Decision Algorithms for Emergency Neurology

Foreword
Preface
Contents
1.: Transient Loss of Consciousness
Introduction
Definition
Etiology and Pathophysiology
Diagnosis
Anamnesis
Patient Management with TLoC in the Context of Emergency [1, 12, 13]
References
2.: Coma
Definition
Signs and Symptoms for Differential Diagnosis
History
General Physical Examination
Neurological Examination
State of Consciousness
Cranial Nerves
Brain Herniation Syndromes
Diagnostic Procedures
Arterial Blood Gas Analysis
Serum Chemistries
Neuroimages
CSF Examination
Electroencephalogram
Electromyography
Therapeutic Approach
Appendix
References
3.: Delirium/Acute Confusional State
Definition
Diagnostic Criteria for Delirium According to DSM-V
Classification
Epidemiology and Pathophysiology
Prognosis
Rating Scales
Identification of Predisposing and Precipitating Factors
Differential Diagnosis
History
The Most Important Questions
Age
Life Habits Age
Medical History
Medications History
Neurological Evaluation
General Clinical Evaluation
Criteria for Identifying the Causes of Delirium
Medication-Induced Delirium
Infective Delirium
Hydroelectrolytic Imbalance
Endocrine Metabolic Disorders (Uremia, Liver Encephalopathy, Hypoglycemia, Hyperthyroidism, and Adrenal Insufficiency)
Intracranial Disorders
Cardiopulmonary Impairment and/or Hypoxia
Alcohol and Withdrawal Syndrome
Preexisting Dementia, Whether or Not Associated with Visual and Auditory Impairment
Differential Diagnosis
Diagnostic (Laboratory, Radiology, and Neuropathophysiology) Procedures
Laboratory and Blood Gases
Instrumental Investigations
Indications to Urgent CT Scan
EEG Features
Pharmacological and Non-pharmacological Treatments
Non-pharmacological Interventions
Protocol of Preventive Interventions [40]
Environmental Prevention Measures
Pharmacological Interventions
Typical Antipsychotics
Atypical Antipsychotics
Benzodiazepines
Other Drugs
Quality Indicators
Appendix
References
4.: Motor and Nonmotor Epileptic Seizures
Introduction
Definitions
Differential Diagnosis
Etiology of Epileptic Seizures
Triggering Factors
Laboratory and Instrumental Investigations
Laboratory Investigations
Neuroimaging
Computed Tomography Imaging
Magnetic Resonance Imaging
Other Tests
Electrocardiogram
Lumbar Puncture
Electroencephalogram
Status Epilepticus
Single Seizures
Therapy
General Criteria
Patient Management
Antiepileptic Drugs in Emergency Care [17–19]
Initial SE
Defined SE
Other Drugs [28]
Nonconvulsive Refractory SE
Refractory Convulsive SE
Setting Up Chronic Drug Therapy
Further Patient Care
Further Issues
Advice to the Patient
Special Situations
References
5.: Headache
Definition
Diagnosis
Signs and Symptoms: Differential Diagnoses
Scenario 1: ‘A Sudden Headache’
Scenario 2: ‘Headache with Fever or Neck Stiffness’
Scenario 3: ‘New Onset Headache in Non-headache Adults’
Scenario 4: ‘The Headache Attack in Known Headache Patient’
Rating Scales
Treatment
References
6.: Fever and Neurological Signs
Submission Methods
Fever and Headache
Fever, Delirium and Agitation
Diagnostic Framework
Diagnosis in ED: Priority Goals
Synthetic Anamnestic Sheet: Main Questions to Ask
History: Broad Spectrum of Initial Stage Variability
CSF Examination
Diagnostic and Therapeutic Priorities
Diagnostic Priorities [10–12]
Therapeutic Priorities [13, 14]
Diagnostic Procedures Based on the Clinical Scenario
Interpretation of Brain MRI patterns
References
7.: Acute Vision Disorders
Introduction
Vision Loss [2]
Definition
Etiology
Diagnosis
Visual Drop from Prechiasmatic Cause
Visual Loss from Prechiasmatic Neurological Cause on Inflammatory Basis (Optic Neuritis) [4]
Visual Loss from Prechiasmatic Neurological Cause on Vascular Basis
Retinal TIA (Amaurosis Fugax: Transient Visual Darkening) [8]
Retinal Infarction
Ischemic Optic Neuropathies
Diagnostic Workflow for Acute Visual Impairment of Pre-chiasmatic Nature
Visual Loss Due to Chiasmatic/Retro-Chiasmatic Causes (Fig. 7.2) [17, 18]
Diagnostic Workup for Acute Visual Loss of a Chiasmatic/Retro-Chiasmatic Nature
Therapy for Acute Visual Impairment of a Chiasmatic/Retro-Chiasmatic Nature
Differential Diagnosis of Acute Visual Impairment (Figs. 7.3, 7.4, 7.5, and 7.6)
Extraocular Muscle Palsies [21]
Definition
Causes of Extraocular Muscle Palsies
Semeiology of Acute Ophthalmoplegia
Diagnostic Procedures for Acute Ophthalmoplegia (Figs. 7.7 and 7.8)
Differential Diagnosis
Causes of Diplopia Usually Without Strabismus
Causes of Strabismus with Ptosis
Causes of Ptosis Without Strabismus and Isolated Muscle Paresis [23–25]
Causes of Strabismus Without Ptosis and Multiple Muscle Palsy [27]
Causes of Internuclear Ophthalmoplegia [27]
Causes of Vertical Diplopia (Skew Deviation)
Neuro-Ophthalmological Changes in the Patient with Disorders of Consciousness
References
8.: Dizziness and Vertigo
Introduction
Clinical Criteria for Differential Diagnosis Between Vertigo of Peripheral or Central Origin
Proposal for a Diagnostic Algorithm for Vertigo in the Emergency Room
Definitions
History Taking and First Evaluation of Vertigo
Neurological Examination in the Patient with Vertigo
Nystagmus (Table 8.2)
Peripheral Vestibular Nystagmus
Gaze Evoked Nystagmus
Vertical Nystagmus (Directed Upwards or Downwards)
Pendular Nystagmus
Head Impulse Test (HIT)
Cover Test (or Test of Skew)
HINTS Evaluation
Positioning Maneuvers
Dix-Hallpike Manoeuver
Appendix 1. Migraine with Brainstem Aura [21, 22]
Diagnostic Criteria
Notes
Comments
Appendix 2. Vestibular Migraine [23]
Diagnostic Criteria
Notes
Other Symptoms
Relation to Migraine Aura and Migraine with Brainstem Aura
Appendix 3. Diagnostic Algorithm
Diagnostic Algorithm A
Diagnostic Algorithm B
Diagnostic Algorithm C
Diagnostic Algorithm D
Diagnostic Algorithm E
Diagnostic Algorithm F
Diagnostic Algorithm G
References
9.: Diagnostic Algorithm for Patients Presenting with Acute Dizziness: The ATTEST Method
Introduction
Misdiagnosis
Diagnostic Algorithm
History
AVS
s-EVS
t-EVS
Physical Examination
AVS
s-EVS
t-EVS
Testing
References
10.: Focal Neurological Deficits
Introduction
From What Point of View Are We Observing the Phenomenon
Pathway Organization According to the Level of Complexity of the Hospital
Clinical Pictures
Focal Neurological Deficits
Patient with Altered State of Consciousness: Stupor/Coma
Diagnostic Pathway of Ischaemic Stroke and Revascularization Treatments
Revascularization treatments (Fig. 10.2)
Patient Eligibility to Intravenous Thrombolytic Treatment
Acute Complications of Intravenous Thrombolysis
Eligibility of the Patient to Endovascular Treatment
Admission to Stroke Unit
Transient Ischaemic Attack
Patient with Suspected Cerebral Venous Thrombosis
Patient with Intraparenchymal Haemorrhage
Subarachnoid Haemorrhage
Other Causes of Focal Neurological Deficit
References
11.: Para- and Tetraplegia in the Emergency Room and in the Intensive Care Unit
Introduction
Injury Level: Clinical Implications and Assessment Scales
Level Diagnosis in Spinal Cord Syndromes
Assessment Scales
Systemic Effects of Spinal Cord Injury
Respiratory Dysfunction
Perineal Dysfunction
Causes of Acute Paraplegia and Tetraplegia
Vascular Myelopathy
Ischemic Myelopathy
Spinal Hemorrhage and Vascular Malformations
Inflammatory and/or Infectious Myelopathies
Noninflammatory Expansive Diseases
Para- and Tetraplegia in Intensive Care Unit
References
12.: Head Injuries
Definition and Epidemiology
Diagnosis and Evaluation Scales
Moderate to Severe Head Injury
Management of Severe Head Trauma
References
13: Muscle Pain, Weakness and/or Sensory Disorders
Introduction
Patient with Acute Onset of Diffuse Muscle Pain
Patient with Generalized Acute Muscle Weakness (Myogenic)
Patient with Acute Muscle Weakness (Neurogenic and Non-traumatic)
Patient with Acute Sensitivity Disorder (Peripheral Type)
References
14.: Movement Disorders Emergencies
Introduction
Hypokinetic Disorders
Patient Without Parkinson’s Disease
Signs and Symptoms for Differential Diagnosis
Clinical Evaluation
Diagnostic Procedures
Treatment
Patients with Parkinson’s Disease
Treatment
Hyperkinetic Disorders
Mimics
Clinical Evaluation
Neurological Examination
Diagnostic Procedures
Treatment
References
15.: Respiratory Emergencies in Neurological Diseases
Introduction
Pathogenesis of ARF
Pathogenesis of Respiratory Complications
Clinical Management and Treatment
Acute Respiratory Failure in Chronic Progressive Neurological Diseases (Acute on Chronic Respiratory Failure)
Movement Disorders
Chronic Neuromuscular Diseases with Slow Progression
Rapidly Progressive Acute Respiratory Failure
Stroke
Convulsive Status Epilepticus
Severe Head Injury
Spinal Cord Injuries
Diaphragmatic Paralysis
Rapidly Evolving Neuromuscular Diseases
References
16.: Neurological Emergencies in Pregnancy and Puerperium
Introduction
Pathophysiology
Neurological Syndromes
Other Rare Causes of Acute Neurological Deficit
Diagnostic Algorithms
Seizure Algorithm
Therapeutic Approach
Headache Algorithm
Therapeutic Approach
Acute Neurological-Deficit Algorithm
Therapeutic Approach
Anti-Platelet Therapy
Acetylsalicylic Acid
Clopidogrel and Association of Several Anti-Platelets
Anticoagulant Therapy
Vitamin K Antagonists (Warfarin and Acenocoumarol)
Fractional Heparin and Low Molecular Weight Heparins
Direct Opponents of Factor II and X (DOACs: Dabigatran, Rivaroxaban, Apixaban and Edoxaban)
Recanalization Therapy in Acute Ischemic Stroke
Fibrinolytic Treatment IV (t-PA)
Mechanical Thrombectomy
Fever Algorithm and Neurological Signs
Therapeutic Approach
Multiple Sclerosis Algorithm
Disease Progression and Relapse Management
Therapeutic Approach
Algorithm of Delirium and Pregnancy Psychosis
Therapeutic Approach [29]
Therapy of Psychotic Disorders
Pharmacological Therapy in Pregnancy [29]
Drug Therapy During Breastfeeding
Neuromuscular Diseases Algorithm
Acquired Compressive Nerve and Root Disorders During Pregnancy and Puerperium
Carpal Tunnel Syndrome
Lower-Limb Neuropathies and Lumbosacral Radiculopathies
Other Neuropathies
Bell’s Palsy
Intercostal Neuralgia and Radial Neuropathy
Inflammatory Neuropathies
Guillain-Barré Syndrome
Chronic Inflammatory Demyelinating Polyneuropathy and Multifocal Motor Neuropathy
Neuromuscular Junction Disorders
Myasthenia Gravis
Botulism
Tetanus
Respiratory Failure in Pregnancy (Fig. 16.8)
Therapeutic Approach
Carpal Tunnel Syndrome
Lower-Limb Neuropathies and Lumbosacral Radiculopathies
Paralysis of Bell
Guillain-Barré Syndrome
Chronic Inflammatory Demyelinating Polyneuropathy and Multifocal Motor Neuropathy
Myasthenia Gravis
Treatment of MG in Pregnancy
Treatment of MG During Breastfeeding
Botulism
Tetanus
Algorithm on Dizzying Syndromes
Therapeutic Approach
Diagnostic Tests and Radiation Protection During Pregnancy
Ionizing Radiation
Fluoroscopy
Nuclear Medicine
Nuclear Magnetic Resonance Imaging [63–67]
Contrast Medium [63–67]
References
17.: Functional Disorders in Emergency
Epidemiology
History and Clinical Overview
Neurological Examination
Non-organic Paralysis
Instrumental Investigations
Therapy
References
18.: Neurotoxicological Emergencies
Introduction
The Neurological Diagnosis in Intoxications/Poisonings
Toxidromes
Diagnosis and Treatment of Acute Opioid Syndrome
Diagnosis and Treatment of Acute Cholinergic Syndrome
Diagnosis and Treatment of Acute Anticholinergic Syndrome
Diagnosis and Treatment of Acute Sedative-Hypnotic Syndrome
Diagnosis and Treatment of Acute Sympathomimetic Syndrome.
Toxic Coma and Stupor
Toxic Seizures
Toxic Agitation, Delirium and Psychosis
Toxic Dystonia, Dyskinesia and Rigidity
Frequent and/or Severe Neurotoxic Syndromes
Carbon Monoxide Poisoning
Clinical Manifestations and Neurotoxicity
Fire Smoke Inhalation and Mixed Carbon Monoxide-Cyanide Poisoning
Sodium thiosulfate (12.5 g i.v. over 10 min in adults and 400 mg/kg, up to a maximum of 12.5 g, in children) determines an enhancement of the transformation of cyanide in the less toxic thiocyanate. This mechanism is slower than that of cobalt compound
Diagnosis
Laboratory Diagnosis Confirmation
Differential Diagnosis
Treatment
NPS: New Psychoactive Substances
Synthetic Cannabinoids/Synthetic Cannabinoid Receptor Agonists/CB1R “Super Agonists”
Synthetic Cathinones (β-Keto Amphetamines)
Ketamine and Ketamine Derivatives (Arycyclohexylamines)
NPS Psychostimulants
New Hallucinogen Phenethylamine- and Tryptamine-Derived Drugs
Peripheral Neurotoxic Syndromes
Thallium
Tetanus
Ciguatoxin
Neurotoxic Adverse Drug Reactions
Serotonin Toxicity
Clinical Picture and Diagnostic Criteria
Neuroleptic Malignant Syndrome
Lithium Toxicity due to Chronic Overmedication
The Role of the Poison Control Centre and the Toxicological Analyses
Toxicological Analysis on Blood/Urine
Selected Antidotes Useful for the Treatment of Neurotoxic Effects
References
19.: Neurological Emergency Services: A Case for Change to the Model of Care?
Background
Shortage of Neurologists at a Global Level
Limited Number/Access to Neurology Training Programs Between Countries of Various Income Groups
Suboptimal Organization of Neurology Emergency Care
Models of Care
Unmet Needs: A Case for Change
References