Concussion (Uncomplicated)

Patient with h/o concussion presents s/p direct head injury. Reports headache, nausea, dizziness/balance disturbances, sleep disturbances, disorientation, difficulty concentrating, anxiety/irritability following injury and during past 72 hours. No LOC, amnesia, vomiting, convulsions. Oriented to date/time. No c-spine tenderness. Balance deficits noted; neurologic exam otherwise intact. Immediate word memory for 5 words over three trials. Able to recite numbers and months in reverse.

• Perform MRI if symptoms continue for > 10 days or any of the following develop:

  • LOC/decreased responsiveness

  • Vomiting

  • Seizure

  • Focal neurologic deficit

  • Decline in current condition

• Remove from play with 6-day graded return pending resolution of symptoms

• Pt counseled about risk of chronic traumatic encephalopathy with repeat concussions

Notes

• Pediatric Emergency Care Applied Research Network (PECARN) Rules

  • Rule out clinically important traumatic brain injuries (100% sensitive)

  • Pending risk factors, may allow clinician to forgo CT (see calculator)

  • Outperform CHALICE and CATCH decision aids

Migraine

Pt with h/o headache episodes lasting 4-72 hours presents with unilateral pulsatile/pounding headache accompanied by N/V, photophobia, phonophobia, aura. Headaches occur 4 or more times per month, are disabling, and adversely affect quality of life. No h/o glaucoma, liver disease, kidney stones; denies currently being pregnant. Medications include oral contraceptives. No focal deficits on neurological exam.

• PRN abortive therapy (select one of the following):

  • Acetaminophen/aspirin/caffeine 250/250/65 mg (Excedrin Migraine) 2 tablets q6 hours; maximum daily dose 8 tablets per day

  • Ibuprofen 600 mg q6 hours; maximum daily dose 2.4 g/day

  • Sumatriptan (Imitrex) 50 mg q2 hours; maximum daily dose 200 mg/day

  • Consider Dihydroergotamine intranasal for refractory symptoms

    • One spray (0.5 mg) in each nostril, repeat once after 15 minutes

    • Do not to exceed 4 sprays per attack, 6 sprays per day, 8 sprays per week

• Four or more headaches per month that adversely affecting quality of life: Start prophylactic therapy with one of the following (listed most efficacious to least)

  • Depakote 250 mg BID; maximum daily dose 1 g/day

  • Topamax 25 mg qd; maximum daily dose 50 mg BID

  • Propranolol ER 80 mg qd; maximum daily dose 160 mg qd

  • Amitriptyline 25 mg qhs; maximum recommended dose 50 mg qhs due to risk for adverse effects at higher doses

• Counseling

  • Pt encouraged to keep a headache diary with attention paid to potential triggers

  • Pt counseled that successful treatment is defined as 50% reduction in headaches

  • Pt counseled that prophylactic agents must be trialed for a minimum of 6 months before switching to another medication

  • Pt advised to seek emergency treatment if headache acutely worsens and/or if neurological deficits develop

Notes

• Etiology

  • More common in women (3:1 ratio)

  • Oral contraceptives may precipitate migraine headaches

• Common migraine triggers include

  • Schedule changes (sleep disturbances, missed meals)

  • Foods and beverages (alcohol, caffeine, artificial sweeteners, chocolate, soft cheese)

  • Environmental factors (light, odors, smoke, weather changes)

• POUND mnemonic for migraine:

  • Pulsatile quality (headache described as pounding or throbbing)

  • One-day duration (episode may last 4-72 hours if untreated)

  • Unilateral in location

  • Nausea or vomiting

  • Disabling intensity (altered usual daily activities during headache episode)

• Prophylactic agents

  • Effective in adults, but not children

  • Start at lowest effect dose and titrate every 2-4 weeks

  • Require 6 to 12 months to reach maximum effect

  • Contraindications

    • Depakote and Topamax: Liver disease, current pregnancy

    • Topamax: Glaucoma, kidney stones

Hemiplegic (Complex) Migraine

Pt with family h/o hemiplegic migraine presents with second occurrence of unilateral headache with aura associated with weakness. Pt reports transient visual field defect, numbness, paresthesia, weakness; all symptoms lasted between 5 to 60 minutes. Witnesses report transient aphasia, seizure-like activity. Afebrile with unilateral motor weakness on exam with ABCD2 score ≤ 3.

• Obtain FS, BMP, CBC, PT/PTT/INR

• Consider UDS, RPR

• Obtain EKG, CT head/neck

• Consider MRI within 24 hr, carotid doppler within 1 week

• Treatment

  • Consider neurology consult

  • Start verapamil 240 mg qd in 3 divided doses

  • Refractory symptoms: Consider starting lamotrigine 25 mg qd and titrating to 100 mg qd

• Pt advised that common migraine treatments (e.g. beta-blockers, triptans, ergotamines) should be avoided

Notes

• Rare disorder

• Diagnosis

  • Two attacks must occur before formal diagnosis

  • Aura must be accompanied by fully reversible motor weakness, visual symptoms, sensory symptoms, or speech deficits

  • At least two of the following must occur

    • Unilateral aura symptom

    • Aura symptoms followed by headache within 60 minutes

    • Two or more symptoms in succession with at least one aura symptom spreading gradually over 5 minutes

    • Symptoms last longer than 5 minutes but do not persist for greater than 1 hour for aura symptoms and 72 hours for motor symptoms

• Beta-blockers, triptans, and ergotamines may predispose pt to prolonged aura or ischemia

Viral Meningitis

Pt with h/o cold sores, genital herpes presents in August with H/A, neck stiffness, AMS x 48 hours. Reports irritability, lethargy, nausea, decreased appetite. Ill-appearing with fever, herpetic facial/genital lesion, multiple mosquito bites, positive Kernig/Brudzinski tests on exam.

• Pt < 19 y/o with bacterial meningitis score ≤ 2

• Obtain CBC, blood cx, CMP, TSH, RPR, B12, urine drug screen

• Obtain CSF

  • Immunosuppression, recent seizure, bradycardia, and/or AMS/neurologic deficit: Obtain head CT, start empiric antibiotics and dexamethasone prior to lumbar puncture

  • No contraindication to lumbar puncture: Perform procedure and start antibiotics, dexamethasone s/p CSF collection

• Treatment

  • See bacterial meningitis for prophylactic antibiotic and dexamethasone dosing

  • CSF with < 100 WBCs, < 50% neutrophils, protein < 20 g/L, normal glucose: Stop empiric antibiotics

  • CSF positive for > 1:700 WBC:RBC ratio and HSV on PCR: Start acyclovir 10 mg/kg q8h

  • Provide supportive care

Notes

• Etiology

  • Most commonly caused by enterovirus (51% of all US meningitis cases)

  • Most enterovirus cases occur between June and October with peak season in August

  • HSV accounts for 8% of all US meningitis cases

• Aseptic meningitis

  • Meningitis not caused by bacteria/fungi (i.e. culture negative)

  • Includes meningitis due to viruses, medications, etc.

• Time from symptom onset to hospital presentation averages 48 hours vs. 24 for bacterial meningitis

• Normal CSF glucose = serum glucose*0.67

Bacterial Meningitis

Pt with no h/o HiB/meningococcal/pneumococcal vaccination presents with H/A, neck stiffness, AMS x 24 hours. Reports irritability, lethargy, nausea, decreased appetite. Ill-appearing with fever, rash, and positive Kernig/Brudzinski tests on exam.

• Pt < 19 y/o with bacterial meningitis score ≥ 2

• Obtain CBC, blood cx, CMP, TSH, RPR, B12, urine drug screen

• CSF with WBCs > 500/hpf, neutrophils > 80%, protein > 50 g/L, glucose < 40 mg/dL, and PCR negative for HSV

  • Immunosuppression, recent seizure, bradycardia, and/or AMS/neurologic deficit: Obtain head CT, start empiric antibiotics and dexamethasone prior to lumbar puncture

  • No contraindication to lumbar puncture: Perform procedure and start antibiotics, dexamethasone s/p CSF collection

• Treatment

  • > 6 weeks old: Administer dexamethasone 0.5 mg/kg/day divided into four daily doses; discontinue if no H. influenza or S. pneumoniae on CSF culture

  • > 1 month old: Add CTX 1g q24h and vancomycin 15 mg/kg/dose q6h with trough goal 15-20

  • > 50 y/o: Add ampicillin 200 mg/kg/day divided every 4 hours to vancomycin/CTX for L. monocytogenes coverage

• Counseling

  • Family counseled that condition carries 15% mortality risk

  • Family advised that dexamethasone may reduce risk of hearing loss, mortality

  • Family counseled that close contact PPX will be necessary if H. influenzae, N. meningitidis, or S. pneumoniae present in CSF

  • F/u s/p discharge and administer HiB/meningococcal/pneumococcal vaccines

Notes

• Bacterial meningitis accounts for 14% of all US meningitis cases

  • N. meningitidis is more common in adolescents while S. pneumo is more common in adults

  • Healthy patients age 16-23 y/o should receive meningococcal vaccination

• Time from symptom onset to hospital presentation averages 24 hours vs. 48 for viral meningitis

• Normal CSF glucose = serum glucose*0.67

• Adjust antibiotic coverage and duration of therapy based on culture results

Focal Seizure

Patient with h/o epilepsy presents with acute onset shaking/jerking. Event lasted < 3 minutes and preceded by visual distortion, perception of flashing lights, unilateral extremity numbness/tingling; symptoms s/p event include H/A. Witnesses describe shaking/jerking that proceeded distally to caudally along affected extremity. Patient displayed facial grimacing, chewing/lip smacking, word repetition during even. Confusion, unilateral weakness on exam.

• Obtain FS glucose, CBC, CMP, magnesium/phosphorus level, U/A, urine drug screen

• Imaging

  • New onset seizure: Obtain MRI to evaluate for structural lesion, ischemic stroke

  • Obtain EEG to evaluate for interictal spikes

  • Consider video-EEG monitoring

• Treatment

  • Correct any underlying metabolic derangements

  • If seizure does not remit within 5 minutes, initiate status epilepticus protocol

  • Continue current seizure prophylaxis

  • Consult neurology

• Counseling

  • Pt counseled about driving restrictions, seizure precautions

  • Pt advised to keep a seizure calendar including seizure events and potential provoking factors

Notes

• Jacksonian march classically described as numbness/tingling in face, hand, or foot followed by jerking in affected extremity of face

• Todd paralysis: Unilateral paralysis following unilateral focal motor seizure

• Evaluation for interictal spikes has poor sensitivity

Generalized Seizure

Pt with h/o hyperthyroidism, DM, traumatic brain injury, alcohol/benzodiazepine abuse and recent meningitis/encephalitis presents with acute loss of consciousness preceded by a screaming/choking sound. Bystanders report initial arm stiffening/cyanosis followed by jerking/switching, frothy sputum production, urinary incontinence. Event lasted < 5 minutes and followed by confusion, suppressed awareness. Fever, confusion, weakness on exam.

• Labs

  • Obtain fingerstick glucose, CBC, CMP, magnesium/phosphorus level, urinalysis, urine drug screen

  • Consider lumbar puncture to r/o infection

• Imaging

  • Obtain head CT to r/o intracranial hemorrhage, evaluate for intracranial lesions

  • Obtain MRI to r/o ischemic stroke

  • Consider video-EEG monitoring

• Treatment

  • Correct any underlying metabolic derangements

  • If seizure does not remit within 5 minutes, initiate status epilepticus protocol

  • Consult neurology

• Seizure Prophylaxis

  • First provoked seizure: No seizure prophylaxis indicated

  • Repeat provoked seizure or first unprovoked seizure: Discuss risks and benefits of seizure prophylaxis

  • Repeat unprovoked seizure: Start seizure prophylaxis per neurology recommendations

• Counseling

  • Pt counseled about driving restrictions, seizure precautions

  • Pt advised that 33% of adults with an unprovoked seizure will have recurrent seizure within 5 years

  • Pt advised to keep a seizure calendar including seizure events and potential provoking factors

Notes

• Seizures may be precipitated by metabolic disturbances, e.g. hypoglycemia, hyperglycemia, hyponatremia, hypomagnesemia, hypocalcemia, hyperthyroidism, uremia, withdrawal, acute intoxication

• Driving restrictions may vary by state or province

Status Epilepticus

Pt with h/o generalized convulsive seizures presents actively seizing. Witnesses report 2 seizure episodes without complete recovery of consciousness in between. Current seizing episode has lasted longer than 5 minutes. Bilateral tonic stiffening with unilateral, rhythmic muscle jerking on exam.

• Initial action

  • Obtain vital signs

  • Respiratory compromise: Initiate oxygen +/- mechanical ventilation

  • Start continuous cardiac monitoring with pulse oximetry

  • Establish two IV catheters

  • Obtain fingerstick glucose, CBC, CMP, magnesium/phosphorus level, U/A, urine drug screen

• Initiate treatment

  • Correct metabolic abnormalities

  • In first IV line: Administer lorazepam 2mg IV q1 minute while blood pressure remains >90/>60

  • In second IV line

    • Administer fosphenytoin 20 mg PE/kg at 100mg PE/min

    • Repeat dose 5 mg PE/kg at 100 PE/min if seizure continues

• Refractory status epilepticus

  • Midazolam 0.2mg/kg IV bolus at 2mg/min followed by 0.1mg/kg/hr infusion; titrate infusion until seizures stop (max 3 mg/kg/hour)

  • If seizure continues s/p 1 hour midazolam treatment, start propofol

  • If seizure continues s/p 1 hour propofol, start phenobarbital

• Patient's family counseled that status epilepticus may lead to alteration of neuronal networks and/or neuronal injury/death

Note: Patients in focal motor status epilepticus may present without impaired consciousness

Stroke

Transient Ischemic Attack (TIA)

Pt with h/o cigarette smoking, DM, HLD and previous TIA presents with sudden onset focal neurologic deficit. Reports monocular blindness, difficulty speaking, unilateral weakness/paresthesias, dizziness. Denies LOC, memory loss, headache, blurry vision, convulsions, bladder/bowel dysfunction. Speech disturbance, facial droop, unilateral weakness, unilateral dysmetria with FTN/heel-to-shin reported on initial exam. HTN, carotid bruit, arrhythmia on repeat exam; initial neurologic findings resolving.

• Initial evaluation

  • Low suspicion for seizure, migraine, metabolic disturbance, syncope

  • Event occurred < 72 hours ago with ABCD2 score 4 or greater; admit for observation and telemetry

• Labs

  • Fingerstick glucose, BMP WNL

  • Obtain CBC, PT/PTT/INR, lipid panel; consider UDS, RPR

• Imaging

  • EKG showing atrial-fibrillation; obtain f/u cardiac echo

  • Stat CT to evaluate for intracranial hemorrhage

  • MRI within 24 h of symptom onset to evaluate for infarction

  • Carotid doppler or CT angio recommended within 1 week

• Treatment

  • Obtain neurology consult

  • Maintain BP goals and administer IV labetalol 20 mg for HTN

    • TPA administered: 140/90 < BP < 180/110

    • No tPA: 140/90 < BP < 220/120

  • Start aspirin 81 mg qd, atorvastatin 80 mg qd

  • F/u s/p discharge to address DM type 2 (goal HbA1c < 7%) and HTN

• Pt advised to stop smoking, start exercising, adhere to Mediterranean diet

Ischemic Stroke

Pt with h/o HTN, AFib, symptomatic CAD, sickle cell disease, DM, physical inactivity, and smoking awoke with focal neurological deficit. Reports acute vertigo lasting > 1 hour, H/A, N/V. Denies LOC, convulsions. No h/o coagulopathy. Speech disturbance, facial droop, and unilateral weakness on exam.

• Labs

  • Fingerstick glucose, whole blood glucose WNL

  • Obtain SPO2, CMP, CBC, troponins, PT/PTT/INR, UDS

• Imaging

  • EKG shows atrial fibrillation

  • Head CT negative for acute intracranial hemorrhage

  • Obtain MRI or head/neck CT angio within 24 hours

  • Concern for acute vestibular syndrome and/or posterior infarction: Obtain f/u MRI in 3-7 days if initial imaging is negative

• Treatment

  • Consider tPA if symptom onset prior to arrival <

    • 4.5 hr with suspicion for small vessel disease

    • 16 hr with suspicion for large vessel occlusion

  • Initiate mechanical thrombectomy for pt meeting the following criteria:

    • Suspected internal carotid artery/proximal MCA occlusion

    • Symptom onset within 6 hours

    • Age ≥ 18 years

    • NIHSS score ≥ 7

  • Maintain BP goals and administer IV labetalol 20 mg for HTN

    • TPA administered: 140/90 < BP < 180/110

    • No tPA: 140/90 < BP < 220/120

  • Start aspirin 24h s/p tPA

  • Neurology consult

• Counseling

  • Pt and family educated about stroke symptoms and need for urgent evaluation

  • Pt counseled to exercise regularly, decrease sweetened beverage consumption, and follow the Mediterranean diet

Hemorrhagic Stroke

• Coming soon!

Notes

• Ischemic stroke: 80-85% of all strokes

  • Thrombotic: 50% of ischemic stroke

  • Embolic

    • 30% of ischemic stroke (e.g. due to atrial fibrillation)

    • NNT warfarin to reduce 1 stroke over 1 year = 30 patients

• Antiplatelet therapy

  • Aspirin is the only antiplatelet agent shown to be effective in treatment of early acute ischemic stroke

  • Dual antiplatelet therapy (aspirin + Plavix) is only recommended for up to 90 days s/p stroke

• Permissive hypertension

  • < 72 hours s/p stroke, goals apply to patients without comorbid conditions, e.g. acute MI, acute HF, aortic dissection

  • ≥ 72 hours s/p stroke in patients with stable neurologic condition, goal BP returns to <140/<90

• 2018 American Stroke Association Early Ischemic Stroke Management Guidelines

ABCD Score for Transient Ischemic Attack

• Age ≥ 60 years (1)

• Blood pressure: systolic ≥ 140 mm Hg or diastolic ≥ 90 mm Hg (1)

• Clinical presentation

  • Unilateral weakness (2)

  • Speech impairment without weakness (1)

  • History of diabetes mellitus (1)

• Duration of symptoms

  • ≥ 60 minutes (2)

  • < 60 minutes (1)

If event occurred <72 hours ago and score is 4 or greater, admit for observation and telemetry

Cervical Radiculopathy

Patient age 52 years presents with neck pain associated with upper extremity paresthesia and weakness. Neck spasm/pain is worse with lateral neck movement and radiates to the posterior shoulder and upper extremities. Denies recent neck trauma, fever, urinary urgency. Denies history of IV drug use, immunocompromised state, malignancy. Diminished triceps reflex and positive Spurling test, upper limb tension test on exam. No skin changes, ataxia, clonus, hyperreflexia, Hoffman’s sign noted.

• Fever or other concern for spinal abscess: Obtain CBC, blood cultures, ESR, CRP and consult spinal surgery

• Cervical radiculopathy suspected, but cannot rule out peripheral neuropathy: Refer for electromyography (EMG)

• Conservative management

  • Start naproxen 500 mg BID

  • Consider cyclobenzaprine (Flexeril) immediate release 5 mg TID PRN

  • Consider methylprednisolone dose pack (21 x 4 mg tablets): 24 mg day 1, 20 mg day 2, 16 mg day 3, 12 mg day 4, 8 mg day 5, and 4 mg day 6

  • Refer for physical therapy

  • Recommend massage

• Pt counseled that most cases resolve spontaneously without treatment

Refractory pain: No improvement after 6 weeks conservative management

• Obtain cervical spine x-ray

• Progressive neurologic deficit or concern for alternate diagnosis:

  • Obtain MRI

  • Refer to orthopedic (spine) surgery for evaluation and discussion of epidural steroid injections and/or alternative surgical intervention

Notes

• Most common etiology: Cervical spine degenerative disease (e.g. disc degeneration) → nerve root compression

  • Pain/numbness may radiate to one or both upper extremities

  • Evaluate dermatomal distribution on exam

• Red flags

  • Trauma: History of neck injury

  • Infection (abscess): Fever, IV drug use, immunocompromised state

  • Malignancy: Spinal tumors, osteochondromas may present with fever and symptoms may be exacerbated with Valsalva maneuver (obtain MRI)

  • Myelopathy: Urinary urgency and/or ataxia, clonus, hyperreflexia on exam

• Additional differential considerations (distal to proximal):

  • Peripheral neuropathy: Paresthesias, weakness limited to distal extremities (EMG)

    • Carpal tunnel syndrome: Thenar weakness, radial numbness

    • Cubital tunnel syndrome: Grip weakness, ulnar numbness

    • Interosseous nerve entrapment: Pain, extensor weakness

  • Rotator cuff tendinosis: Shoulder pain with radiation to arm (U/S, EMG)

  • Arteriovenous malformation: Variable pain/weakness, skin changes (U/S, EMG)

• Do not obtain nerve conduction studies without also performing needle EMG to evaluate for pinched nerve in neck/back

Multiple Sclerosis

Young adult presents with acute onset weakness. Reports associated fatigue, weakness, dizziness, changes in vision, discoordination/gait disturbances, and paresthesias. Experienced a similar event previously that resolved spontaneously. Denies h/o seizures, aphasia. Nystagmus, red color desaturation, Lhermitte sign, decreased strength, decreased sensation, spasticity, and gait disturbance noted on exam.

• Labs

  • Obtain CBC, ESR, ANA, vitamin B12 level, RPR

  • Consider obtaining HIV test, Lyme titre, ACE level

  • CSF analysis shows IgG oligoclonal bands

• MRI shows periventricular white matter lesions including Dawson’s fingers

• Treatment: Refer to neurology

  • Start methylprednisolone 1000 mg qd x5 days; no oral taper necessary

  • Start glatiramer 20 mg subcutaneous injection daily

  • Spasticity and/or neuropathic pain: Start baclofen 5 mg TID and increase by 5 mg per dose q3 days; max daily dose 80 mg

• Counseling

  • Pt counseled that fatigue, spasticity, neurogenic bladder, and/or sexual dysfunction may develop and/or worsen as the condition progresses

  • Pt counseled that family members may wish to start 25-hydroxyvitamin D supplementation to decrease risk

Notes

• Most common permanently disabling CNS disorder in young adults

• More common at higher latitudes

• Diagnosis requires two neurologic deficits separated in time and space

  • Lhermitte sign: Neck flexion produces electrical sensation that radiates down spine

  • ACE level is used to r/o sarcoidosis

  • Oligoclonal IgG bands is suggestive, but not diagnostic

  • Dawson’s fingers: White matter lesions that radiate from the lateral ventricles into the corpus callosum

• DMARDs

  • Should be started shortly after diagnosis and reduce disease progression

  • There are multiple options; glatiramer and its dosing is given as one example

Fibromyalgia

Pt with h/o IBS, PTSD, depression presents with chronic pain, fatigue, and sleep disturbances. Pt reports diffuse muscle pain/tenderness and difficulty concentrating that is affecting her quality of life. Muscle tenderness, joint stiffness on exam.

• Evaluate symptoms per American College of Rheumatology 2010 Diagnostic Criteria

• Obtain CBC, TSH

• Consider ESR, CRP, rheumatoid factor to r/o connective tissue disorder

• Treatment

  • Start CBT

  • Medication for pain, sleep disturbance, fatigue (choose one of the following)

    • Amitriptyline 25 mg qhs

    • Duloxetine 30 mg daily x1 week, then increase to 60 mg daily

    • Milnacipran: 12.5 mg on day 1, 12.5 mg bid on days 2-3, 25 mg bid on days 4-7, then 50 mg bid

  • Additional agents

    • Cyclobenzaprine (Flexeril) 15 mg daily for pain, sleep quality

    • Pregabalin (Lyrica) 75 mg BID for pain

  • Consider alternative therapies, i.e. massage, hydrotherapy, acupuncture

  • Consider rheumatology consult

• Counseling

  • Pt advised to engage in aerobic exercise for 30 min 3x per week

  • Pt counseled realistic expectations for pain control

  • Pt counseled about sleep hygiene

  • Pt encouraged to keep symptom diary

  • Close follow-up; schedule appointment in 4 weeks

Notes

• 30% of fibromyalgia patients have irritable bowel syndrome

• 45% of fibromyalgia patients meet PTSD criteria

• Tender point site testing is no longer used in diagnosis

• Do not test for Lyme in the absence of appropriate history and exam findings

• Write non-pharmacologic therapies as prescriptions

• NNTs for commonly used medications: Amitriptyline (4), duloxetine (9), milnacipran (11) 

Anterior Cutaneous Nerve Entrapment Syndrome

F pt with h/o abdominal surgery presents with chronic pain localized to lateral abdominal wall. Pain worse when lying on affected side, changing position, or with increased abdominal muscle tension (e.g. during cough/sneeze); not exacerbated by bowel movements, stress. Denies fever, chills, anorexia, unintended weight loss, change in bowel habits, diarrhea, dark/tarry stools, BRBPR, polyuria, dysuria, vaginal discharge/AUB. No h/o DM. Tenderness is superficial and located near lateral border of rectus abdominis; positive Carnett test on exam.

• Obtain U/S at site of maximum tenderness

• Administer 5 mL lidocaine 2% local injection at site of maximal tenderness; resultant pain reduction of 50% or greater confirms diagnosis

• Treat with 10 mg triamcinolone/1 mL lidocaine 2% trigger point injection; refer for surgical neurectomy if >2 injections required

Notes

• Etiology

  • Often initially misdiagnosed with functional abdominal pain or IBS

  • Rule out injury, surgery and DM as potential causes

• Patients generally able to localize pain location with one finger

• Carnett test: Abdominal pain worse with abdominal muscle tension

Alcohol Withdrawal Syndrome

Pt with h/o chronic alcohol abuse presents s/p alcohol cessation. Reports insomnia, anxiety/agitation, H/A, photophobia, palpitations, N/V, decreased appetite, pins/needles sensation in extremities. H/o seizures, DT during previous withdrawal episodes; not currently pregnant. Alert by not oriented with tachycardia, sweating, hand tremor on exam.

• Monitor for

  • Hallucinations at 12 to 24 hours

  • Generalized tonic-clonic seizures at 24 to 48 hours

  • Delirium tremens at 48 to 72 hours

• Labs

  • EtOH 0.00 at admission

  • Obtain CMP, Mg level

• Clinical Institute Withdrawal Assessment (CIWA) for Alcohol

  • Evaluate q4-8h until scoring < 10 x 24h, then evaluate CIWA score PRN

  • No h/o cirrhosis, normal CMP: Chlordiazepoxide (Librium) 50-100 mg for CIWA > 8

  • Elderly and/or h/o cirrhosis: Lorazepam (Ativan) 2-4 mg for CIWA > 8

• Treatment

  • Dehydration with electrolyte abnormality on CMP: Administer 100 mg thiamine IV and start IV NS

  • Start standing thiamine 100 mg qd, multivitamin

  • Hypomagnesemia: Replete with magnesium sulfate

  • H/o CAD with persistent tachycardia: Metoprolol succinate 25 mg qd

  • Active hallucinations with no h/o seizure, QT prolongations: Haloperidol 2.5 mg IV loading dose followed by 0.5-2 mg/hr IV

• Disposition

  • Start naltrexone 50 mg qd vs. topiramate (see below) at discharge for continued abstinence

  • Concern for kindling phenomenon

    • Pt and family counseled that h/o recurrent detoxifications may increase alcohol cravings and withdrawal symptoms

    • Consider discharge with topiramate 25mg qd followed by titration to 150 mg BID as outpatient to promote continued abstinence

  • Discharge to outpatient vs. inpatient rehabilitation program

Opioid Withdrawal Syndrome

Pt with h/o opioid abuse presents with acute on chronic anxiety, drug craving, and fear of withdrawal. Reports dysphoria, restlessness, insomnia, chills, myalgias, abdominal cramping, diarrhea. Tachycardia, HTN, dilated pupils, lacrimation, rinorrhea, yawning, N/V, diaphoresis, piloerection on exam. Naloxone administered in ED.

• Obtain CBC, BMP, urine drug screen

• Medications

  • Clonidine 0.1 mg PO QID x 4 days provided BP > 90/60

  • Trazadone 100 mg QHS x 4 days and then PRN for insomnia

  • Phenobarbitoal 30-60 mg BID as needed for anxiety/sedation

  • Gastrointestinal

    • Prochlorperazine 5-10 mg q4h PRN for N/V

    • Loperimide 4 mg q6h PRN for diarrhea

  • Pain

    • Acetminophen 650 mg q4h PRN

    • Naproxen 500mg BID PRN for myalgias

  • Hydroxyzine 50 mg TID PRN for anxiety/dysphoria, lacrimation, rinorrhea

• Reassess COWS every 4 to 24 hours pending symptoms severity

• Observe for 72 hours; monitor for suicidality

• At discharge, start methadone 10mg TID for 3-4 days

  • Taper by 10 mg/day

  • Administer 5 mg x 1 on the final day of treatment

• Monitor for relapse due to loss of opioid tolerance after 3-7 days

Notes

• Physical withdrawal symptoms generally last 5-10 days

• Methadone withdrawal occurs later than other opioids and lasts longer (2-3 weeks) due to its longer half-life

• Psychological withdrawal symptoms may last weeks to months

Serotonin Syndrome

Pt with h/o depression, seizure disorder, bipolar disorder polysubstance abuse presents with sudden onset agitation s/p suicide attempt with SSRI. Reports concomitant onset of xerostomia, palpitations, diarrhea. Recently started SSRI, SNRI, tricyclic antidepressant, and sumatriptan. Additional medications include carbamazepine, valproic acid, lithium, cyclobenzaprine, Zofran, dextromethorphan. Hypertension, tachycardia, fever pupillary dilation, ocular clonus, diaphoresis, tremor, hyperreflexia, clonus on exam.

• Obtain CBC, CMP, creatinine kinase, PT/PTT/INR, urine drug screen

• Consider lumbar puncture

• Obtain EKG, CXR, head CT

• Treatment

  • Discontinue all serotonergic medications; do not start fentanyl

  • Administer 1L saline bolus

  • Administer lorazepam 2 mg IV and evaluate response

  • Start cyproheptadine 12 mg loading dose and then 4 mg q2h PRN for symptom control

• T > 41.1C and/or CK > 10,000:

  • Administer vecuronium 0.1 mg/kg and intubate

  • Continue vecuronium 1.2 mcg/kg/min for 24 hours

Notes

• Medications prescribed for seizure and bipolar disorders may be serotonergic. However, seizure and bipolar disorders do not inherently increase risk for serotonin syndrome.

• MDMA and PCP intoxication can mimic serotonin syndrome

• Symptoms typically resolve within 24 hours