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22 results

Page 1 of 2

  • Chapter 2 - Indications

  • from Part I - Introduction
  • Neville M. Jadeja, University of Massachusetts Medical School, Kyle C. Rossi, University of Massachusetts Medical School
  • Book:
    Critical Care EEG Basics
    Published online:
    22 February 2024
    Print publication:
    29 February 2024, pp 17-23

  • Summary

    The most important indication for electroencephalography (EEG) in critically ill patients is to evaluate fluctuating or persistently abnormal mental status (or other focal neurological deficits) that cannot otherwise be explained. Commonly, these symptoms are a manifestation of physiological diffuse cerebral dysfunction (encephalopathy), or they may be due to seizure activity without apparent clinical manifestations. Such “nonconvulsive” seizures (NCS), that may only be detected by EEG, occur in at least 8–10% of critically ill patients. Continuous or frequent NCS is called nonconvulsive status epilepticus (NCSE), and may result in secondary neurological injury, including neuronal death or alteration of neuronal networks. Left untreated, NCSE can become increasingly refractory to treatment. EEGs may be indicated in acute brain injury to detect seizure activity. They are useful in monitoring the depth of anesthesia and in the management of refractory status epilepticus. EEGs may also be used in the intensive care unit to characterize paroxysmal clinical events and in prognostication after cardiac arrest or determining brain death.

  • 8 - Meningitis and Encephalitis

  • from Section 2 - Infectious Disease Emergencies
  • Edited by Kaushal Shah, Weill Cornell Medical Center, New York, Jarone Lee, Massachusetts General Hospital, Boston
  • Edited in association with Clark G. Owyang, Weill Cornell Medical Center, New York, Benjamin Christian Renne, Massachusetts General Hospital, Boston
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    02 November 2023
    Print publication:
    23 November 2023, pp 70-76

  • Summary

    • Meningitis is inflammation of the meningeal membranes of the brain and spinal cord. Encephalitis is inflammation of the brain parenchyma with or without inflammation of the meninges. Cerebral perfusion is a function of arterial pressure and intracranial pressure (i.e., cerebral perfusion pressure = mean arterial pressure – intracranial pressure). Hypoperfusion results from cerebral edema and increased intracranial pressure (ICP). Meningitis is a life-threatening condition with up to 30% mortality and high risk of long-term neurological complications.

    The differential diagnosis for meningitis and encephalitis includes subarachnoid hemorrhage, cerebral venous thrombosis, metabolic/toxic encephalopathy and other infections not involving the central nervous system (CNS).

  • Chapter 5 - Coma, Delirium, and Dementia

  • from Section 2 - Common Neurologic Presentations: A Symptom-Based Approach
  • Edited by Thomas P. Campbell, Allegheny Health Network, Pittsburgh, Kevin M. Kelly, Allegheny Health Network, Pittsburgh
  • Book:
    Handbook of Emergency Neurology
    Published online:
    10 January 2024
    Print publication:
    17 August 2023, pp 51-69

  • Summary

    Alterations in mental status are a frequently encountered chief complaint that the emergency physician is asked to evaluate. These changes vary from marked depression of mental status to extreme over-activation. The differential diagnosis of altered mental status (AMS) is perhaps one of the broadest encountered in medicine. Here we will discuss alterations in mental status, and a diagnostic approach to these types of patients.

  • Neurology in the psychiatric patient: how to think about differentials in altered mental status and diagnoses not to miss

  • Jonathan McLaughlin, Tim Young
  • Journal:
    BJPsych Advances / Volume 28 / Issue 4 / July 2022
    Published online by Cambridge University Press:
    29 November 2021, pp. 226-238
    Print publication:
    July 2022
    • Article
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  • A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.

  • MP14: Prospective external validation of the Ottawa 3DY screening tool for the detection of altered mental status of elderly patients presenting to the emergency department

  • B. Kim, Q. Salehmohamed, R. Stenstrom, S. Barbic, D. Barbic
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
    Published online by Cambridge University Press:
    15 May 2017, pp. S69-S70
    Print publication:
    May 2017
    • Article
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  • Introduction: Altered mental status (AMS) and cognitive impairment are common problems in elderly patients presenting to the emergency department (ED). The primary objective of this study was to test the diagnostic accuracy of the Ottawa 3DY (O3DY) screening tool for the detection of AMS in the ED. Methods: This was a prospective cohort study conducted at an inner city, academic ED with an annual census of 85,000 visits. Study investigators and trained research assistants screened and approached a convenience sample of patients for informed written consent. Patients completed the O3DY, Short Blessed Test (SBT) and Mini-Mental Status Exam (MMSE). Descriptive statistics using counts, medians, means and interquartile ranges (IQR) were calculated. Sensitivity and specificity of the O3DY compared to the MMSE were calculated in STATA (version 11.2). Results: We screened 163 patients for inclusion, 150 were eligible to participate, and 116 patients were enrolled in the final study. The median age of participants was 81 (IQR 77-85), 44.8% were female, and the most common pre-existing comorbidity was hypertension. The median ED LOS at the time of O3DY completion was 1:40 (IQR 1:34-1:46). Characteristics of patients eligible, yet who declined to participate, were similar to the study population. The sensitivity of the O3DY for AMS was 71.4% (95%CI 47.8-95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were moderate. Conclusion: In a cohort of geriatric patients presenting to an inner-city, academic ED the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of AMS.

  • Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

  • Matthew V. Kiefer, H. Gene Hern, Harrison J. Alter, Joseph B. Barger
  • Journal:
    Prehospital and Disaster Medicine / Volume 29 / Issue 2 / April 2014
    Published online by Cambridge University Press:
    15 April 2014, pp. 190-194
    Print publication:
    April 2014
  • Introduction

    Prehospital first responders historically have treated hypoglycemia in the field with an IV bolus of 50 mL of 50% dextrose solution (D50). The California Contra Costa County Emergency Medical Services (EMS) system recently adopted a protocol of IV 10% dextrose solution (D10), due to frequent shortages and relatively high cost of D50. The feasibility, safety, and efficacy of this approach are reported using the experience of this EMS system.

    Methods

    Over the course of 18 weeks, paramedics treated 239 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 203 patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 164 of the 203 patients. The 164 patients’ capillary glucose response to initial infusion of 100 mL of D10 was calculated and a linear regression line fit between elapsed time and difference between initial and repeat glucose values. Feasibility, safety, and the need for repeat glucose infusions were examined.

    Results

    The study cohort included 102 men and 62 women with a median age of 68 years. The median initial field blood glucose was 38 mg/dL, with a subsequent blood glucose median of 98 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100 mL D10 infusion. Of 164 patients, 29 (18%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia, and one patient required a third dose. There were no reported adverse events or deaths related to D10 administration. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation.

    Conclusions

    In addition to practical reasons of cost and availability, theoretical risks of using 50 mL of D50 in the out-of-hospital setting include extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. The results of one local EMS system over an 18-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative. Additionally, the linear regression line of repeat glucose measurements suggests that there may be little or no short-term decay in blood glucose values after D10 administration.

    KieferMV , HernHG , AlterHJ , BargerJB . Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia. Prehosp Disaster Med. 2014;29(2):1-5.

  • 49 - Disseminated intravascular coagulation and thrombotic thrombocytopenic purpura/hemolytic uremic syndrome

  • from Section 8 - Hematology–oncology emergencies
  • Edited by Kaushal Shah, Jarone Lee, Kamal Medlej, American University of Beirut, Scott D. Weingart
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    05 November 2013
    Print publication:
    24 October 2013, pp 330-336

  • Summary

    This chapter discusses the diagnosis, evaluation and management of gastrointestinal bleeding including upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). It describes the special circumstances with regard to aortoenteric fistula, liver disease, and Jehovah's Witnesses. In UGIB, patients typically present with hematemesis, coffee-ground emesis, and/or melena. In LGIB, patients typically present with bright red blood per rectum (BRBPR), also known as hematochezia. Higher severity of disease is indicated by signs of shock such as hypotension, tachycardia, altered mental status (AMS), decreased urine output (UOP), cool skin, syncope, orthostasis. Change in pulse with posture is more sensitive than hypotension, but may be masked by medications (e.g., beta-blockers). Hypotension, tachycardia, and tachypnea can indicate hemorrhagic shock and requires immediate treatment. Massive transfusion protocols are helpful for significant bleeding in order to prevent further coagulopathy due to transfusion of high volume of crystalloid or only red cells.

  • Chapter 17 - Depression in the patient with hepatitis C

  • Edited by James J. Amos, University of Iowa, Robert G. Robinson, University of Iowa
  • Book:
    Psychosomatic Medicine
    Published online:
    04 August 2010
    Print publication:
    27 May 2010, pp 153-162

  • Summary

    This chapter discusses cortical dementias that include Alzheimer's disease, fronto-temporal dementia and dementia with Lewy bodies, subcortical dementias that include Parkinson's disease and Huntington's disease, and mixed dementias that include vascular dementia. Deficits characteristic of both cortical and subcortical dementias, depending on the location and extent of cerebrovascular lesions, may occur. Numerous neuropsychiatric sequelae are associated with traumatic brain injury (TBI), making it difficult to identify a well-defined syndrome. Thorough psychiatric and medical histories are critical in diagnosing patients who present with agitation and cognitive changes. Laboratory and neuroimaging studies are of variable utility in evaluating for reversible causes of altered mental status. A number of medications have been studied for their effects on dementia-related agitation. The most common categories include antipsychotics, antiepileptic medications, antidepressants, and cognitive enhancers. Controlled studies on pharmacologic treatment for agitation in Huntington's disease are rare.

  • 30 - CT Imaging of the Head

  • from PART III - COMPUTED TOMOGRAPHY
  • Edited by J. Christian Fox, University of California, Irvine
  • Book:
    Clinical Emergency Radiology
    Published online:
    07 December 2009
    Print publication:
    29 September 2008, pp 420-437

  • Summary

    Head computed tomography (CT) is one of the most common imaging studies ordered from the ED. Head CT is used in the evaluation of the patient who presents with headache, altered mental status, suspected stroke, or other acute neurological abnormalities. Current third-generation CT scanners are very sensitive for the detection of acute hemorrhage and bony injury, the two principal pathologies sought in evaluation of patients with head injury. In the patient with head injury, head CT will readily identify skull fractures, although fractures through the thinnest areas of the base of the skull may be missed in the axial cuts. In patients with altered mental status and other neurological abnormalities, head CT is extremely valuable in detecting pathology that requires emergent intervention. The vast majority of head CTs performed in the ED are done without contrast. Artifact is an important consideration in the interpretation of head CTs.

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