Altered female

[mycrofft]

Going back to OP

"Most of the writhing is on the right side. Right leg up in the air, right arm twisting and flexed."

Writhing=dystonia. Unilateral=probably intracranial and either vascular or traumatic. MAYBE some other sort of infarct or abscess, but focal.
Uh, put IV in unwrithing arm.

 

[tylerp1]

Narcan was mentioned as a diagnostic tool, although it probably wouldn't have crossed my mind to use it either.

If we're thinking along the lines of dystonic reaction, 50 mg diphenhydramine..

 

[NomadicMedic]

Well, to cut to the chase on this, my differentials on scene were the following: dystonic reaction, some sort of OD or an inter-cranial insult.

Either way, the prehospital treatment was the same. She needed to be at the ED with the quickness, not a medic mucking about on scene.

About an hour after I transported her to the ED I got a text from a CCT/flight medic friend who was flying the PT to a level I. It was a basilar bleed with midline shift and bleeding into the ventricles and the spinal column. The word it was it was a devastating bleed and appeared to be a non survivable insult.

 

[Brandon O]

Well, no :censored::censored::censored::censored:. Traumatic? Wonder if there were any risk factors.

 

[NomadicMedic]

The doc said it might have happened early on in the day when she was complaining of a headache and took excedrin and more oxy. Not trauma related.

 

[Localmotion34]

It was a basilar bleed with midline shift and bleeding into the ventricles and the spinal column

You my friend witnessed a somewhat rare occurrence in the field of CVA. I mentioned in my post that something producing bilateral signs at the level of the pons/midbrain could be either the basilar or vertebral artery. 13 years in EMS and i have never come across a basilar or vertebral bleed, EXCEPT a patient who *already had* locked-in syndrome. I should have guessed that you posted this because it was so rare an occurrence, and figured a lower origin.

And yes, I have a Ph.D. in Neuroscience with significant experience in clinical Neuroscience. EMS is my volunteer gig. But clinical neuro taught me to "trace the wires back to their origin" and find overlapping regions of the brain that are affected by each particular sign. Then, you know what is the most likely cause for that region.

This is a perfect case for illustrating to new Medics that just because there is Oxy involved, it does not always mean overdose. Every altered mental status patient I get I do a check for Babinski sign, Hoffman's sign, and as much of a full cranial nerve exam as I can depending on how alert they are. If there is evidence of fluctuating cognition, I always ask them to count backwards by 7 from 100, and spell two words backwards. Those tests alone can differentiate pretty accurately a vascular incident from a delirium or drug interaction.

 

[NomadicMedic]

I will admit that I originally "diagnosed by zip code". The obvious environmental clues were dragging me down the OD road, but as I spent time with the PT, it was clear that it was some type of CVA.

I was asking her cognition questions and while her responses were confused and inappropriate, it was clear that this was obviously not an opiate OD, nor was it presenting as a typical dystonic reaction.Just goes to show I really need to learn how to do a better cranial nerve assessment, with a better knowledge of what I'm seeing.

Do you have a specific method for assessing these patients you could share in a "step by step" type of path?

 

[Brandon O]

Local, I would be eager to hear how you use/apply Babinski, Hoffman's, serial sevens and spelling in your (or rather in a prehospital-type) assessment.

 

[Dwindlin]

"Most of the writhing is on the right side. Right leg up in the air, right arm twisting and flexed."

Writhing=dystonia. Unilateral=probably intracranial and either vascular or traumatic. MAYBE some other sort of infarct or abscess, but focal.
Uh, put IV in unwrithing arm.

Just to point out dystonia and writhing are not the same. Dystonia is muscle rigidity and contraction.

Writhing is a non-puposeful movement.

Writhing (Athetosis):
[YOUTUBE]J_wIDm1_ax4[/YOUTUBE]
Dystonia:
[YOUTUBE]nXGXQ0tykhA[/YOUTUBE]​

 

[Localmotion34]

Do you have a specific method for assessing these patients you could share in a "step by step" type of path?

Just a disclaimer here: this would NOT BE for a trauma patient!! Haha. Also, I take a VERY holistic approach, and focus on the obvious problem at hand, and then radiate outward to adjacent cranial nerves. But generally, I start at bundles of problem areas and then move to less common regions of deficit. We also use the NIH stroke scale, but if I don't have the time to do it, I can do this assessment in about 6 min flat:

Let's say we have a patient complaining of a moderate weakness/numbness in the right hand/arm. So I test for equal power/strength and verify this. Next, I check sensory and motor in the legs, and while I am there I run a tongue depressor along the bottom of their foot and look for Babinski sign. This can tell us if there is a wider area of upper motor neuron damage. I generally start with extremity sensory/motor to see if there are deficits on BOTH SIDES, which would point to a very low lesion in the brain - eg midbrain/pons/medulla. If it is unilateral, I then move to the "cluster" areas of the midbrain and pons.

Cranial nerve I (Olfactory) - eh, unless you have perfume ect forget it

Cranial Nerves II (Optic), III (Occulomotor), IV (Trochlear), and VI (Abducens) can be tested together for vision, pupillary reflex, movement, and heminopsia.

This is probably the most important part of the assessment. In less than two minutes, you could potentially detect severely life-threatening blockages/bleeds. You can test occulomotor function as well as higher association areas, which if not intact, is warp 9 to the hospital.

Also, here we are checking not only vision, but the tempo-parietal junction for RECOGNITION of objects, as well as NAMING objects and possible aphasia.

We check the pupillary reflex in both eyes, and the size of the pupils. We swing the penlight between eyes and look for consensual constriction. We have the patient follow the tip of the penlight side to side, top to bottom, and in a circle. We move the penlight away from the patient to test accommodation, and then toward them to test convergence. Here we are looking for saccades of the eye, and "freezing" of one eye on a lateral or convergent gaze. We also have the patient tilt their head and see if any double vision pops up. Basically, using this pattern will find most if not all occulomotor abnormalities.

Now at this point, we can also have the patient fixate on on object, and then we roll their head side to side and watch the "dolls eyes" phenomenon, and check for evidence of saccades or freezing of an eye midline.

If there is double vision, we have them close one eye to see if it goes away. If it does go away, then we can be fairly sure the double vision arises from an eye muscle overcompensating from another eye muscle weakness.

We are also testing here for spatial NEGLECT. We are seeing if they ignore fingers we hold up in each region of space. If they are, there are more advanced techniques you can use by turning their head or presenting an unusual stimulus (making a weird face) on the side they are neglecting. Since crossing your eyes and making a weird mouth expression is out of the ordinary, their frontal association areas will turn their ATTENTION subconsciously to that side. But later on, they will deny ever having seen you do that! This is very rare, but can be very informative to the Doc in the ER.

So while we are testing vision/neglect, we also test for naming and recognizing objects. I hold up my notebook and ask them what it is. I have them close their eyes and hand them a stuffed toy we have in the back for kids and ask me to tell me what it is.

Also, we can have them repeat a sentence to examine for dysarthria and comprehension.

If there is evidence of neglect, one of the BEST possible methods to DOCUMENT this - so the docs don't think you are crazy if it spontaneously resolves - is to have them draw a clock with the hands at 2:10!! Patients with neglect will invariable ignore whatever side, and presto, you have written incontrovertible proof of this for a physician.

Cranial Nerve VII (Facial) - Now there is some weirdness with the facial nerve. The LOWER face is innervated by CONTRALATERAL fibers, so any lower facial deficit from CORTICAL damage should be on the same side as the motor deficit.

We do the smile, wrinkle your nose, raise your eyebrows, and then bury/hide your eyelashes. I also have them wink at me with one eye, then the other, and then in rapid succession.

Cranial nerves VIII-XII - Here is gets a bit more tricky, but the tongue is a GREAT way to test lower in the brain lesions. Stick out your tongue, move to the right, left, and then try to touch their nose with it. Any fasiculations (ridges) on the tongue are a dead giveaway for a cranial nerve XII deficit.

Other techniques:

-Nose to finger
-Having them hit their palm with the top and then bottom of their other hand in rapid alternating succession - we are looking for evidence of dysdactokinesia
-Instruct them to fold a piece of paper in half, hand it to you, and then touch their hand to their chest - we are testing memory, praxis, following commands, and spatial awareness

So in short:
1) Focus on the obvious deficit, and then identify extremity deficits in sensory/motor
(2 and 3 can be interchangeable depending on your patient)
2) Check occulomotor function, vision, object recognition, and evidence of aphasia
3) Check the face and see if facial deficits correlate to the side of the extremity deficit
4) Go lower in the brain and check the tongue, and then follow up with the cerebellum and dysdactokinesia
5) Come up higher and check praxis, higher commands, memory, and visuospatial awareness - take into account motor deficits that are existing

If you simply do 1-3 and even forget testing for neglect, you will nail most CVA patients, and get them the priority they deserve at the ER. 4-5 may identify a global problem superimposed on top of a CVA, and get a good CYA for the ER doc transferring immediately to Neuro.

You may also say, hey that is the NIH stroke scale minus fine motor skills and the cards! Well yes and no. It was how I was trained to do it that does not take the strict and regimented and quantifiable of the NIH. No one I know can do NIH in the time most of our jurisdiction is to the hospital. No one.

If I really have the time, I give the patient the Mini-cog. I ask them to remember "ball, tree, and flag" as words to recall, have them draw a clock at 2:10, and then ask them to recall the words. This is a GREAT test for dementia, delirium, as well as executive and memory deficits from cerebrovascular disease.

@Brandon Oto
See above for Babinski, and Hoffman's sign can be done right after checking their power to squeeze. Just flick their middle finder while you already have their hand in yours!

Serial 7s and words backwards can be done after 3) above if you feel there is evidence of an executive dysfunction.

 

[mycrofft]

Dystonia versus writhing, thanks!

I avoided picking up the "larynx" spelling/spelling trap and got caught on that one.

How long does that workup take? How far into the time factor to allow clot busting does it intrude?Can it be practically done enroute?

 

[Melclin]

Just a disclaimer here: this would NOT BE for a trauma patient!! Haha. Also, I take a VERY holistic approach, and focus on the obvious problem at hand, and then radiate outward to adjacent cranial nerves. But generally, I start at bundles of problem areas and then move to less common regions of deficit. We also use the NIH stroke scale, but if I don't have the time to do it, I can do this assessment in about 6 min flat:

Let's say we have a patient complaining of a moderate weakness/numbness in the right hand/arm. So I test for equal power/strength and verify this. Next, I check sensory and motor in the legs, and while I am there I run a tongue depressor along the bottom of their foot and look for Babinski sign. This can tell us if there is a wider area of upper motor neuron damage. I generally start with extremity sensory/motor to see if there are deficits on BOTH SIDES, which would point to a very low lesion in the brain - eg midbrain/pons/medulla. If it is unilateral, I then move to the "cluster" areas of the midbrain and pons.

Cranial nerve I (Olfactory) - eh, unless you have perfume ect forget it

Cranial Nerves II (Optic), III (Occulomotor), IV (Trochlear), and VI (Abducens) can be tested together for vision, pupillary reflex, movement, and heminopsia.

This is probably the most important part of the assessment. In less than two minutes, you could potentially detect severely life-threatening blockages/bleeds. You can test occulomotor function as well as higher association areas, which if not intact, is warp 9 to the hospital.

Also, here we are checking not only vision, but the tempo-parietal junction for RECOGNITION of objects, as well as NAMING objects and possible aphasia.

We check the pupillary reflex in both eyes, and the size of the pupils. We swing the penlight between eyes and look for consensual constriction. We have the patient follow the tip of the penlight side to side, top to bottom, and in a circle. We move the penlight away from the patient to test accommodation, and then toward them to test convergence. Here we are looking for saccades of the eye, and "freezing" of one eye on a lateral or convergent gaze. We also have the patient tilt their head and see if any double vision pops up. Basically, using this pattern will find most if not all occulomotor abnormalities.

Now at this point, we can also have the patient fixate on on object, and then we roll their head side to side and watch the "dolls eyes" phenomenon, and check for evidence of saccades or freezing of an eye midline.

If there is double vision, we have them close one eye to see if it goes away. If it does go away, then we can be fairly sure the double vision arises from an eye muscle overcompensating from another eye muscle weakness.

We are also testing here for spatial NEGLECT. We are seeing if they ignore fingers we hold up in each region of space. If they are, there are more advanced techniques you can use by turning their head or presenting an unusual stimulus (making a weird face) on the side they are neglecting. Since crossing your eyes and making a weird mouth expression is out of the ordinary, their frontal association areas will turn their ATTENTION subconsciously to that side. But later on, they will deny ever having seen you do that! This is very rare, but can be very informative to the Doc in the ER.

So while we are testing vision/neglect, we also test for naming and recognizing objects. I hold up my notebook and ask them what it is. I have them close their eyes and hand them a stuffed toy we have in the back for kids and ask me to tell me what it is.

Also, we can have them repeat a sentence to examine for dysarthria and comprehension.

If there is evidence of neglect, one of the BEST possible methods to DOCUMENT this - so the docs don't think you are crazy if it spontaneously resolves - is to have them draw a clock with the hands at 2:10!! Patients with neglect will invariable ignore whatever side, and presto, you have written incontrovertible proof of this for a physician.

Cranial Nerve VII (Facial) - Now there is some weirdness with the facial nerve. The LOWER face is innervated by CONTRALATERAL fibers, so any lower facial deficit from CORTICAL damage should be on the same side as the motor deficit.

We do the smile, wrinkle your nose, raise your eyebrows, and then bury/hide your eyelashes. I also have them wink at me with one eye, then the other, and then in rapid succession.

Cranial nerves VIII-XII - Here is gets a bit more tricky, but the tongue is a GREAT way to test lower in the brain lesions. Stick out your tongue, move to the right, left, and then try to touch their nose with it. Any fasiculations (ridges) on the tongue are a dead giveaway for a cranial nerve XII deficit.

Other techniques:

-Nose to finger
-Having them hit their palm with the top and then bottom of their other hand in rapid alternating succession - we are looking for evidence of dysdactokinesia
-Instruct them to fold a piece of paper in half, hand it to you, and then touch their hand to their chest - we are testing memory, praxis, following commands, and spatial awareness

So in short:
1) Focus on the obvious deficit, and then identify extremity deficits in sensory/motor
(2 and 3 can be interchangeable depending on your patient)
2) Check occulomotor function, vision, object recognition, and evidence of aphasia
3) Check the face and see if facial deficits correlate to the side of the extremity deficit
4) Go lower in the brain and check the tongue, and then follow up with the cerebellum and dysdactokinesia
5) Come up higher and check praxis, higher commands, memory, and visuospatial awareness - take into account motor deficits that are existing

If you simply do 1-3 and even forget testing for neglect, you will nail most CVA patients, and get them the priority they deserve at the ER. 4-5 may identify a global problem superimposed on top of a CVA, and get a good CYA for the ER doc transferring immediately to Neuro.

You may also say, hey that is the NIH stroke scale minus fine motor skills and the cards! Well yes and no. It was how I was trained to do it that does not take the strict and regimented and quantifiable of the NIH. No one I know can do NIH in the time most of our jurisdiction is to the hospital. No one.

If I really have the time, I give the patient the Mini-cog. I ask them to remember "ball, tree, and flag" as words to recall, have them draw a clock at 2:10, and then ask them to recall the words. This is a GREAT test for dementia, delirium, as well as executive and memory deficits from cerebrovascular disease.

@Brandon Oto
See above for Babinski, and Hoffman's sign can be done right after checking their power to squeeze. Just flick their middle finder while you already have their hand in yours!

Serial 7s and words backwards can be done after 3) above if you feel there is evidence of an executive dysfunction.

Ahhhh I just finished restructuring my neuro exam.

Stick around mate, I have much to learn.

 

[Aidey]

The doc said it might have happened early on in the day when she was complaining of a headache and took excedrin and more oxy. Not trauma related.

I wonder how the ASA contributed to the event. Depending on how many pills she took she could have received a pretty large dose of it.

 

[RocketMedic]

I tend to overanalyze things here, and take a different approach than most to altered mental status but here goes:

Altered, confused with slurred speech and asymmetrical mouth
Can result from a 7th cranial nerve damage, OR upper motor neuron damage in the cortex associated with motor tone
10 and 12th cranial nerve damage possible as well

History of multiple drug use. Uses OxyContin, no idea how many taken today and can't find the bottle. Pupils 2mm, reactive
Generally a 3rd cranial nerve abnormality ruled out, and the fact pupils are not pinpoint lessens the certainty that opioids are the root cause

took excedrin and pain meds
Possibly a delirium super imposed on top of whatever else is going on, depending on whatever else she took with the Oxy, due to CYP450 drug metabolism and interactions. Oxy and Excedrin are both partially metabolized by CYP2D6

Slow, languid twisting motions of her arms and legs
Were the movements in any way purposeful? Were pain and deep tendon reflexes intact? She could be in transition to decorticate, and then decerebrate disinhibition.

What was her breathing like? Any signs of degeneration into Cheyne-Stokes respirations? Were Babinski sign present? Sign of Hoffman?

Reported to have stumbled against a door at approx 1500, some slight abrasions around her left eye. Facial bones intact, no crepitus or pain on palp
See Natasha Henstridge as a prime example of how a knock to the head in just the perfect way can kill someone, after the person is seemingly fine since the trauma.

So, you have a deficit at possibly the level of cranial nerve 7 (pons) and/or 10 and 12 (medulla), symmetrical extremity motor abnormality, possibly affecting both corticospinal and cortico-thalamic tracts.

All this would seem to point to an increase in intracranial pressure, which presses the brain downward on the midbrain, pons, and medulla. This downward pressure affects motor tone and movement bilaterally, and ultimately if untreated, can affect the respiratory centers (re Cheyne-Stokes) Just enough asymmetrical pressure on the side ipsilateral to the 7th cranial nerve deficit is enough for a lower facial palsy.

There are very, very few other things that can affect the motor system bilaterally, including CVA. You'd have to have a near complete blockage of the basilar or vertebral artery, or profuse bleeding into the pontine cisterns.

Seems like a CVA of that magnitude would be A) unlikely, based on patient demographics and B) really, really unlikely to have not been noted before, unless all blocks literally formed at the same pace and with no prior effects at all.

I'd lean towards TBI myself. With a possible differential of Bell's palsy- but that's unlikely, to say the least.

I'd treat this as a closed head injury/aneurism (spelling's wrong, I know).

 

[Aidey]

CVA is unlikely, but the pt did have a major basilar bleed, so obviously not that far outside the realm of possibility.

 

[mycrofft]

Rocketmedic, roger that last line.

CVA may be unlikely, but they happen.
USAF raised the subject of paraspinal aneurysms a little while back as well.
If your genes say "aneurysm", then the clock is ticking, and not much to do in ambulance...or is there?
Not only do you get infarct of the deprived regain and potential for ICP, but extravascular blood really bothers grey matter.

 

[RocketMedic]

Not to mention that pesky surgical repair indicated..

 

[mycrofft]

I remember when I was an EMT and wanted avidly to find to what was "really going on".
Later, I was more concerned with "If this is going wrong, what can I do in my time frame prehospital and without my Armee Suisse Ambulance (sixteen tools in one) when I se S/S XYZ occurring.

 

[Handsome Robb]

I remember when I was an EMT and wanted avidly to find to what was "really going on".
Later, I was more concerned with "If this is going wrong, what can I do in my time frame prehospital and without my Armee Suisse Ambulance (sixteen tools in one) when I se S/S XYZ occurring.

Is it wrong to be curious? If you have an idea of what's going on you have an idea of where it could go rather than blindly trying to be prepared for "xyz symptoms".

 

[mycrofft]

Not wrong to be curious. Just being more utilitarian, and my prospects for advancement are nil.
Overstudying for EMT-A made me a better EMT-A and better going into nursing college.