Neurology

Shifts pearls returns with multiple sclerosis.

A 15-year-old female with PCOS, obesity, asthma, and recurrent otitis media with bilateral tympanostomy tube placement reports three weeks of increasing sanguineous drainage, ear pain, fevers, and worsening left-sided headaches not improving with NSAIDs.  She localizes the pain behind the left eye and additionally reports loss of lateral vision in her left eye, as well as double vision when looking to the left. On exam, she has a thickened, inflamed appearing left tympanic membrane with sanguinopurulent drainage from the left tympanostomy tube. She additionally has tenderness and swelling to the left mastoid process. Examination of the eyes reveals normal, symmetric, and reactive pupils.  The patient has binocular horizontal diplopia on left lateral gaze and downgaze, which resolves with covering either eye.  She has decreased vision in the lateral visual fields of the left eye on confrontational field exam.

How do you manage the patient with benzodiazepine-refractory status epilepticus?

Welcome to the emDOCs Videocast. Today we focus on acute brain injury, including the effects of hypotension, antibiotics in mechanically ventilated patients, transfusion thresholds, and ventilation strategies.

Davis Sugar, Jess Pelletier, and Brit Long cover multiple sclerosis in the ED.

The emDOCs cast with Jess Pelletier and Brit Long covers the challenging diagnosis of spontaneous cervical artery  dissection.

A 58-year-old female presents with severe headache and nausea. Her symptoms started shortly after leaving the office of her pain management doctor, where she had an epidural steroid injection to alleviate her chronic back pain approximately 30 minutes before she arrived in the ED. The patient denies any trauma to the head, fevers, nuchal rigidity, changes in vision, focal weakness, paresthesia, or anticoagulation use.  On arrival, she is awake and alert and in obvious distress. Her vitals signs include temperature of 98.8F, HR of 64, BP 133/78, and O2 saturation of 98% on room air with a respiratory rate of 18. Her exam, including a complete neurological exam, is grossly benign. Given her acute complaint and recent history, labs and CT of the head are obtained. The clinician orders analgesics. The CT shows intracranial air.

How should you manage blood pressure in the patient with acute ischemic stroke or intracerebral hemorrhage?

A 50-year-old female with no past medical history presents to the ED with a diffuse, constant headache onset a few weeks. The patient describes droopiness of the left eye and double vision associated with specific directional movements of the eye. On exam, you note ptosis of the left eye with findings as indicated in the photograph below (inability to adduct, ability to abduct). The left pupil is dilated at 5mm and minimally reactive to light; the right pupil is 3mm and reactive. The remaining cranial nerve testing and components of the neurological exam are normal.