I'd say this rotation has been the most enjoyable so far, in no small part because it actually had a reasonable schedule: 7am-5pm 6 days per week, and it felt like a vacation. Whats more, the time on the job was much more relaxed because we were actually well staffed and the service wasn't exploding with patients. I had ample opportunity to ask a ton of questions of some really smart residents and attendings. I had a great time. The rotation was unfortunately only 2 weeks long, so I still have a lot to learn when it comes to neurology, but I think I learned some of the most important things I set out to learn on this rotation, which I will outline below.
My most important goals for this rotation were to really work on my neuro exam, the approach to common neuro conditions (stroke, seizure, weakness), common medications knowledge, and how to read a head CT...
1 - THE NEURO EXAM IN THE ALTERED, SEDATED, OR UNAROUSABLE PATIENT
Before starting the neuro rotation, I honestly thought that I had the neuro exam down. I spent quite a bit of time in school getting a hang of the routine, practicing on classmates, and using it in clinic. I was quite confident in my skills. HA! This seems to be a common theme for newbies: we walk into things thinking that we know what we're doing... but "you don't know what you don't know". In this case, my error in judgement stemmed from the fact that I only learned and practiced a neuro exam meant for a normal, healthy patient. Ironically, these are the patients that odds would say might not need a neuro exam at all. The patients who need it most are the ones who truly sick, have a difficult time following commands, are altered, or even unresponsive. The neuro exam that I knew simply wouldn't work on these patients. I now know that you need to know multiple neuro exams, each catered to the unique patient sitting in front of you. Similarly, you need to know how to do a neuro exam on a mobile patient and an immobile/supine patient. Since the exam on the altered, sedated, or unarousable patient is what I learned learned most this rotation, I'll outline it here:
Always start w/ OBSERVATION. ABCs, vitals, head to toe sweep.
Without doing or saying anything... are the eyes open, moving all 4 extremities, any asymmetry (facial droop)?
AROUSABILITY and ABILITY TO FOLLOW COMMANDS - introduce yourself and ask them to open their eyes. If they don't -> noxious stimuli. Ask their name, AOx3. If they don't respond or can't talk, ask "can you squeeze your hand if you understand me?".
EYE EXAM. If needed, physically open their eyes. Observe their gaze - one sided preference?
(remember, if patient is looking away from the side of hemiparesis, assume its a stroke. If they're looking towards the side of hemiparesis, it will almost always be a seizure).
Assess pupil size, reactivity to light.
See if they can follow commands w/ EOM. Try to get them to gaze past midline if they have gaze preference or neglect.
(eye exam continued, now assessing brainstem function, the most important part of the unarousable patient exam)
check doll's eye reflex (oculocephalic reflex) -- see youtube for this and many explanations on google.
check corneal reflex - don't use saline; take a cotton swab and use your finger to get a make a light pointy strand of cotton.
check gag reflex w/ tongue depressor; cough reflex w/ suction thru ETT if intubated.
SENSORY + MOTOR. if they can follow commands, do a normal neuro exam. Make sure you know how to assess motor strength in very weak patients (maneuvers to eliminate gravity). If they can't follow commands...
go extremity by extremity, assessing for A) tone, while ROMing their extremity. B)response to pain - looking for withdrawal or posturing. Make sure all is symmetrical.
REFLEXES - DTRs. Make sure you know how to do these on a bed bound patient (I didn't know how to do this before this rotation!) - mostly looking for asymmetry.
Clonus, babinski, etc.
I can plow through this little exam in a couple of minutes, and it is great at assessing a lot of important things. In doing this exam we can establish GCS, mental status, brainstem function, and cortical function. I'll post my notes below that will also contain my updated "4 minute neuro exam" on the awake and normal patient. Pretty straightforward, so I didn't think it worthwhile to post here.
Check out the EM basic neuro exam supplement podcast.
I'd highly recommend that once you have the exam down you take some time looking up videos of what abnormal findings look like. This way, it will be more than just going through the motions of an exam; you will actually know what you're looking for. Youtube always has good videos. I've heard that neuroexam.com is good.
check out this great article for more of an explanation of the neurology behind the exam maneuvers. Great website! http://lifeinthefast...scious-patient/
more good stuff:
2 - THE APPROACH TO COMMON NEURO CONDITIONS
For the sake of time, I won't go into a ton of depth on these. If you'd like more info, check out my notes I made on this rotation - attached on the dropbox link below.
I remember seeing my first patients with seizures come into the ED when I was in PA school. I was always terrified. It seemed like a very intimidating thing, what with this patient thrashing around and a whole hoard of family members and nurses panicking at bedside. The few weeks of didactic lecture we got in school didn't help at all and I always felt clueless. I've since learned that seizures are actually somewhat straightforward.
When a patient starts actively seizing in front of you, what do you do?
-First, check clock and note the time it started. The neurologists will appreciate it if you or family gets video recording of the seizure (with consent from family), because neurologists will be able to ascertain a lot of information from seeing the seizure.
-Call to get 2mg IV ativan at bedside (assuming you have venous access; if not consider IM versed)
-Safety: move the patient's bed to to the ground, rails up, 30 degrees head of bed elevation.
-Head to toe eval: which way is head turned, eyes turned? Eyes open or closed (best predictor of pseudo seizure)? Mouth secretions, tongue biting? Breathing pattern? Note which extremities are moving - tonic or clonic? Urinary incontinence?
-Roll the patient to their side.
-At this point, its probably been around 2-3 minutes. If it hasn't resolved spontaneously by the time nurse comes back with the meds, give the ativan.
-Check fingerstick, vitals.
-You wait a bit and If it still hasn't stopped, repeat ativan. Get ready for status epileptics protocols (not going to go into that here).
The seizure has stopped, how do you approach the workup?
The approach depends entirely upon whether the patient is known epileptic on meds or is a new onset seizure for the first time. If its the first time, think of it like a fib in that it should be thought of as a symptom/manifestation of a secondary cause that you should seek out. Look up the ABCDEI mnemonic for etiologies for first time seizures. Most commonly in those under 35 is trauma, tumor, alcoholism/withdrawal, and cocaine. For those over 35, its most commonly cardiovascular dz, metabolic derangements, alcoholism, brain tumor.
There is a lot more to say about seizures. Listen to the EM basic podcast. Read up on seizure vs pseudo seizure as well. Good stuff.
I'll just talk about a few of the most important points emphasized the during the rotation. The neurologists I worked with talked a lot about the variety of ways a stroke can present, depending on which part of the brain is being affected. Similarly, they discussed a lot about stroke mimics (in particular, seizure or post ictal hemiparesis called Todd's paralysis, and hypoglycemia).
You are working in the ED and you hear a stroke alert as EMS wheel the patient to an exam room, what to do? What are the most important things to immediately assess in a suspected stroke?
-Age of patient
-ABCs - make sure maintaining airway and will be okay for CT
-Vitals - crucial to know the BP immediately. Flags should go off if its over 180/110 (tPA c/i)
-Blood sugar (easily ruled out mimic)
-Quick history: Exact onset of sx. last known normal. Consider calling the last dialed number on their phone!
-What is their baseline? Prior deficits.
-Rapid exam: if you are quick, you can run thru the NIHSS in 1-2 min, otherwise some just do something like the Cincinatti "FAST" exam to get a gestalt of whats going on. Facial asymmetry when asked to smile. Arm asymmetry/weakness when asked to raise both arms up. Speech abnormality when repeating a sentence ("no ifs ands or buts"). Time of onset of sx.
send them to the CT scanner ASAP.
Then there is a many more things to do. For a great podcast that is up to date, check out the SUNY downstate neurology podcast "stroke code". Also, I'd highly recommend putting some time into reading up on the NIH stroke scale, watching videos of it being done (there are a bunch on youtube that have good discussions), and practicing it yourself, because there are some intricacies.
There are new/revised tPA contraindications that are worth checking out.
Also, we talked a lot about how CTA head is becoming a standard of care along with IR interventions. Be sure to get the CTA soon after CT (often while patient is still on the table) if the NIH is 8+ and the CT head was negative and no renal dz (or HTN/DM).
Last, neurologists go-to antiHTNsive med is labetolol. I swear I saw labetolol 10mg IV push PRN per MAP goals on every patient.
You have gathered the information and are ready to call a neurologist. How do you present the case to them in the middle of the night? (they like very specific presentations)
"Hi Dr X, we've got a stroke alert patient in the ED. Patients name is Y in room Z.
AGE/SEX - and R/L Handed. Last known normal was X. Presents w/ s/s XYZ. NIHSS #, no known prior deficits. CT head negative. BP, blood sugar XYZ. Not on any anticoagulants. No tPA contraindications. What we've done so far... BP control, etc. What do you think... should we do tPA? CTA? call IR?"
3 - COMMON MEDICATION KNOWLEDGE FOR NEURO MEDS
I have been thinking a lot lately about what the most valuable things you can learn while doing a rotation on a specialty's service, and I've come to the conclusion that it is the things that you would have the most difficulty learning anywhere else. The things that only somebody living and breathing their specialty day in and day out would be able to ascertain, distill, and share with you... knowledge that can't be efficiently found in a textbook or online reference. I wrote a whole thread post about this on the student forum actually haha. (
Anyways, a perfect example of this is medications. I've found that trying to learn information about medications is very challenging because you look at the textbooks and uptodate and you see just laundry lists of hundreds of bits of random, impossible to memorize information. What I've always wanted to learn is something equivalent to "the top 5 things you have to know" for any given drug. In other words, what are the things that the specialists think about when ordering a drug? What do they chart check before giving? What PMH, labs, meds do they look out for? What are the truly common side effects and the actually worrisome adverse events they look out for? These are the things that specialists know and these are the things that are so hard to look up in the book. Thus, I set out to make like a sponge and try to soak up as much of this information as I could from the neurologists, and I think it worked really quite well! I'll give you an example with anti epileptic drugs, including not all the info but some important points.
ANTIEPILEPTIC DRUGS (AEDs)... In general, these are a few of the things that neurologists think about whenever they see or consider an AED. These are the things we should have running through our heads in the ED as well, because we commonly order these medications.
BEFORE ORDERING AN AED...
Chart check PMH:
-Look out for psychiatric conditions -- avoid keppra in these patients (bcz it commonly causes agitation, personality changes, psychosis).
-Look out for CKD and dialysis in the chart, because many AEDs are renally excreted and will present with AED toxicity (see below).
-If the pt is a woman, don't forget that AEDs are generally very teratogenic.
Chart check Med List:
-Warfarin is one of the main things my neurologists looked out for, because AEDs notoriously interact with warfarin and have been known to cause jumps in INR up to 10 in a matter of days. If you must give a patient on warfarin an AED, they need to have very close INR checking even within 2 days of DC.
-There are some medications that interact with AEDs and increase or decrease their efficacy. Unfortunately I forgot the most important ones (oops! let me know if you know them)
Chart check Labs:
-LFTs (most AEDs can cause liver damage)
COMMON SIDE EFFECTS FOR MOST AEDS:
-fatigue, weight gain, headaches, dizziness/nystagmus, tremors
WHENEVER A PT W/ A HX OF SEIZURES ON AEDs COMES IN, BE WARY OF THE FOLLOWING COMPLAINTS:
Rash: These are common side effects of AEDs, however be aware that the dreaded adverse rxn for many AEDs is SJS/TENS. This should be on your radar if one of these patients complains of a rash.
"Post Ictal": This was perhaps the most interesting thing taught to me and unbelievably important to keep in the back of your head, and it again shows the disconnect between textbook/reference information and real work clinical experience. Some of the most common side effects, especially severe in OVERDOSE/TOXICITY of AEDs, are drowsiness, sedation, lethargy and headache. Picture this symptom combination in your head and what do you think it resembles? Yep... the post ictal period. Why is this vitally important to know? Because if a patient comes in supposedly found "post ictal" and you decide "well we better load them with their home AED because noncompliance is the likely etiology of their breakthrough seizure", you could very well be giving an already SUPRATHERAPEUTIC patient MORE aed... toxicity here we come. Yikes! Very easy mistake to make (the neurologists said it has been done many times!). Take home point, whenever a patient comes in "post ictal", you had better check a drug level on them BEFORE giving them their home med AED!
The meds you can check levels for: phenytoin/dilantin, carbamazepine/tegretol, depakote/depakene/valproate, lamotrigine/lamictal (in general, the first generation AEDs). If you can't check a level on their med, you better wait until they resolve from their postictal state before giving them their home dose. If it takes them hours and hours to resolve, it might not truly be postictal, and you should hold the med.
MORE GOOD NEURO RESOURCES
Head CT interp: http://lifeinthefastlane.com/investigations/ct-head-scan/
There is actually a new ENLS (emergency neurological life support) course similar to ACLS. I think Scott Weingart sang its praise, so maybe its pretty good! there is a course you can purchase online to go through them in detail I believe. http://enlsprotocols.org/pdf.html
I thought that this rotation was fascinating and had very helpful information. I hope you all enjoy this info as well. If you all would like me to cover any topics in particular that I have glossed over, just let me know and I'll do my best.