strength in numbers: dizziness

23 Apr

Cribbed from this March ACEP Now article:


DIZZINESS/VERTIGO: numbers to consider

clinical factors associated with stroke in vertiginous patients

  • gait instability: Odds Ratio (OR) 9.3
  • subtle neurological findings: OR 8.7


predictors for serious neurological disease with complaint of dizziness, vertigo, or imbalance

  • Focal neurological abnormalities: OR 5.9
  • 60 years of age or older: OR 5.7
  • Imbalance: OR 5.9
  • Isolated dizziness: OR 0.20  (i.e. 80% less likely to be experiencing a serious neurological cause)


Study of 1681 pts w/dizziness:

  • CTs obtained in 48%
  • MRI’s in 5%


  • cost associated with identifying one abnormal CT: $165k
  • cost associated with identifying one abnormal MRI: $22k
  • all patients with positive CT or MRI had headache, neuro findings on exam, or optho complaints



  • don’t skimp on the neuro exam
  • walk (gait test) your dizzy patients


References: ACEP Now Article; picture

syringe TMJ reduction

16 Apr

cool trick from a 2014 JEM article:


TMJ dislocation:

  • commonly from excessive mouth opening (e.g. yawning, laughing)
  • anterior TMJ dislocations most common (non-traumatic)



  • 30/31 successful reductions (all anterior dislocations)
  • 77% took < 1 min


  • take 5-10 mL syringe
  • pt gently bites down on syringe (placed across molars)
  • ask pt to roll syringe back & forth



  • hands-free (no bite risk to provider)
  • quick
  • no procedural sedation needed


Seems pretty cool.  Add it to the toolbox.


References: JEM article; picture

visual aid: quick pressor reference

14 Apr

good refresher aid from March’s Emergency Medicine mag below.  The article goes through each pressor a bit more in depth, but the table here is a nice quick reminder of receptor activity and dosing, particularly with dopamine, which can have different effects at lower or higher doses.



References: article including table.

neat trick: morgan lens for lateral canthotomy

9 Apr

from March’s ACEP Now:

couple neat tricks to keep in your back pocket for the rare but nerve-wracking procedure



place a Morgan lens to protect the globe from iatrogenic rupture

risk: corneal abrasion

benefit: less likely to poke the globe



bent paper clip to hook/retract the eyelid bluntly

easy to find, low-cost


There you go.


References: ACEP Now article + picture from article

strength in numbers: meningitis

7 Apr

just to keep you honest (highlights via this EMdocs article)

“classic triad” (fever, altered mental status, stiff neck)

  • 95% had fever,
  • 88% had neck stiffness,
  • 78% had altered mental status.
  • only 44% of patients with meningitis had all three 


Neck pain: 28% sensitivity

headache: 50% sensitivity


avoid minimizing afebrile patients, especially in the elderly population: as many as 18% of these patients with meningeal infection may be afebrile

Kernig and Brudzinski signs

  • 95% specificity
  • sensitivity is as low as 5%.


“jolt test” (headache accentuated by horizontal rotation of the head at a frequency of two to three times per second)

  •  sensitivities ranging from 97% to 21%


opening pressure: as many as 9% are less than 14 cm/H20


their conclusion: “Ultimately, outside of a positive CSF culture, no one test or exam should rule in or out the diagnosis of meningitis
References: emdocs article; picture

visual aid: Seidel sign

3 Apr

(repost, but a good timely refresher)


look for a Seidel’s sign: leaking fluid from the eye/globe on fluorescein exam



came across these nice videos on the magical internet, check out the first video if you can only spare a few seconds.  check out the 2nd video for some voiceover and a little more detail.




References: video 1; video 2


Baclofen pump toxicity and withdrawl

30 Mar

Baclofen is a gamma-aminobutyric acid (GABA) derivative, an inhibitory neurotransmitter that functions ultimately to relieve muscle spasticity.

Conditions in which you might see it used:  cerebral palsy, spinal cord injury, generalized dystonia, multiple sclerosis, intractable hiccups

How it’s given: oral or IV, topical creams, intrathecal via implantable device (baclofen pump)

Abrupt discontinuation of intrathecal baclofen has resulted in

  • high fever,
  • altered mental status,
  • itching,
  • exaggerated rebound spasticity,
  • muscle rigidity,
  • rhabdomyolysis,
  • multiple organ-system failure,
  • and death.

Typically, neurosurgery or a pain specialist (anesthesia) can be consulted to interrogate the pump. Treatment involves supportive care, administration of oral or enteral baclofen, and benzodiazepines.

Toxicity results in

  • muscular hypotonia,
  • areflexia,
  • somnolence,
  • respiratory depression,
  • bradycardia,
  • hypotension,
  • temperature instability,
  • coma. 

Measuring serum levels are not always reliable- the diagnosis is clinical.

Treatment involves supportive measures (IV fluids, vasopressors for hypotension, airwary support), discontinuation of the pump (as well as draining the reservoir to stop the motor), withdraw fluid/CSF from the catheter access port (to extract any baclofen that is still in the catheter or adjacent to it), and consideration of physostigmine (be aware of side effects of bradycardia and increased airway secretions).


Submitted by K Estes


References: Yeh RN1, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump. J Emerg Med. 2004 Feb;26(2):163-7. PMID: 14980337.


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