥ 5 attacks with the following:
      • Lasting 4-72 hours
      • Headache as 2 of the following:
      • Unilateral
      • Pulsating quality
      • Moderate/severe
      • Aggravation by exertion
    • ≥ 1 of the following:
      • Nausea or vomiting
      • Photophobia or phonophobia
  • With an Aura
    • ≥ 2 attacks with the following:
      • ≥ 1 of the following reversible aura symptoms:
        • Visual
        • Sensory
        • Speech
        • Motor
        • Brainstem
        • Retinal
    • ≥ 2 of the following:
      • Aura spreads and/or 2 or more occur in succession
      • Each aura lasts 5-60 min
      • At least 1 aura is unilateral
      • Aura is accompanied or followed by headache within 60 min

Treatment

  • Acute/Abortive Therapy
    • Without nausea or vomiting
      • NSAIDs
    • With nausea or vomiting
      • Triptans
        • Sumatriptan
          1. SQ 6mg
          1. IN 20mg
      • Antiemetics
        • Metoclopramide 10mg
        • Prochlorperazine 10mg
      • Dihydroergotamine 1mg IM/SQ
        • Generally combined with metoclopromide
      • Dexamethasone 10mg IM
        • More for prevention of migraine recurrence
  • Preventative Therapy
    • Think about compelling indications and concomitant diseases
    • Antihypertensives
      • Beta Blockers
        1. Metoprolol, propranolol
      • Calcium Channel Blockers
        1. Verapamil, flunarizine
      • ACE/ARB
        1. Lisinopril, candesartan
    • Antidepressants
      • Amitriptyline, venlafaxine
    • Anticonvulsants
      • Topiramate, valproate, gabapentin
    • Calcitonin Gene-Related Peptide (CGRP) Antagonist
      • Erenumab, fremanezumab, galcanezumab
    • Acupuncture, nerve stimulation

Cluster

Epidemiology

  • <1% of headaches
  • Men > women

Pathophysiology

  • Complex and incompletely understood
    • Most widely accepted theory
      • Hypothalamic activation with secondary activation of the trigeminal-autonomic reflex

Clinical Features

  • Unilateral attacks of severe orbital, supraorbital, or temporal pain
    • Autonomic phenomena
      • Ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
        • Only occur during the episode
        • Ipsilateral to the pain site
    • Circadian periodicity
      • Occur daily for several weeks and then remit for up to a year

Diagnostic Criteria

  • At least five attacks characterized by severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes with at least one of the following:
    • Conjunctival injections and/or lacrimation
    • Nasal congestion and/or rhinorrhea
    • Eyelid edema
    • Forehead and facial sweating
    • Miosis and/or ptosis
    • Sense of restlessness or agitation
  • Classification
    • Episodic
      • Occur in circardian periodicity in clusters
        • At least two cluster periods lasting 7 days to one year separated by a pain-free remission of at least 3 months
    • Chronic
      • Attacks occur without a remission period or remission lasting less than 3 months
  • Imaging
    • Initial event warrants an MRI to rule-out intracranial pathology that also can cause autonomic dysfunction

Treatment

  • Acute/Abortive Therapy
    • 100% oxygen via non-rebreather
    • SQ sumatriptan 6mg
    • IN lidocaine 4-10% 1mL
    • Ergot-derivitives
    • Octreotide 100mcg SQ
  • Preventative Therapy
    • Verapamil 240mg daily
      • Bridge with prednisone 60-100mg daily for 5 days, with a 10mg/day taper
    • Galcanezumab can be used for chronic
    • Lithium has limited data
    • Topiramate can be used as add-on therapy


Up-to-Date. 2020

Up-to-Date. 2020

The Cottage Physician (1893)



References

  1. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia : an international journal of headache. 2018; 38(1):1-211. [pubmed]
  2. Goadsby PJ. Migraine and Other Primary Headache Disorders. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxy.uthsc.edu/content.aspx?bookid=2129&sectionid=192532155 . Accessed May 03, 2020.
  3. Koyfman A, Long B. Headache. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxy.uthsc.edu/content.aspx?bookid=2353&sectionid=189593946 . Accessed May 03, 2020.
  4. Hainer BL, Matheson EM. Approach to acute headache in adults. American family physician. 2013; 87(10):682-7. [pubmed]
  5. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019; 92(3):134-144. [pubmed]
  6. Lyrer PA, Brandt T, Metso TM, et al. Clinical import of Horner syndrome in internal carotid and vertebral artery dissection. Neurology. 2014; 82(18):1653-9. [pubmed]
  7. Loder E, Weizenbaum E, Frishberg B, Silberstein S, . Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. ; 53(10):1651-9. [pubmed]
  8. Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache. 2018; 58(2):339-345. [pubmed]
  9. Martelletti P, Birbeck GL, Katsarava Z, Jensen RH, Stovner LJ, Steiner TJ. The Global Burden of Disease survey 2010, Lifting The Burden and thinking outside-the-box on headache disorders. The journal of headache and pain. 2013; 14:13. [pubmed]
  10. Bendtsen L. Central sensitization in tension-type headache–possible pathophysiological mechanisms. Cephalalgia : an international journal of headache. 2000; 20(5):486-508. [pubmed]
  11. Moore RA, Derry S, Wiffen PJ, Straube S, Bendtsen L. Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. Pain. 2014; 155(11):2220-8. [pubmed]
  12. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007; 68(5):343-9. [pubmed]
  13. Laurell K, Artto V, Bendtsen L, et al. Premonitory symptoms in migraine: A cross-sectional study in 2714 persons. Cephalalgia : an international journal of headache. 2016; 36(10):951-9. [pubmed]
  14. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia : an international journal of headache. 2007; 27(5):394-402. [pubmed]
  15. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015; 55(1):3-20. [pubmed]
  16. Nesbitt AD, Goadsby PJ. Cluster headache. BMJ (Clinical research ed.). 2012; 344:e2407. [pubmed]
  17. May A, Schwedt TJ, Magis D, Pozo-Rosich P, Evers S, Wang SJ. Cluster headache. Nature reviews. Disease primers. 2018; 4:18006. [pubmed]
  18. Obermann M, Holle D, Naegel S, Burmeister J, Diener HC. Pharmacotherapy options for cluster headache. Expert opinion on pharmacotherapy. 2015; 16(8):1177-84. [pubmed]
  19. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology. 2010; 75(5):463-73. [pubmed]

PAINE #PANCE Pearl – Neurologic



Question

A 47yo man is being evaluated for a headaches that he describes as “someone jabbing my brain through my eye”. He reports these headaches occur several times a day for the past several weeks, lasting only for a minute, and only affecting his right side of this head. While speaking with him, he has another episode and you notice his eye becomes red and injected with significant tearing and nasal drainage present. On closer examination, he also notice his pupil on the affected side is constricted and he has a mild lid lag.

  1. What is the treatment protocol of choice for this patient?

#53 – Ottawa Rules



***LISTEN TO THE PODCAST HERE***



Background

  • These studies are conducted at the Ottawa Hospital Research Institute and University of Ottawa starting in 1992 and the main researcher behind these is Ian Stiell.
  • They are international recognized and have been validated multiple times to decrease unnecessary radiographic testing and decrease healthcare costs

Disclaimer for Using Clinical Decision Instruments

  • Your clinical judgement should ALWAYS trump using any CDI
    • Distracting injuries
    • Intoxication
    • Inability to fully examine
    • Gestalt

Ottawa Rules of the Foot and Ankle

  • The Numbers
    • Ankle xrays are the second most commonly ordered film in the ED
    • < 15% fracture incidence rate
  • The study
    • Published in 1992, validated in 1995
    • 7 months long
    • 750 patients
    • 21 EM physicians looking at 32 clinical variables
  • Variables
    • Lateral malleolus tenderness
    • Medial malleolus tenderness
    • Base of 5th metatarsal tenderness
    • Navicular tenderness
    • Inability to bear weight immediately and in the emergency department for four steps
      • Limping counts
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased ankle imaging 36% and foot imaging 21%
  • Clinical Pearls
    • Be sure to palpate the entire 6cm of the distal tibia and fibula
    • Do not confuse soft tissue tenderness for bony tenderness

Ottawa Rules of the Knee

  • The Numbers
    • >600,000 patients annually present to ED with knee complaints
    • 80% of these patients have radiography
      • Majority have soft tissue injuries
  • The study
    • Published in 1995, validated in 1996
    • 14 months long
    • 1,047 patients
    • 33 EM physicians looking at 23 clinical variables
  • Variables
    • > 55 years of age
    • Isolated patella tenderness
    • Fibular head tenderness
    • Inability to flex knee to 90o
    • Inability to bear weight immediately and in the emergency department for four steps
      • Limping counts
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased knee imaging by 28%
  • Clinical Pearls
    • Use only for injuries < 7 days old
    • Patella tenderness only significant if an isolated finding

Ottawa Rules of the Cervical Spine

  • The Numbers
    • C-spine series is the most common radiograph for trauma
    • > 1,000,000 series performed annually
      • > 98% being negative
  • The study
    • Published in 2001, validated in 2003
    • 3 years long
    • 8,924 patients
      • Blunt trauma only
      • Stable vital signs
      • GCS of 15
    • Looked at 20 clinical variables
  • Variables
    • ≥ 65 years of age
    • Dangerous mechanism
      • Fall from height > 3 feet or 5 stairs
      • Axial load
      • High speed (> 60mph) MVC, rollover, or ejection
      • Motorized recreational vehicle accident
      • Pedestrian or cyclist versus automobile accident
    • Immediate pain
    • Non-ambulatory at scene
    • Inability to rotate neck
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased cervical spine imaging by 42%
  • Clinical Pearls
    • Not applicable if:
      • Non-trauma
      • GCS < 15
      • Unstable vital signs
      • Age < 16 years of age
      • Acute paralysis
      • Known vertebral disease
      • Previous cervical spine history

Canadian Head CT Rule

  • The Numbers
    • > 2 million ED visits annually for minor head trauma
      • Average cost of CT scan ~ $1200
        • Average annual cost > $900 million
    • < 3% incidence of clinically significant intracranial injuries
  • The study
    • Published in 2001, validated in 2005
    • 3 years long
    • 3,121 patients
      • Blunt trauma only
      • GCS between 13-15
      • < 24 hours on presentations
      • Must have loss of consciousness, altered mental status, or amnesia
    • Across 10 academic hospitals
    • Looked at 22 clinical variables
  • Variables
    • High risk variables (need for neurosurgical intervention)
      • GCS < 15 at 2 hour after injury
      • Suspected open/depressed skull fracture
      • Signs of basilar skull fracture
      • ≥ 2 episodes of vomiting
      • ≥ 65 years of age
  • Variables
    • Medium risk variables (predicting clinically important brain injury)
      • Retrograde amnesia ≥ 30 minutes
      • Dangerous mechanism
        • Pedestrian versus auto
        • MVC ejection
        • Fall from height > 3 feet or > 5 stairs
  • Outcomes
    • Identified 100% of high risk patients and 98.4% of medium risk patients
    • Reduction in head CT by > 30%
  • Clinical Pearls
    • Not applicable if:
      • < 16 years of age
      • On anticoagulation
      • Witnessed seizure post-injury
      • Unstable vital signs
      • Acute focal neurologic deficit

Ottawa Rules for Subarachnoid Hemorrhage

  • The Numbers
    • 2% of all ED visits are for headache
    • 2% incidence of subarachnoid hemorrhage
    • 51% mortality if missed
  • The study
    • Published in 2010, validated in 2013
    • 5 years long
    • 1999 patients
      • Non-traumatic
      • < 1 hour from onset
      • GCS 15
    • Looked at 13 clinical variables
  • Variables
    • ≥ 40 years of age
    • Neck pain
    • Witnessed loss of consciousness
    • Exertional onset
    • Added on validation study:
      • Thunderclap headache
      • Limited neck flexion on exam
  • Outcomes
    • Identified 100% of subarachnoid hemorrhages
    • 100% negative predictive value
    • Decreased head CT or lumbar puncture rates by 20%

The Cottage Physician (1893)



References

  1. The Ottawa Rules. [online] Available at: http://www.theottawarules.ca/ [Accessed 10 Nov. 2019].
  2. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Annals of emergency medicine. 1992; 21(4):384-90. [pubmed]
  3. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993; 269(9):1127-32. [pubmed]
  4. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994; 271(11):827-32. [pubmed]
  5. Stiell I, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ (Clinical research ed.). 1995; 311(7005):594-7. [pubmed]
  6. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Annals of emergency medicine. 1995; 26(4):405-13. [pubmed]
  7. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996; 275(8):611-5. [pubmed]
  8. Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997; 278(23):2075-9. [pubmed]
  9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001; 286(15):1841-8. [pubmed]
  10. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. The New England journal of medicine. 2003; 349(26):2510-8. [pubmed]
  11. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet (London, England). 2001; 357(9266):1391-6. [pubmed]
  12. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005; 294(12):1511-8. [pubmed]
  13. Perry JJ, Stiell IG, Sivilotti ML, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ (Clinical research ed.). 2010; 341:c5204. [pubmed]
  14. Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013; 310(12):1248-55. [pubmed]

PAINE #PANCE Pearl – Neurology



Question

There are two tests that you can perform at bedside in patients with suspected myasthenia gravis. One is an easy adjunct to the neurologic exam and the other is only included for historical purposes. Name these tests.



Answer

The most reliable way to diagnose myasthenia gravis is through serologic laboratory studies assessing acetylcholine receptor and muscle-specific tyrosine kinase antibodies. But……………there are two bedside tests that can help prior to expensive labs.

  • Ice Pack Test
    • Used as part of the neurologic examination, it is based on the physiologic principle that neuromuscular transmission improves at lower muscle temperature. In patients with myasthenia gravis, placing an ice pack over a closed eyelid for 2 minutes can improve ptosis in 80% of patients.
https://www.nejm.org/doi/full/10.1056/NEJMicm1509523
  • Edrophonium Test
    • Taught more for historical purposes, edrophonium is an acetylcholinesterase inhibitor with a rapid onset and short duration of action. The main effect is prolonging acetylcholine in the neuromuscular junction to improve muscular strength.
    • It is not available in the US, nor used in the diagnosis