Mild Traumatic Brain Injury
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Mild Traumatic Brain Injury Mild Traumatic Brain Injury Document Transcript

  • Completing the Neurologic Exam in Emergency Department CVA Patients Edward P. Sloan, MD, MPH, FACEP A 62-year-old female acutely developed aphasia and right sided weakness while in the grocery store. The store clerk immediately called 911, with the arrival of CFD paramedics within 9 minutes, at 6:43 PM. She arrived at the ED at 7:05 PM, completed her head CT at 7:25 PM, and obtained a neuro consult at 7:35 PM, approximately one hour after the onset of her symptoms. On exam, BP 116/63, P 90, RR 16, T 98, and pulse oximetry showed 99% saturation. The patient appeared alert, and was able to slowly respond to simple commands. The patient had a patent airway, no carotid bruits, clear lungs, and a regular cardiac rate and rhythm. The pupils were pinpoint, and there was neglect of the R visual field. There was facial weakness of the R mouth, and R upper and lower extremity motor paralysis. DTRs were 2/2 on the left and 0/2 on the right. Planter reflex was upgoing on the right and downgoing on the left. The patient’s estimated weight was 50 kg. What are the next Rx steps?
  • Neuro Exam in ED CVA Patients Page 2 of 11 Edward P. Sloan, MD, MPH Completing the Neurologic Exam in Emergency Dept CVA Patients Introduction Emergency Physicians are on the front line in managing patients with cerebrovascular accidents (CVAs) and many other acute neurologic disorders. Much has been written about conducting the neurologic exam, both in general terms and in the Emergency Department setting. The goal of the Emergency Physician is to accurately diagnose neurologic diseases and to provide effective and timely therapies to maximize patient outcome. Given the time constraints placed upon the Emergency Physician, every effort must be made to streamline this process, leading to the concept of a “focused neurologic exam”. What is meant by this term remains unclear to many, even those physicians who have practiced for many years in the ED. Considering the CVA patient as a model for discussing the focused neurologic exam is important for many reasons. Patients commonly present to the Emergency Department with acute CVAs. Over 700,000 patients will have a CVA each year, with a 20% one year mortality rate. The annual costs of these CVAs is over $30 billion, including both direct medical costs and the indirect costs associated with the long-term effects of this disease. At the same time, it is important to note that tPA use for the ED CVA patient is being considered by many local and national organizations that guide the healthcare of the public. The ACEP Clinical Policies Committee is working with the ACEP board to develop a policy regarding tPA use in stroke, one that will optimize patient outcome and the ability of the Emergency Physician to fulfill that objective. One cornerstone of tPA use is the ability to assess risk and benefit for each stroke patient, in large part based on the patient’s neurologic exam. In the clinical trials that led tPA to be deemed efficacious, the NIH Stroke Scale (NIHSS) was used to quantify the severity of the CVA. Even though it has been shown that it is essential to use tPA only in settings in which the clinical trial protocol can be recreated, many Emergency Physicians do not know how to assess stroke severity using the NIHSS. More importantly, even fewer understand the components of this stroke scale, such that their neurologic exam can be focused to include those components that predict outcome and guide ED tPA use. The purpose of this article is to address the issue of the neurologic exam in ED patients who present with an acute CVA. Upon review of this article, the reader should have a better understanding of how the neurologic exam can be focused in ED stroke patients. Information will be provided that will allow the ED physician to quickly identify important stroke syndromes and allow their neurologic exam to support this tentative diagnosis. The neurologic exam will also be focused so that the stroke etiology, need for further diagnostic testing, and ED therapy can be consistently determined for each patient.
  • Neuro Exam in ED CVA Patients Page 3 of 11 Edward P. Sloan, MD, MPH Rationale for a Focused Neurologic Exam In instances when there are confusing, non-persistent, or mild symptoms, a complete neurologic exam is in order. It is only in detecting all of the specific neurologic findings that a provisional diagnosis can be made. In the setting of an acute CVA, the fact that the patient has a stroke is usually not hard to ascertain. As such, when a “stroke” patient presents to the ED, the same neurologic exam that might be utilized for a TIA patient may not be necessary. The question is raised; therefore, as to what “focused neurologic exam” must be completed. Strokes can occur as a result of thrombotic and embolic vascular phenomena, as well as due to acute hypoperfusion in the setting of cardiogenic shock. There are several stroke syndromes that result from these events, including anterior and posterior circulation strokes, cerebellar and lacunar infarcts, and carotid artery dissection strokes. In US Emergency Departments, where access to CT scanning is readily available, one might ask why it is necessary to identify one of these syndromes on physical exam. The answer to this question is yes, since the initial CT scan will often be negative, especially in the setting of an ischemic stroke. The rationale for the focused neurologic exam is to suggest a provisional stroke syndrome diagnosis, to identify the likely precipitants of the stroke, to determine what further testing must be completed, and to determine the appropriate ED therapies that will optimize patient outcome. Additionally, a focused neurologic exam will allow for appropriate documentation to be completed. In general, the neuro exam must identify whether the stroke is an anterior or posterior circulation event, as well as to determine if the stroke is in the cerebellum, the brain stem, or whether the findings are the result of a spinal cord lesion. The Emergency Physician is also attempting to determine if the stroke is hemorrhagic, but the availability of CT makes this requirement a bit less important. Determining this prior to obtaining the CT, however, will allow the Emergency Physician to immediately begin required therapies such as intubation or to plan for subsequent therapies such as tPA or nimodipine. Anterior circulation stroke is the stroke syndrome that most of people think of when considering the use of tPA. Commonly as the result of middle cerebral artery occlusion, the patient will present with unilateral paralysis speech and sensory abnormalities, and visual and gaze findings of sudden onset. Posterior strokes present with a more insidious onset, often with minimal motor findings, marked sensory findings, and ataxia. Cerebellar hemorrhage is a diagnosis that should be suspected clinically because the diagnosis of this requires CT scanning utilizing thin cuts of the posterior fossa and because there is a specific therapy for this stroke: operative evacuation of the clot. Also, determining that the hemorrhage is actually in the posterior fossa can be difficult, even when this diagnosis is suspected. The neurologic findings of a cerebellar hemorrhage include headache, nausea, vomiting, ataxia, and altered mental status (when brain stem compression occurs due to the cerebellar hemorrhage). Significant brain stem lesions usually present a picture of critical illness, with prominent alteration in mental status. Vital signs often will be abnormal, as will respirations, suggesting the need for immediate intubation. Spinal cord lesions present either in the setting of acute injury or with findings that are so specific that a cerebrovasuclar accident is not part of the View slide
  • Neuro Exam in ED CVA Patients Page 4 of 11 Edward P. Sloan, MD, MPH differential diagnosis. For example, a patient with an epidural abcess may have sensory or motor findings in one lower extremity in conjunction with back pain, with no other associated prodromal or neurologic findings. Besides attempting to identify the likely stroke syndrome, the neurologic exam is being completed in order to identify the etiology of the stroke: embotic, thrombolic, hemorrhagic or subarachnoid. Embolic CVAs are most often sudden in onset and involve the anterior circulation. They are suggested by a carotid bruit, atrial fibrillation, or heart murmur, all as sources of embolism. Thrombotic strokes are suggested by gradual symptom onset, posterior circulation symptoms, and findings suggesting atherosclerosis, such as a carotid bruit, ventricular heave suggesting LVH, an abdominal aortic aneurysm, and poor extremity pulses. Hemorrhagic CVAs present with impaired consciousness as a key element, with symptoms of abrupt onset and maximal severity at symptom onset. Hypertension and bradycardia are found with large ICH, as well as papilledema and retinal hemorrhages. Subarachnoid hemorrhage patients may have varied symptom onset and severity, but most often present with noted headache, neck meningismus, and possibly retinal hemorrhage. The neurologic exam should also direct the need for further diagnostic tests and therapies. An EKG and CXR are reasonable baseline screening tests to rule out cardiac ischemia or infaract, as well as CHF and a pulmonary source of a metastatic CNS lesion. A contrast CT is useful when the plain brain CT shows a suspected lesion with mass effect or midline shift. Angiography is useful to detect a aneurysm in the setting of SAH. CT or ultrasound testing will detect an AAA, and echocardiography will detect suspected cardiac lesions. Other testing, such as MRI, is not at this time indicated in the acute evaluation of the stroke patient. Emergency therapies for ischemic stroke are limited to aspirin, heparin, and tPA. Hemorrhagic stroke patient therapy is limited to mannitol, decadron, phenytoins, and operative intervention. Nimodipine and operative intervention are the only therapies that should be considered by the Emergency Physician for subarchnoid hemorrhage. The focused neurologic exam also allows for proper documentation of the stroke patient’s clinical status when emergency care was provided. The documentation allows other healthcare providers to determine stroke severity at the time of presentation as well as to establish if the ED therapies were consistent with the patient’s stroke severity. A well documented exam will also allow for the NIHSS to be determined in retrospect, especially when CQI audits are examining the efficacy of tPA use in each institution. The Focused Neurologic Exam in ED CVA Patients There are three components of the focused neurologic exam in the ED: the history, the general physical exam, and the neurologic part of the physical exam. Each of these components are used to develop a provisional stroke syndrome diagnosis, to determine the etiology of the stroke, and to direct emergent diagnostic testing and therapy. View slide
  • Neuro Exam in ED CVA Patients Page 5 of 11 Edward P. Sloan, MD, MPH The history catalogues the symptoms that will usually lead to a provisional stroke syndrome diagnosis even before the physical exam is initiated. The time of symptom onset is also critical when tPA use is contemplated in anterior circulation strokes. Associated symptoms or medical history may assist in determining the etiology of the stroke. The most important components of the general physical exam are the appearance of the patient, the vital signs, and the patient’s mental status. These elements answer for the Emergency Physician the most important clinical question: is this patient stable enough to get a CT scan, or must something be done to treat the ABCs or prevent a stroke complication? Once determined, the general physical exam will detect important findings such as carotid bruits, atrial fibrillation, CHF, meningismus, and the presence of an AAA. The neurologic exam in stroke patients should focus on seven elements: level of consciousness (LOC), cranial nerve (CN) exam, visual exam (including neglect), motor, sensory, cerebellar, and language. LOC should be measured using the AVPU or GCS systems for documentation, since all health care providers can consistently use them. The CN exam should focus on facial motor function and the presence of a gag reflex. The eye exam will detect nystagmus, CN palsies, and papillary findings that may suggest the etiology of the stroke symptoms. Neglect of one part of the visual field confirms the presence of an anterior circulation stroke. The motor exam includes the exam for pronator drift of the upper extremities and dorsi- and plantarflexion of the ankle. In the presence of hemiparesis, neither of these is indicated. The sensory exam only requires the detection of sensory light touch abnormalities in order to confirm the motor findings in a suspected anterior circulation stroke. In posterior circulation stroke, when the prominent symptom may be marked sensory dysfunction with minimal motor paralysis, a more complete sensory exam is indicated. Only rarely is it indicated to detect cerebellar findings are rarely indicated in the presence of clear anterior circulation stroke symptoms. Having the patient attempt to sit on the cart can test truncal ataxia. Otherwise, no cerebellar tests need to be performed. The presence of pathologic reflexes such as clonus and a positive Babinski’s sign suggest the loss of upper motor neuron control of lower motor neuron function. This is evident in the presence of anterior circulation stroke flaccid paralysis, and, as such, does not necessarily add to the Emergency Physician’s ability to confirm a stroke syndrome. Language testing is useful in establishing the location of the stroke syndrome vascular event. Aphasia, sign of abnormal language processing, is more commonly seen in anterior circulation stroke, and dysarthria, a motor dysfunction, is more commonly seen with symptoms such as dysphagia and dizziness in posterior circulation stroke. The NIHSS utilized seven general parts of the neurologic exam to determine stroke severity. These include LOC, CN, motor, sensory, cerebellar, visual, and language. In the NINDS stroke trial, the median NIHSS score in tPA-treated patients was 14, a score that suggests moderate stroke severity. To put this in perspective, the authors of that clinical trial manuscript state in the methods, under outcome measures, “the NIHSS, a serial measure of neurologic deficit, is a 42- point scale that quantifies neurologic deficits in 11 categories. For example, a mild facial paralysis is given a score of 1, and a complete right hemiplegia with aphasia, gaze deviation, visual field deficit, dysarthria, and sensory loss is given a score of 25.”
  • Neuro Exam in ED CVA Patients Page 6 of 11 Edward P. Sloan, MD, MPH Both the neurologic exam and the use of the NIHSS can be facilitated through the use of the internet. Using the Google search engine, the term “neurologic exam” will suggest sites that facilitate the general neurologic exam, some of which specifically address calculation of the NIHSS. Documentation of the ED Neurologic Exam The neurologic exam should be described in terms of what was done, not the conclusion of the testing. For example, do not state “CN II-XII intact”. Instead, document that “cheek, eye, shoulder shrug, and tongue function were tested to be normal”. Also, in documenting the exam of the stroke patient, state clearly the provisional stroke syndrome diagnosis as the neurologic exam is described. For example, state “the L sided weakness and dysphagia are consistent with an anterior circulation stroke”. The neurologic findings should be also framed in terms of the seven areas of the NIHSS. Even if a formal NIHSS cannot be completed, a card that outlines how each of the components is scored will allow for an estimated score to be calculated. This score, if estimated, should be stated to be an estimate only. Finally, all of the general physical findings that support an etiology should be listed as pertinent positives and negatives in the documented patient physical exam. Conclusions When treating the ED stroke patient, the Emergency Physician should develop a provisional stroke syndrome diagnosis, use the focused neurologic exam to support this diagnosis, and attempt to establish the suspected etiology of the stroke. In addition, the exam should direct further diagnostic testing and required ED therapies. Finally, the ED documentation must support the diagnosis and therapies provided in the ED, as well as allow for CQI audits to retrospectively determine stroke severity using the NIHSS, especially when tPA use is considered.
  • Neuro Exam in ED CVA Patients Page 7 of 11 Edward P. Sloan, MD, MPH Completing the Neurologic Exam in Emergency Dept CVA Patients Emergency Department Management and Case Outcome The patient’s CT scan of the head showed no low-density areas or ICH. There were no clear contraindications for the use of tPA. The NIHSS was approximately 20. Consultation with a neurologist cleared the use of tPA. No family was present to defer the use of tPA and tPA was administered without complication. The administration of tPA occurred at approximately 8:20 PM, about 1 hour and 45 minutes after the onset of the stroke symptoms. An initial bolus of 5 mg was given slow IV push over two minutes, followed by an infusion of 40 mg over 1 hour. Upon re-exam at 90 minutes, the patient had some increased speech and the use of her right arm, and the amount of mouth droop and visual neglect was decreased. The repeat NIHSS score at that time was approximately 14-16. In the hospital, the patient had no ICH and had improved neurologic function. At the time of hospital discharge, the patient had near complete use of her right upper extremities, speech and vision were improved and there was some residual gait difficulties based on right lower extremity weakness. At disposition from the hospital, the patient went to a rehabilitation hospital.
  • Neuro Exam in ED CVA Patients Page 8 of 11 Edward P. Sloan, MD, MPH Completing the Neurologic Exam in Emergency Dept CVA Patients Annotated Bibliography 1. NINDS Study. N Engl J Med 1995; 333:1581-1587 This is the landmark study that examined the effectiveness of tPA in acute ischemic stroke. Patients who received tPA within 180 minutes of symptom onset had a better three month outcome than did those treated with standard therapy. Symptomatic ICH at 36 hours was 10x greater in patients treated with tPA (6.4 vs. 0.6%). Mortality was similar at three months. This article is a must read for all EM physicians. 2. Sturmann K, The Neurologic Examination, in Jagoda A (ed) Neurologic Emergencies: Emergency Medicine Clinics of North America, WB Saunders, Philidelphia, 1997. This chapter outlines how exactly to conduct parts of the neurologic examination. A good “how to” book for the actual examination steps. 3. Orebaugh S: Strokes and TIAs, in Hamilton, GC (ed) Presenting Signs and Symptoms in the Emergency Department: Evaluation and Treatment, Williams and Wilkens, Baltimore, 1993. This chapter includes many tables that allow for different stroke syndromes to be distinguished one from another. It also provides a good overview on how to treat TIA patients using a clinical pathway. 4. The Nervous System, in Bates B, A Guide to Physical Examination, 2nd ed, JB Lipincott Co, Philidelphia, 1979. This is the standard text for how to complete the physical exam. It is now available in a “small book” format over the internet. 5. Mikel HS, The Neurologic Examination in the Emergency Setting and Gott PA, Barsan WG, Stroke, TIA, and Other Central Focal Conditions, in Tintinalli JE (ed) Emergency Medicine: A Comprehensive Study Guide, McGraw Hill, New York, 2000. These chapters, from the EM study guide, provide an excellent overview of both the neurologic exam and the entities of stroke and TIA.
  • Neuro Exam in ED CVA Patients Page 9 of 11 Edward P. Sloan, MD, MPH 6. Scott TP, The Neurologic Examination, and Frankel MR and Chimowitz M, Cerebrovascular Disease, in Shah SM (ed) Emergency Neurology: Principles and Practice, Cambridge University Press, New York, 1999. These chapters, like those from the study guide, address both the neurologic exam and stroke as they apply to the Emergency Physician. This is a good textbook that is written for emergency healthcare providers. 7. These websites address the NIHSS. The first two address the components in detail. The third allows it to be calculated on-line. 8. These websites address the issue of the neurologic exam, and are a good online reference.
  • Neuro Exam in ED CVA Patients Page 10 of 11 Edward P. Sloan, MD, MPH Completing the Neurologic Exam in Emergency Dept CVA Patients Questions 1. All are true statements about the rationale for a focused neurologic exam except: a. Most stroke patients have a group of symptoms that suggest a stroke syndrome. b. A complete neuro exam is useful when symptoms are vague, non-persistent, or confusing. c. The focused neuro exam should guide further diagnostic testing, ED therapies, and disposition. d. Upon completion of the neuro exam, the ED physician must know if an ICH is present. e. A focused neurologic exam should suggest the etiology of the stroke. 2. Items in the differential diagnosis of stoke include all of the following except: a. Hypetensive encephalopathy, hypoglycemia b. Subdural and epidural hematoma c. Acute myocardial infarction. d. Status epilepticus and Todd’s paralysis. e. Meningitis, encephalitis, brain abcess. 3. Anterior stroke syndrome includes all of the following except: a. Ataxia and hemiballism. b. Motor and sensory symptoms on the same side of the body as the CN findings. c. Symptoms that are contralateral to the side of the CVA. d. Visual field deficits and gaze abnormalities. e. Aphasia. 4. A thrombotic etiology of the CVA is suggested by all of the except: a. Posterior ciruculation stroke. b. Sudden symptom onset. c. Extremity atherosclerosis suggested by diminished pulses. d. Abdominal aortic aneurysm on abdominal exam. e. Left ventricular heave suggesting LVH on cardiac exam. 5. All are true of the NIHSS in acute stroke except: a. The higher the NIHSS, the more severe is the stroke. b. Patients with NIHSS scores above 15-20 are considered more severe stroke patients. c. The NIHSS 7 include CN, motor, sensory, cerebellar, visual, LOC and reflexes. d. The median stroke scale score in the NINDS tPA clinical trial was 14. e. The NIHSS can be calculated by going to
  • Neuro Exam in ED CVA Patients Page 11 of 11 Edward P. Sloan, MD, MPH Completing the Neurologic Exam in Emergency Dept CVA Patients Answers 1. Answer d. It is not necessary for the EM physician to know whether or not an intracranial hemorrhage (ICH) is present in stroke patients based solely on the neurologic exam. In all stroke patients, the head CT will ultimately confirm whether or not an ICH is present. 2. Answer c. Atlhtough AMI is a possible etiology of an acute CVA, it is not part of the differential of symptoms that suggest a CVA. 3. Answer a. Ataxia and hemiballism are more commonly seen in posterior circulation strokes. 4. Answer b. Sudden symptom onset suggests an anterior CVA and an embolic event. 5. Answer c. The NIHSS 7 do not include reflexes. The missing item in answer c is language. Edward P. Sloan, MD, MPH