By: Jeffrey Rixe, MD

One Minute Neuro Exam of the Hand

Median Nerve (OK)
-Sensory: test 2nd digit light touch
-Motor: thenar muscles, thumb pincer grasp, form the “OK” sign
-Injury: supracondylar fracture, laceration near flexor retinaculum, carpal tunnel syndrome

Radial Nerve (Thumbs UP)
-Sensation:  dorsum of the hand between digits 1-2
-Motor: thumbs up sign
-Injury: humeral shaft fracture, shoulder dislocation (Sx: wrist drop)

Ulnar Nerve (Crossed Fingers)
-Sensory: test lateral aspect of 5th digit
-Motor:  test, cross fingers (or peace sign)
-Injury: medial epicondyle fracture, laceration to medial wrist

Two Point Discrimination
-Testing on the digit pads with paper clip (radial or ulnar border)
-Normal spread: 5mm, compare both side

 

Iron Deficiency Anemia : Considering IV Iron…
https://emergencymedicinecases.com/iv-iron-for-anemia-in-emergency-medicine/
-Low Hgb, Low MCV (<85), ferritin <30
-Tx: Once per day PO iron (300mg QHS), Iron Sucrose  (IV) ~$150
-WOMB Trial: RCT with post partum anemia patients, transfusion vs IV iron. No difference in primary outcome (hgb recovery at 6 wk)
-Possible IV Iron Indications in Stable Patients: Hgb <9, ACD, Iron Def, poor PO tolerance, poor GI absorption
-Contraindication: Sepsis, CKD stage IV, allergy
-SE: anaphylaxis, hypotension, myalgia/arthralgia, transient fever

 

Hem/Onc Case
-Expect: WBC elevated (27), platelets low, easy bruising and bleeding from gums
-Labs DIC: prolonged PT/INR, low fibrinogen, high d-dimer
https://lifeinthefastlane.com/ccc/disseminated-intravascular-coagulation/
-New Acute Leukemia diagnosis – AML
-Needs emergent hematologic consult – Blast crisis, acute leukemia, TTP, DIC
-Review of the ED management for blast crisis:
http://www.emdocs.net/blast-crisis-ed-focused-management/

 

Boarding Issues
-American Journal of EM: higher rates of delay to home medications, delayed antibiotics, increased adverse events due to boarding
-Academic Emergency Medicine: increased mortality increased over ED boarding time
-Resuscitation: decreased survival in post-ROSC patients with delay in the ED

ACEP 2011 Policy: https://www.acep.org/Clinical—Practice-Management/Boarding-of-Admitted-and-Intensive-Care-Patients-in-the-Emergency-Department/#sm.0001l5fdbjo78d7euee1p1s82wp72

Interventions: Consider ED ICU
-Improves the physician to patient and nurse to patient ratio
-Allows more time for  necessary procedures on sick patients

-Intra-hospital transport of vented patients = worse outcomes
-ETT dislodgement? Head/neck flexion moves tube >70% of the time
-Use Continuous WAVE FORM Capnography for intubation verification
-Consider a checklist for transport (vent settings, tube status, access, monitor vitals, waveform CO2)

 

Acute Stroke/TIA Management
IV TPA Inclusion:
-Acute ischemic brain infarct with onset 4.5 hours (if not witnessed, must use last seen normal/baseline)
-Significant deficit expected to result in long-term disability
-Non-contrast CT scan showing no hemorrhage or well-established infarct

-Dose:0.9mg/kg, max dose 90mg (Give 10% as bolus over 1 minute, Give remaining 90% as continuous infusion over 60 minutes)

-NINDS IV TPA Trial (RTC with tPA vs placebo)
-32% relative increase in number of patients with minimal or no disability at 3 months (medial NIH stroke scale prior to intervention was 14)

-Stroke Mimics (seizure, migraine, conversion disorder) – less likely to bleed (no patients with ICH in one study), no brain injury  present

-Intra-arterial Procedures
-Intra-arterial trials: Key? Patient selection with particular imaging findings
-MR CLEAN, ESCAPE, EXTEND IA, SWIFT-PRIME: good outcomes with stent retrieval device (almost 90% of these patients also received IV tPA)
-Ideal candidate? Small core of infarct, large perfusion deficit (area able to be saved)

-Imaging Test of Choice: CT Angiogram of Head and Neck
-Should NOT be held up for a Cr level

ACEP tPA Guideline: https://www.acep.org/uploadedFiles/ACEP/practiceResources/Stroke%20tPA%202%20Final%202013.pdf

 

 

Resident Author: Jeffrey Rixe, MD