HiNTS exam

What

Series of three quick, bedside, physical exam maneuvers that can potentially rule out a central cause of vertigo

 

Hi for head impulse testing, or head thrust testing.
N for nystagmus to remind you to look for direction-changing or vertical nystagmus
TS for test of skew.

 

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Why

  • Nearly two-thirds of patients with stroke lack focal neurologic signs that would be readily apparent to a nonneurologist

  • Presence of all three “reassuring” exam findings suggests it can be ruled out with a 100% sensitivity for ischemic stroke in AVS while an initial MRI with diffusion-weighted imaging (DWI) had a 88% sensitivity





 

Who

Maneuvers used to help distinguish between central and peripheral vertigo in patients experiencing an acute vestibular syndrome (AVS) which is best defined as: rapid-onset vertigo, nausea and/or vomiting, gait unsteadiness, head motion intolerance, and nystagmus.

 

When

The patient must be experiencing continuous vertigo for the results to be reliably interpreted.

How

Head Impulse Test

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  • Ask the patient to relax his/her head and maintain his/her gaze on your nose. Gently move the patient’s head to one side, then rapidly move it back to the neutral position. The patient may have a small corrective saccade. The head impulse test is positive (consistent with peripheral vertigo) if there is a significant lag with corrective saccades. If you can see the correction, it is abnormal. Compare this to the contralateral side; a difference in the speed of correction should be noted.

  • In acute vestibular syndrome, an abnormal result of a head impulse test usually indicates a peripheral vestibular lesion, whereas a normal response virtually confirms a stroke.

  • Abnormal exam rules in peripheral vertigo and thus rules out central vertigo if only unilateral

  • Video- https://www.youtube.com/watch?v=XpghlvnrREI&feature=youtu.be&t=665

 

Nystamus

  • Note if it is present in primary gaze (i.e. looking straight ahead) and or in lateral gaze. Unidirectional, horizontal nystagmus is reassuring for peripheral vertigo where as purely bidirectional, vertical or torsional can be consistent with central cause

  • The most common peripheral nystagmus, BPPV, in the posterior semicircular canal consists of a unidirectional horizontal nystagmus with a torsional component.

 

Test of Skew

  • Have the patient maintain his/her gaze on your nose. Alternate covering each of the patient’s eyes

  • Positive result will be the deviation of one eye while it is being covered, followed by correction after uncovering it.

https://www.youtube.com/watch?v=WAPaIMMsV_A

 

Summary

  • If the HiNTs exam is entirely consistent with peripheral vertigo (positive head impulse test, unidirectional and horizontal nystagmus, negative test of skew), then, according to the derivation paper, it is 100% sensitive and 96% specific for a peripheral cause of vertigo.

  • Use of HiNTs exam in the ED is currently controversial as the primary study was performed by neurologists in a partially differentiated patient population

  • likely has higher utility in the patient population in whom the clinician suspects a peripheral cause of their vertigo to rule out central cause and limit needless imaging

 

 

Limitations

  • Do not perform on any patient that has head trauma, neck trauma, an unstable spine, or neck pain concerning for arterial dissection.

  • Do not perform in patients with known severe carotid stenosis as it may embolize unstable plaque

  • Challenging to differentiate between catch up saccade and nystagmus

  • Patients with acute active AVS likely to not tolerate the testing

  • Patient must be awake and cooperative.

  • Essentially an awake “doll’s eye” that requires conscious fixation on an object. Cannot perform on mentally impaired or sedated patients

  • Not yet been validated by a large external group, let alone a large external group of emergency medicine providers.

  • In the study, exam performed by ophtho neurologists

 

References

 

NUEMBlog

Tamingthesru

Nelson, James A., and Erik Viirre. "The clinical differentiation of cerebellar infarction from common vertigo syndromes." Western Journal of Emergency Medicine 10.4 (2009): 273.

Kattah, Jorge C., et al. "HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging." Stroke 40.11 (2009): 3504-3510.

Tarnutzer, Alexander A., et al. "Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome." CmAJ 183.9 (2011): E571-E592.




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POTD: Tongue Blade Test in Minor Mandibular Blunt Trauma

Minor trauma with mild swelling and want to avoid imaging the patient?

Tongue blade test:

How is it done? Have the patient attempt to "clamp down on” a tongue blade between the teeth with enough force that the examiner is unable to pull it out from the teeth.

When the examiner twists the blade, a patient should be able to generate enough force to break or crack the blade.

A positive test: if the patient cannot clench the tongue blade between the teeth or if the examiner cannot break the blade while it is held in the patient’s bite. If the test is positive, imaging is indicated.  

A negative test: If the blade can be gripped by the patient and be broken by the examiner, fracture of the mandible is much less likely, and additional imaging is likely not needed. In a prospective series of 110 patients with suspected mandible fracture, the test was found to be approximately 96% sensitive and 65% specific.

Who is not likely to benefit from this test? Major trauma that would indicate further imaging, signs of mandibular fracture such as: intraoral bleeding, tooth malocclusion, trismus, ecchymosis, and intraoral swelling.

Sources: https://www.aliem.com/2010/07/trick-of-trade-tongue-blade-is-as/

^ Check out this awesome aliem post and especially for the video demonstration

Alonso L, Purcell T. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med. 1995;13(3):297-304. [PubMed]

Peer IX

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POTD: Ludwig’s Angina

History: Named after German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836.

Overview:

•        Submandibular Space Cellulitis

•        Bilateral

•        Aggressive, fast spreading

•        70% of Ludwig’s angina is dental in origin

•        Real risk of airway compromise: This can result in rapid airway decompensation.


Physical Exam (useful things to document the presence of absence of in the chart):

•        Floor of the mouth: is described as: “woody,” which means firm, indurated, taut

•        Tongue: displaced superiorly and posteriorly

•        This result in: Slow suffocation, drooling, sniffing position, muffled voice, stridor

•        Labs

•        Vbg, cbc 7, blood cultures

•        Imaging

•        CT face and neck with IV contrast

•        Be very cautious if you are sending them to CT without airway secured

•        Consults

•        ENT, anesthesia

 

Treatment

•        ABCs…A! Airway obstruction in 33%

•        sit upright

•        Secure/verify integrity of airway

•        Awake fiberoptic nasal intubation

•        Mentally prepare yourself for a surgical airway. This is the time to have the materials set up at the bedside.

•        Abx: polymicrobial

  • Oral anaerobes and aerobes

  • PCN G + flagyl

  • Unasyn

  • Clinda

  • Immunocompromised? Cefepime +flagyl

•        Steroids

  • Dexamethasone  8-12 mg IV

•        Dispo

  • ICU

  • 3-4 day process, gets worse before better


Complications

•        Mortality usually associated with airway compromise

•        with appropriate treatment, 8% mortality

•        Spread of infection: IJ thrombophlebitis, intracranial infection, mediastinitis

 

Brush up!

Brush up!

Sources: LIFL https://lifeinthefastlane.com/ccc/ludwigs-angina/

Uptodate Lugwig’s angina

Tintinelli’s Lugwig’s angina

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POTD: Foreign Body of the Nose

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Foreign body of the Nose

•        Most common age range: 2-5 yo

•        Most common FB: beads, beans, peanuts, toy parts

•        Beware of: button batteries and two magnets, as always.

•        Can lead to septal perforation/necrosis of tissue.

•        Be suspicious of nasal FB when you see unilateral discharge, often malodorous

•        Complications: infection, aspiration, epistaxis

  

To remove:

•        Topical lidocaine or afrin?

  • Pro: improve tolerance of/cooperation with the procedure

  • Con: risks displacement of the FB

 

How to remove

1) Mechanical extraction: You need a cooperative child and good visualization.

2) Suction: must exercise extreme caution not to push further back and aspirated into the trachea

3) Positive Pressure: Parent’s kiss, bag mask, continuous pressure

  • Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

  • Parent’s Kiss: One of my preferred methods. Has a 50 % success rate.

Kissing parent: The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing. See picture below for demonstration.

Nothing working? You may need an ENT consult because the FB is so posterior that above methods are futile.

Now that it’s removed:

·       Don’t forget to inspect for trauma or retained FB

References:

•        PEM playbook foreign bodies: excellent peds podcast by Dr. T Horeczko - ‎2015

•        Wiki EM: Nose foreign body

Look at this retro parent’s kiss!

Look at this retro parent’s kiss!

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POTD: Foreign bodies, Ears!

potd kid ear.png

This is a two part series for POTD. Foreign bodies: Ears and Nose! Today, Ears!

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Quick Anatomy review to help locate that FB:

•        Anatomy

–       medial 2/3 is fixed in temporal bone –where many FBs are lodged and/or where trauma

•        Ask yourself: is it graspable or non-graspable?

–       Graspable: 64% success rate, 14% complication rate

–       Non-graspable: 45% success rate, 70% complication rate

•        What instrument/method should I use for what?

–       Alligator forceps: think something graspable like paper, foam

–       Suction tip: think something non graspable like a round object such as a bead

–       Irrigation: think something non graspable like a bead (note: do not irrigate organic material as will swell or break apart)

–       Glue: something non graspable like a bead or organic material that might swell or break if irrigated

 

Pearls on insect FB:

·       Kill it first. They will fight.

-        What to use? Lidocaine jelly, viscous lidocaine (2%), lidocaine solution, isopropyl alcohol, or mineral oil.

-        After they are dead, you can remove or can send to ENT for removal (most patients will want it out, can you blame them?)

o    An ENT friend of mine says to keep the insect in the ear and let them remove because we tend to cause trauma. Something to keep in mind.

 

What if I caused or the FB (like that insect fighting for their life) caused local trauma?

•        TM rupture?

–       Keep dry

•        When to use otic abx drops

–       Any trauma or dirty FB injury (think: that insect crawling around) or canal lacerations/abrasions.

–       What to give? Ofloxacin drops or the very expensive ciprodex.

•        ENT f/u

 

Pitfalls

•        Inspect after removal

–       Something else in there? Abrasions/trauma and need prophylactic antibiotic ear drops

•        If at first you don’t succeed, try again. But consider changing the technique of removal. Remember the law of diminishing returns.

 

References:

Pem playbook: excellent peds podcast by Dr.  T Horeczko - ‎2015

Wiki EM: Ear foreign body

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POTD: Cavernous sinus thrombosis (CST)

Clinical Scenario:

A 30-year-old woman presents with headache, fever, and decreased vision in her right eye over the past 24 hours. Examination reveals exophthalmos of the right eye and no pupillary reflex and a clear anterior chamber. When asked, she denies weakness and numbness.

What is the most likely diagnosis?


Last week we talked about cerebral venous sinus thrombosis (CVST), today let’s talk about cavernous sinus thrombosis (CST), or the infected subset of cerebral venous sinus thrombosis.

What is it?

  • Cavernous sinus thrombosis (CST) is a rare condition, defined as a septic thrombophlebitis of the cavernous sinus. It is caused by a bacterial infection that typically originates in the face, sinuses, ears, or orbits. Most infectious etiologies in cavernous sinus thrombosis are from Staphylococcus or Streptococcus species. 

  • The two cavernous sinuses are located on both sides of the sella turcica. Important structures are located in, or run through, the cavernous sinus, including the pituitary gland, cranial nerves III, IV, V and VI, and the internal carotid arteries (ICA)

  • It causes significant morbidity and the mortality rate is at 20-30%.

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Risk Factors

  • Sphenoid and ethmoid sinusitis are the most common causes of CST. 

  • Other risk factors include dental infections, facial cutaneous infections, otitis media, maxillofacial surgery, and trauma.

Presentation

  • Most patients will have fever, headache, and vision changes/ocular complaints (proptosis, periorbital edema and/or chemosis). 

  • Most will also have external ophthalmoplegia, due to venous congestion of orbital tissues, extra-ocular muscle inflammation and/or inflammation of cranial nerves III, IV and VI. 

  • Other symptoms include eyelid erythema, autonomic dysfunction, sensory changes in the ophthalmic and maxillary trigeminal nerve distributions, pupillary abnormalities, and papilledema. 

  • Vision loss is rare as the orbital nerve lies outside the cavernous sinus. 

  • CST commonly spreads from one eye to both within 24 to 48 hours.

KeralaJOphthalmol_2016_28_1_61_193869_f1.jpg

Evaluation

Blood cultures, CBC, and coagulation studies (PT and PTT) should be ordered, as well as CT of the head and orbits with contrast.

Treatment

  • Parenteral antibiotic treatment should be started with gram-positive coverage (nafcillin plus a third-generation cephalosporin or vancomycin if concerned for MRSA). The patient should be admitted with neurology and ophthalmology consultations

  • Anticoagulation and steroids, remain controversial.

    • Steroids may confer improved cranial nerve function.

    • Anticoagulation may confer a risk of systemic and intracranial bleeding and may result in dissemination of septic emboli. Consider anticoagulation only if there is no evidence of severe bleeding risk or current hemorrhage.

Differences between CVST and CST

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Tooth Avulsion

Piggybacking on Dr. Cueva and Dr. Yetters tooth injury pearls earlier this year, I am here today to give some practical advise that you may not have time to look up in a trauma We are going to go over how to QUICKLY SPLINT A TOOTH AVULSION.

  • Note: Time is tooth, after one hour of avulsion viability is severely decreased; preferably <30min!

1)      While setting up for the procedure soak the tooth: Saliva is a great medium (place in mouth) = Hanks solution > Milk > Saline.

2)      Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.

3)      Implant tooth in anatomical position

4)Splint: Use N95 respirator mask metal piece or metal piece from non-rebreather; both pliable and cut to size to include adjacent teeth.

  • File edges of any cut metal to prevent abrasions/laceartions.

5)Dry teeth – most important step!

  • Ensure this by using nasal canula or yankhauer connected to O2 source.

6)      Apply metal splint to tooth with dermabond. Apply dermabond between adjacent teeth and to splint.

7)      Hold splint in place for one minute.

Other important tips:

Start prophylactic antibiotics.

Urgent dental consultation.

CT if alveolar fracture suspected.

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