Lightning Lectures – Guillain Barre, Myasthenia Gravis, Botulism

Guillain Barre – Dr. Tyler Bayers

-Immune system attacks myelin sheath causing ascending paralysis

-Progressive, mostly symmetric muscle weakness with absent or decreased DTRs

-Clinical diagnosis with CSF support showing albuminocytologic dissociation (increased CSF protein with normal CSF WBC)

-Monitor for signs of respiratory failure

-Treatment with IVIG; can also do plasma exchange

Myasthenia Gravis – Dr. Blaine Jordan

-Autoimmune NMJ disorder of postsynaptic Acetylcholine receptors causing fluctuating skeletal muscle weakness/true muscle fatigue.

-Highly associated with thymus disorders (thymoma); consider chest CT

-Often presents with ocular myasthenia, but can be weakness of any muscle group, often see ptosis, expressionless face

-Avoid drugs that can worsen MG – ex. fluoroquinolones, macrolides, aminoglycosides, beta blockers

-Infection, pregnancy can cause MG crisis – look for them

-In MG crisis, initiate steroids in ED; consider intubation as meds for crisis take days to work and could worsen prior to meds taking effect

Botulism – Dr. Avery Newcomb

-Clostridium bacteria with botulinum neurotoxin blocking presynaptic Acetylcholine release causing symmetric and descending flaccid paralysis

-Different types: Infant botulism involves ingestion of spores that colonize GI tract and release toxin produced in vivo; food borne botulism occurs after ingestion of food contaminated with preformed botulinum toxin; wound botulism with in vivo production of neurotoxin.

-Sxs may range from minor cranial nerve palsies associated with symmetric descending weakness to rapid respiratory arrest.

-Clinical diagnosis – tests take days to result. Botulinum antitoxin should be given as soon as suspected for age > 1 year. Botulinum immune globulin (BabyBIG) for infants <1 year of age.

Procedure Sim: LPs Dr. Mary Jane Schumacher and Dr. Dhruv Patel

-LP either left or right lateral decubitus position or sitting up

-Landmarks midline of spinous processes and anterior iliac crests = L4; go a space above or below (L3-L4, L4-L5 interspace). Ultrasound can assist in identifying landmarks. Prep and drape the patient. Use local anesthesia. Prepare manometer and collection tubes. 20-22 g spinal needle with stylet, aim towards umbilicus. Bevel edge should be parallel to the ligament fibers (bevel up when patient on side, to right or left when sitting up). Once in Subarachnoid space, obtain pressure then collect 1 cc of fluid in tubes.

-Layers needle goes through: skin, subcutaneous tissues, supraspinous ligament, interspinous ligament, ligamentum flavum.

-Tubes: 1) cell count and differential, 2) gram stain, cultures 3) glucose, protein, 4) cell count and differential; tube 3 and 4 can be used for special tests or additional cultures

tPA pharmacy lecture – Dr. Jade Daugherty

-Alteplase FDA approved for acute PE, acute ischemic stroke, STEMI (not preferred agent), central line thrombosis; several other off label indications

-Half life ~5 min. Fibrinolytic activity persists for up to 1 hour after administration

-Adverse effects: bleeding (notably ICH), hypersensitivity and angioedema

-Stroke dosing: 0.9 mg/kg IV (max 90 mg). 10% as IV bolus over 1 min, 90% as continuous IV infusion over 1 hour. Different dosing for different indications, look up dosing.

-Before giving tPA: know BG (<50 or >400 then correct and re-assess), blood pressure (<185/110 prior to tPA, <180/105 after administration), CT head without contrast, last known normal, and a good story.

-Several contraindications – use MD calc to go through list

-Excellent resource: AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke

-“Blood thinners” – antiplatelets are ok, warfarin with INR < 1.7 ok, prophylactic AC is ok, Direct Thrombin inhibitors and Xa inhibitors: check labs (INR, aPTT, platelet, TT, and anti Xa level) if last dose >48 hours and normal renal function then ok for tPA otherwise likely not. Glycoprotein IIb/IIIa inhibitors also not ok.

-Trials over the years: NINDS-II and ECASS-III showed disability benefit but after re-adjusting for baseline imbalances, no benefit showed.

-Wake Up Trial: in patients who awake with stroke sxs or have unclear time of onset >4.5 hours from LKN, MRI to identify diffusion positive FLAIR negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.

-If ICH after tPA administration: stop tPA infusion, emergent CT head, Labs including CBC, PT, INR, aPTT, fibrinogen level, type and cross. Cryoprecipitate: 10 U infused over 10-30 min, administer additional dose if fibrinogen level <150 mg/dL. TXA 1000 mg IV infused over 10 min.

Neuro Exam – Dr. Jeremy Thomas

-If neuro complaint, fever, sxs that don’t make sense, need full neuro exam. Lots of info below, some of the highlights included.

-GCS score in setting of trauma: Eyes 4, Verbal 5, Motor 6

-Low GCS: Do the DON’T: D: Dextrose, O: Oxygen, N: Narcan, T: Thiamine

-Pupillary response: reactive (no brainstem involvement), fixed and dilated (anoxic encephalopathy, exclude anticholinergics), one dilated (herniation with CN III compression or nerve lesion). Small and reactive – usually metabolic or toxic causes; consider thalamic or pontine infarcts

-Testable pupil findings:

Argyll Robertson Pupil (tertiary syphillis, selective damage to pathways from retina to edinger-westphal nucleus) “Prostitute pupil” – accommodates but does not react. Light near dissociation.

Marcus Gunn (total lesion of optic nerve/CN II). De-afferented eye. no response to direct light, constricts to light stimulus in other eye.

Horner’s syndrome (sympathetic denervation), ptosis, miosis, anhydrous. Trauma, stroke, carotid dissection/aneurysm.

Central Lesions – cause contralateral deficits of face and body (ex classic MCA stroke) and produce negative symptoms (ex. decreased sensation, decreased ability to speak); but cerebellar lesions can cause positive symptoms such as nausea/vomiting, nystagmus.

Midbrain Lesions: contralateral hemiplegia, ipsilateral CN III and IV findings

CN III: Oculomotor nerve, pupil size, raising eyelid, most movement of eye

CN IV: Trochlear nerve, movement of eye (superior oblique)

Eye innervation: LR6(SO4)AO3: Lateral Rectus CN VI, Superior Oblique CN IV, All Others CN III

Pons Lesions: contralateral hemiplegia, ipsilateral CN V, VI, VII, VIII findings

CN V: trigeminal nerve, sensation of face and muscles of mastication

CN VI: abducens nerve, lateral rectus as above

CN VII: facial nerve, movement of facial muscles and taste on anterior 2/3 of tongue

CN VIII: vestibulocochlear nerve, hearing and balance

Medulla Lesions: Contralateral hemiplegia, ipsilateral CN IX, X, XI, XII

CN IX: Glossopharyngeal nerve – taste on back 1/3 of tongue

CN X: Vagus nerve – ability to swallow, gag, some taste and part of speech

CN XI: Accessory nerve – move shoulders and neck, turn head from side to side/shrug shoulders

CN XII: Hypoglossal nerve: move the tongue

Cauda Equina: Compression of nerve roots in lumbar spine; loss of bowel or bladder control, saddle anesthesia, pain or weakness in lower extremities

DTRs – can help localize a lesion: Biceps C5/C6, Triceps C7/C8, Abdominal T8-T12, Patella L2/3/4, Achilles L5, Babinski S1/S2.

Grading: DTRs (0 absent, 1 decreased but present, 2 normal, 3 brisk and excessive, 4 with clonus). Strength (0 no movement, 1 flicker, 2 movement, 3 movement against gravity, 4 movement against resistance but weak, 5 normal).

Cerebellum: influences movement of voluntary movement, balance and equilibrium, muscle tone. Eyes open tests cerebellar. Eyes closed tests proprioception.

Clinical Pathways for Status Epilepticus – Dr. Kuzel and Dr. McKinney

In First 5 minutes:

-ABCDEFG (ABC’s, Don’t Ever Forget Glucose).

-Airway considerations: lateral decubitus, nasal trumpets, O2, suction

-Obtain IV access and search for reversible causes, can consider initiation of first line tx with benzos prior to waiting 5 minutes; be aggressive early

5-10 minutes:

First Line Agents: IV Lorazepam 4 mg and up to 0.1 mg/kg, may repeat Q5min or Midazolam 10 mg IM once if no IV access, or IV Diazepam 10-20 mg. Go big or go home. Get the seizures to stop sooner rather than later as more likely to have respiratory depression from status than with benzos.

Second Line Agents: Levetiracetam 60 mg/kg IV (max 4500 mg) or Fosphenytoin or Phenytoin 20 mg/kg IV (max 1500 mg) or Valproate 40 mg/kg IV (max 3000 mg)

Consider intubation if needed.

10-30 minutes:

Medications in refractory status epilepticus: Propofol 2-5 mg/kg IV, then infusion of 2-10 mg/kg/hr. Midazolam 0.2 mg/kg IV, then infusion of 0.05-2 mg/kg/hr. Ketamine 0.5-3 mg/kg IV, then infusion of 0.3-4 mg/kg/hr. Phenobarbital 15-20 mg/kg IV at 70-75 mg/min.

Advanced airway management: RSI. Preoxygenation. Induction: Propofol or Ketamine. Paralytics: Succinylcholine or Rocuronium (however consider status not being seen). When to intubate: when predicted course of seizures will necessitate high dose of respiratory depressing drugs.

–Special considerations: Consider nonconvulsive status epilepticus in known epileptic patient without return to baseline (emergent EEG, consider benzos). Always consider tox causes (avoid Phenytoin of Fosphenytoin in undifferentiated tox patient or drug withdrawal. Also avoid if this is a home medication due to concern of cardiotoxicity). Give Thiamine 100 mg if alcoholic. In isoniazid overdose, give pyridoxine 70 mg/kg, Max 5 gm.

–Pediatric considerations: Access usually a problem. Intranasal Midazolam 5 mg/mL solution dosed at 0.2 mg/kg divided into each nostril. Lorazepam 0.1 mg/kg IV, max 4 mg. See CHOP status epilepticus

Oral Boards – Dr. Shoff

-What do I see when I walk in room? If AMS, get POC glucose early on

-IV access, heart monitor, O2 monitor

-If a vital sign is missing, ask for it, likely will be abnormal

-If vitals are abnormal, start addressing immediately. Can always request “if this intervention changes a vital sign, will you let me know?”

-Always ask allergies before giving meds

-Get history from whoever you can: paramedics, family. Don’t forget social, surgery, family hx

-When to order things: right when you walk in, after history, after physical (can whenever but these are the 3 best times)

-If you ask specifics in regards to exam, they will answer yes/no, don’t want to be too broad but don’t forget to ask things either.

Geriatrics Lecture – Mobility

-Find out who lives at home, steps at home, assistive devices?

-Walk the patient in the ED and see how they do

-Could request PT/OT eval; may be hard from ED but could admit for these services.

-If thinking needs rehab/admit and not obs because they need a 3 day stay for insurance purposes

-If discharging, make sure home health eval can occur. If discharging with pain meds, do only half a pill.

-If patient is falling, consider that this is #1 morbidity/mortality for elderly

Meningitis – Dr. Platt

–Important higher level questions to ask: exposure to recent meningitis, current sinusitis/OM, recent antibiotic use, travel such as to Hajj and Umrah, recent IVDA, progressive rash, recent or remote head trauma, HIV infection, immunocompromised, recent drug use including OTC, age, vaccination status

-Screening CT not necessary if none of these apply: immunocompromised state (HIV, immunosuppressive therapy, solid organ or hematopoietic cell transplant), Hx of CNS disease (mass lesion, stroke, or focal infection), New onset seizure within 1 week of presentation, papilledema, abnormal level of consciousness, focal neurological deficit.

-LP: try to get blood cultures first and quickly do LP before antimicrobial therapy. If there will be a delay, blood cultures, abx.

-Drug that cause aseptic meningitis: NSAIDS!, antimicrobials (Bactrim, Amoxicillin, Isoniazid) most common but others include Muromonab-CD3 (Orthoclase OKT3), Azathioprine, IVIG, Intrathecal methotrexate or cystine arabinoside.

-CSF studies: normal glucose is about 2/3 concentration of blood. Glucose may decrease with bacteria, WBCs, or cells shed by tumors. Small amount of protein is normal in CSF but increases commonly seen with meningitis and brain abscess, brain or spinal cord tumors, MS, GB, syphillis. Don’t forget to order specifics for what you want.

-Don’t forget Dexamethasone prior to/same time as antibiotics

-Antibiotics based on age: <1 month (Ampicillin + Cefotaxime or aminoglycoside), 1 month to 50 years (Vanc + ceftriaxone +/- Rifampin if dexamethasone given), >50 years (Vanc + Ampicillin + Ceftriaxone +/- Rifampin if dexamethasone given).

Journal Club – Dr. Mary Jane Schumacher

-Compression therapy for prevention of recurrent cellulitis of the leg – do it

-TXA vs oxymetazoline for hemostasis in epistaxis: need a better study, would still try Affrin first but remember TXA as another option as this review shows it could be clinically beneficial and may prevent need for nasal packing

72 hour returns/Deaths in ED/Deaths within 24 hours – Dr. Mary Jane Schumacher

-Great job on care of patients and documentation

–For documentation: remember to take out the things that are saved in every note but do not apply. For ex. a patient dies in the ED, do not have in your note: discussed plan and all of their questions were answered or follow up with primary care physician upon discharge

-Important patient care points:

Remember to think of social situation and set patients up for success if going to discharge. Are they going to go home and fall and break a hip/get a brain bleed? Do they have a PCP to follow up with?

If vitals or clinical change on a trauma patient – repeat FAST.

Seizure patients – monitor in ED for a period of time, give their seizure meds/keppra load if they have definitely missed doses and discharging but be cautious of restarting Lamotrigine for risk of SJS if they haven’t been taking it. People coming back with recurrent seizures – neuro consult.

Alcohol withdrawal – really pay attention to these people, they can become sick very quickly. Symptoms can range from mild to severe. Recognize the symptoms from tremors/tachycardia to hallucinations/delusions and seizures. If alcoholic and reported seizure at home and don’t look well, consider admission. If they look well, can give phenobarbital 260 IM if discharging as it has a long half life and can prevent decompensation. You can also give phenobarbital IV if admitting for sxs.

Cirrhotics – use ideal body weight, use LR for resuscitation. Don’t forget considerations of Albumin in SBP, HRS, etc.

Morbidity and Mortality Case – Dr. Caleb Webb

-HIV/AIDS: AIDS when CD4 count <200

-AIDS defining illnesses: Several; discussed cryptococcosis, MAC, PCP

-Cryptococcal Meningitis: HA, fever, neck pain, n/v, photophobia. Will see increased ICP on lumbar puncture. Need to specifically order crypto testing on CSF fluids. Treatment is induction therapy with Amphotericin B and Flucytosine.

-MAC: most likely when CD4 count <50. Disseminated MAC: fever, night sweats, abd pain, diarrhea, weight loss. Diagnosis via isolation of MAC from the blood.

-PCP: diffuse, bilateral interstitial infiltrates. Induced sputum sample. Consider ordering LDH as often elevated.

Electrolytes – Capstone Dr. Dan Grace

Hyperkalemia

Causes: #1 cause hemolysis followed by renal failure, acidosis, cell death, drugs (ACE/ARBS)

Sxs: Abd pain, diarrhea, chest pain, muscle weakness/numbness, n/v, palpitations

EKG changes: variable depending on K; peaked T waves then P flattens and PR lengthens, conduction abnormalities and bradycardia – prolonged QRS up to sine wave, then cardiac arrest

Treatment: stabilize cardiac membrane with calcium gluconate, shift K into cells via 5-10 U regular insulin with 1-2 D50 amps, albuterol neb, sodium bicarb (esp if acidotic), Get rid of K via lasix if properly hydrated, dialysis.

Hypokalemia

Causes: chronic ETOH, malnutrition, diuretics, vom/diarrhea, hyperventilating, alkalosis

Sxs: cramping, weakness

EKG changes: U waves, flattening/loss of T waves, tornadoes, AV block, brady, PVCs

Deficit: For every 0.3 meq/L below 3.5, 100 meq deficit, replace with KCl PO if can, or IV; also have Effer-K, K phos at no more than 60 meq at at time

Hypernatremia

Causes: unreplaced water losses, decreased water intake or excessive Na intake

Sxs: HA, n/v, confusion/AMS, seizure, coma

Treatment: Depends on sxs, mild symptomatic (if euvolemic consider 1/2NS), severe with seizure/coma (D5W), Free water deficit on MDCalc [(serum Na – 140)/140] x 0.6body weight in kg. Don’t correct more than 0.5/hr.

Hyponatremia

Causes: vomiting, diarrhea, diuretics, drinking too much water, dehydration, heart/kidney/liver problems, inadequate salt intake – generally classified into hypovolemic, euvolemic, or hypervolemic

Sxs: dizziness, fatigue, HA, confusion, nausea, seizures

Repletion: no more than 0.5 meq/hr and 8meq/day to avoid osmotic demyelination syndrome. Give hypertonic saline 3% for seizure, coma 100 -150 cc over 10 min, can repeat x 1

Other electrolytes important in ED

Hypercalcemia: bones, stones, groans, psychiatric overtones; Tx if 12-14 with sxs or >14; fluid resuscitate, lasix if fluid overload, calcitonin is faster than bisphosphonates

Hypophosphatemia: anemia, bruising, seizure, coma, constipation, muscle weakness; usually caused by DKA, refeeding, malabsorption, ETOH; tx with NaPhos or KPhos PO or IV

Environmental Kahoot – Dr. Dan Grace

-Killerbees more likely to swarm and sting multiple times

-Acute Mountain Sickness – descend; Acetazolamide works by causing primary metabolic acidosis

-Ruptured TM following ascent from scuba diving – antibiotic drops and ear precautions

-Difference b/t heat stroke/exhaustion = neuro sxs

-Iguana bite – cipro

-ARDS after wet drowning due to water washing away surfactant

Toxic Smoothie – Dr. Bosse

-Digoxin toxicity is only time you do not want to use calcium for hyperkalemia

-Cyanide toxicity: lactate level. Tx with hydroxycobalamin. Other tx: nitrite (causes methemoglobinemia which then scavenges cyanide); thiosulfate, cyanokit (amyl nitrite, sodium nitrite, sodium thiosulfate)

-Antihypertensive overdose: hypotension possible but not common with ACE-I OD

-Few toxins cleared by HD: lithium, toxic alcohols, salicylates, theophylline

Geriatrics Lecture – Mentation

-Normal aging: slowed, need more time.

-Confusion, problems with judgement not normal

-Dementia progresses over years vs delirium acute change in things like attention, falling asleep, disorganized thinking or altered level of consciousness

-Delirum causes – several, but think of infection, meds, seizures, intracranial bleed, NPH

-Can use ADEPT Tool to assess change in mental status

-Use smaller doses of medications for elderly

-If need meds for agitation ex: Haldol 0.5 mg (IV,IM,PO), Seroquel 12.5 mg, Olanzapine 2.5-5 mg, Risperidone 0.25-0.5 mg

Decompensated Cirrhosis – Dr. McGee

-Have high index of suspicion for cirrhosis – use clues from exam and labs

-Search for underlying etiology of portosystemic encephalopathy, GIB, etc.

-Diagnose and treat SBP: diagnostic paracentesis with >250 PMNs, Ceftriaxone 2g Q24 hrs, Alubmin 1.5g/kg on day 1 reduces mortality

-GIB: early GI consult; varies 15-30% risk of death. 2 large bore IVs, cultures, ceftriaxone (or broader), keep Hb around 7. correcting INR with FFP not recommended, transfuse if plt <50 K, cryo for fibrinogen <100. Protonix, octreotide. Blakemore tube if needed.

-Hepatorenal Syndrome: High index of suspicion, Cirrhosis and Cr >1.5. If cirrhotic with AKI, use albumin 5% if hypovolemic, 25% if euvolemic/hypervolemic, non ICU midodrine and octreotide; if ICU levo with MAP >85.

-Medications to AVOID: Never NSAIDs, if opiates needed then fentanyl > Hydromorphone > morphine, avoid benzos as much as possible; can give Tylenol up to 2 g/day

MICU Follow Up – Hypothermia

-ECMO (if available) may be best way to rewarm, 7-10 ⁰C /hr

-Thoracic lavage up to 6 ⁰C/hr

-If coding, can attempt defibrillation x 3; rewarm to at least 86 ⁰ F

-Try to avoid stimulating heart, if need central access, fem line is best

-Rewarming complications include several electrolyte/coag abnormalities; check frequently

-Goal rewarm temp is 86-89 ⁰F

Neuro Cases

1. Stroke in Sickle Cell

-Neuro/hem consults early

-Exchange transfusion as treatment

-Can use upper motor neuron/lower motor neuron signs to help delineate where problem is

ex. UMN: +Babinski, spasticity, hyperreflexia ; LMK: Fasciculations, hypotonia, hypo/areflexia

2. Posterior Circulation Strokes

-Several symptoms: vertigo/dizziness, imbalance, unilateral limb weakness, dysarthria, diplopia, nystagmus, n/v, dysphagia

-HINTS exam can be used if symptomatic (Head Impulse, Nystagmus, Test of Skew)

-Subclavian Steal Syndrome: suspect in a patient with vertebrobasilar territory neuro sxs, arm claudication (exercise-induced arm pain or fatigue; coolness or paresthesias in extremity)

3) tPA

-BP goals for tPA administration <180/110 – may use Labetalol/Nicardipine for BP control

-Know some of the absolute contraindications; ex: any hx of intracranial hemorrhage, BP >180/110, known bleeding diathesis (platelet count <100,000; use of warfarin with INR > 1.7, use of DOACs) Can use MDCALC to run absolute/relative contraindications

-tPA symptom onset < 4.5 hours (prefer <3 hours esp in those >80 years)

Geriatrics Lecture

4 M’s for the ED: Medications

-Medications/polypharmacy should be high on differential for acute change in elderly

-1/3 of elderly patients lose independence in at least 1 activity when admitted

-Several meds are problematic; warfarin, ASA, plavix, digoxin, metformin and other diabetic medications, antibiotics

Room 9 Follow Up Case – Massive Hemoptysis

-Massive hemoptysis, no clear consensus definition. 100-1,000 mL/24 hours or >50 mL in a single event – really any bleed that is life threatening due to airway obstruction, hypotension, or blood loss

-Usually arises from bronchial circulation; MCC usually TB, bronchiectasis, lung abscess, bronchogenic carcinomas

-Airway protection: if having difficulty clearing airway or hypoxic/dyspneic, prepare for difficult intubation; intubation of mainstem of the good lung; can do this via going past the cords and turning ET 90 degrees; have patient lay on side of the bad lung

-TXA: nebulized TXA with 1 g TXA in 10 cc saline. Can also do 500 mg TID. Systemic route also an option, 1gm load in 100 mL NS over 10 minutes and 1 gm over 8 hours.

-Bronchoscopy and CT; CTA may help identify source; consults to consider early: Pulm, IR or CT surgery

EMS Lecture- PreHospital Stroke

-Several scoring systems (RACE, Stroke VAN, FAST-ED, CSTAT, LAMS) to help guide pre-arrival notification and transport to comprehensive stroke center

-CSTAT: Cincinnati Stroke Triage Assessment Tool, Screen for Large Occlusion Strokes >/= 2 is positive

Conjugate Gaze Deviation 2 points

Incorrectly Answers Age or Month and Does not follow at least one command (close your eyes, open and close your hand) 1 point

Arm (right, left or both) falls to the bed within 10 seconds 1 point

-Mobile stroke units – can decrease time to stroke tx by 50%, 20 units worldwide, CT scanner in back; tremendous expense without great improvement in outcomes

-tPA goal 60 minutes door to drug.