Seizures: Prolonged seizures that don’t resolve on their own within a reasonable amount of time require attention because the longer they last, the more likely they are to cause brain damage, Dr. Josephson says. Medications to treat the seizure work more effectively the earlier they are administered. He recommends a protocol for treating status epilepticus that starts with lorazepam (Ativan), proceeds to fosphenytoin (Cerebyx), and is followed by a general anesthetic such as midazolam (Versed) or propofol (Diprivan).
Intracranial pressure (ICP): This could be the result of a stroke or hemorrhage, brain tumor, or trauma. Fast action to control ICP is important because permanent brain injury can result. “I emphasize to hospitalists who are used to targeting ICP that it is better to look at cerebral perfusion pressure (CPP),” Dr. Josephson says, offering the following equation: CPP equals mean arterial pressure minus ICP. He also emphasizes raising the head of the patient’s bed, hyperventilation in early stages of treatment, and using osmotic agents such as mannitol to remove water from the brain.
Neuro-muscular emergencies: Acute disorders of the peripheral nerves, including Guillain-Barre Syndrome (an autoimmune neuropathy often triggered by infection), present a subacute onset of weakness and numbness. “We have good treatments for Guillain-Barre, such as plasmapheresis and administration of intravenous immunoglobulin,” Dr. Josephson says. “But recognition is important because the breathing may be affected. If the disorder reaches the diaphragm, it could kill the patient.” Disorders such as Guillain-Barre commonly present with ascending weakness, from the toes up.
A lumbar puncture (demonstrating few if any cells with an elevated protein) or an electromyogram (EMG) may be required for diagnosis. Hospitalists also are urged to watch for impending respiratory weakness, which can be measured by forced vital capacity or mean inspiratory flow. “Consider this diagnosis for anyone presenting with general weakness,” he says.
Exams on the Run
There is a standard technique for assessing and diagnosing neurological conditions, called the neurological examination. Unfortunately, a full, detailed neurological exam can be time-consuming and unrealistic, given caseload demands and field judgments required from the working hospitalist.
“As a hospitalist, you don’t have to perform an hourlong neurological examination,” Dr. Josephson says. “But for patients presenting neurological symptoms, you need to do a screening examination tied to their specific complaint. Your hypothesis-driven exam can be done in a few minutes if you know which elements are high-yield screening tests.”
These brief screening tests can be part of a routine assessment of the patient, Dr. Likosky adds.
Hospitalists can learn a lot just by walking into the patient’s room. “The bulk of such a neurological exam can be performed while talking to the patient, if you pay attention,” he notes. “There may be subtle signs of weakness. For example, when the patient is lying in bed, the feet should point straight up.” Note if one foot points to the side, or if the patient uses both sides of the face equally when talking.
“You can do sensory exams and test reflexes very briefly, as well,” Dr. Likosky says. “If those issues are on your radar screen, you can do much of the screening work in a stepwise fashion. The rest depends on clinical observation.”
There is not a huge spectrum of neurological disorders likely to confront the hospitalist, but it is important to know about the most common conditions and remember that time is of the essence, Dr. Likosky says. “Most neurological conditions are garden variety, but keep in mind the differential diagnoses, for example, for weakness and headache—common conditions that may rarely have an uncommon cause.”