>EM Reflections – May 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


 

Discussion Topics

  1. Measles – Refresher
  2. Posterior Stroke – Beware of Mimics
  3. Missed Fracture – Distracting Injuries

 

Measles – Refresher

Measles has for many years been an infrequent diagnosis in our population. However falling herd immunity is resulting in cases presenting to Canadian ED’s.

Measles signs and symptoms appear around 10 to 14 days after exposure to the virus.

  • Fever
  • Dry cough
  • Runny nose
  • Sore throat
  • Conjunctivitis

 

Measles causes a red, blotchy (erythematous maculopapular) rash that usually appears first on the face and behind the ears, then spreads downward to the chest and back and finally to the feet. Koplick’s spots can appear 1-2 days before the rash. The rash appearance can be variable, discrete maculopapular or merging erythematous.

 

Visit emDocs.net for this great refresher on EMin5 – Measles

EM in 5: Measles


 

Posterior Stroke – Beware of Mimics

Stroke Mimics

  • Acute peripheral vestibular dysfunction (Don’t forget the HINTS exam)
  • Basilar migraine
  • Intracranial hemorrhage
  • SAH
  • Brain Tumour
  • Toxic or metabolic disturbances
  • Neuroinflammatory or chronic infectious disorders

Note that it is possible to be influenced by past experience with mimics, resulting in falsely diagnosing a mimic in the presence of a stroke.

Stroke Chameleons

Stroke chameleons are disorders that look like other disorders but are actually stroke syndromes

  • Bilateral thalamic ischaemia is such a disorder and may cause reduced consciousness level or a global amnesic syndrome
  • Bilateral occipital stroke may present as confusion or delirium
  • Infarcts limited to the medial vermis in medial posterior inferior cerebellar artery (PICA) territory usually cause a vertiginous syndrome that resembles peripheral vestibulopathy

A very useful BMJ review article on Posterior Stroke can be accessed here.

Be cautious of migraine diagnosis with history that is different to typical migraine presentation. Multiple visits should raise concerns. Importance of thorough neuro exam to find possible deficits that would raise suspicion for more serious pathology. In posterior stroke, special attention should be given to examining the visual fields.

 

Imaging in Stroke and TIA

See Rounds Presentation by Dr. Dylan Blacquiere (Neurologist)

Imaging Recommendations. Dr Jake Swan (Radiologist)

After meeting with Dr. Blacquiere and the ER Department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.

1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.

2) SAH patients should have CT done prior to LP due to false positive LP rates.  If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.

 

The evidence is summarised in this recent paper – Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery


 

Missed Fracture – Distracting Injuries

Standard ATLS teaching, but this error still occurs……

Ensure a complete secondary survey is completed in all patients presenting with history of trauma.

Read the StatPearl Article and then do the MCQ test here

 

Trauma! Initial Assessment and Management

 

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