#EuSEM2018 – Day 4

Hej Hej Glasgow it was fun, now back to work.  Day-4 was full of great Canadian thoughts on neurology (Vertigo, SAH, and TIA) all topped off with a sprinkle of Organophosphates

Vertigo – Guide to the big 3

1. Any features that mandate imaging?

  • Neurology deficit
  • Significant headache
  • Neck pain
  • Unable to stand or walk
  • Spontaneous vertical nystagmus (i.e. not while doing dix-hallpike)

2. History

  • Short episodes <2 min brought on by movement, no spontaneous nystagmus (i.e. only on move)
    • BPPV > Dix-Hallpike
  • Dizzy for Hours
    • Vestibular neuritis vs central > HINTSplus exam (you can only use HINTS if patient is dizzy and has nystagmus)

Horizontal canal BPPV sounds similar to posterior canal (D-H+eply) but tends sever when moves head when upright – tests and how to treat different

Vestibular migraine

One to think about if patient presents without nystagmus  – patient should state:

  • Recurrent (at least 5 episodes)
  • Lasts unto 72hrs
  • Has a temporal relationship to migraine symptoms (this may be aura symptoms not headache) at least 50% of the time

Apparently 2.5% population get this, most un/miss-diagnosed, metacloprimide can help


Ottawa rule out strategy Validation

Something to explore with ED/Med/Rad

1. Inclusion/Exclusion criteria

  • Inclusion
    • Alert
    • > 15 yr of age
    • New acute severe non-traumatic headache that reaches maximum intensity within 1 h of onset. Not to be used in patients
  • Exclusion
    • New neurological deficits
    • Previous aneurysms, SAH or brain tumors
    • History of similar headaches (≥ 3 episodes over ≥ 6 mo)
    • Profound Anaemia

2. Clinical Rule-Out – Patient has NONE of following:

  • Symptom of neck pain or stiness
  • Age > 40 yr
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (peak pain instantly)
  • Limited neck flexion upon exam

ANY features > CT / NONE > No further investigation required

3. CT Head negative

  • SAH excluded if ALL of following :
    • CT performed within 6 hours of headache onset
    • Experienced radiologist (validation used “General radiologists at 2/6 sites, thin slices (initially 10mm at start of study – what can we provide?)
    • NO ‘Ultra-High’ Risk features

Patient doesn’t fit above then need LP.

4. LP results

  • LP Positive  – perform CTA
  • LP negative (RBC <2000×10 6, no Xanthochromia)
    • No ‘Ultra-High’ Risks – Excluded
    • ‘Ultra-High’ Risks
      • Very few RBC – Excluded
      • Moderate – if still clinical concern  – perform CTA

Validation INFO Presented – Dr Perry

  • Studied before and After implementation
  • @ 6 centres in canada 2010-2017  (3669 patients)
  • Clinical rule out – 100% sensitive
  • 6hr rule out CT – 5 misses
    • 1 was miss by radiology
    • 2 un-ruptured aneurysms, (surgeons stated they were incidental but, one open repair no staining of tissues (so no bleed), one coil preventative)
    • 1 Dural vien fistula
    • 1 sickle cell with profound anaemia (Hb 63) – known risk within radiology so profound anaemia included in exclusion
  • How testing changed with implimentation
    • CT rate not changed
    • LP’s fell from 38-25%
    • Mean length of stay 6.4hr unchanged (however, ED responsible for LP so withTime in ED would be shorter)
  • Prev studies canadajapan



Vast majority of complications post TIA (i.e. strokes) happen within 7 days (50% within 2days) so time matters

Risk score

  • ABCD2 – has the most evidence but only has a sensitivity of 31%
  • Canadian risk score – much more complex , but much better characteristics – validation just finishing 


  • Early specialist and carotid imaging vital (Carotid endarterectomy NNT= 3 if done in first 2weeks)
  • Anti-platelet therapy – evidence from CHANCE and POINT trials indicating 21days dual anti-platelet therapy best (then going back to 1)
  • TIA with AF – need anticoagulation if possible NOAC’s prob best and would be easiest for us in ED


Organophosphate (nerve agents)

  • Used several times recently.
  • Decontamination vital – In the Sarin attack (japan), poor decor 20-30% of staff treating the patients @ hospital developed symptoms
  • Sign & Symptoms
    • Miosis/Lacrimation
    • Local Fasciculations
    • Sweating/Hypersalivation
    • Bronchoconstriction (wheezy) >  Resp failure/arrest
    • Fits/coma
  • Blood and skin tests available – do we have any?
  • Therapy
    • Atropine: 2mg im/iv, if not improved double  (i.e. 4mg >8mg>16mg>32mg)
      • looking to have clear chest dry armpits, HR and sBP at about 80
    • Oximes: several available (We get Pralidoxime from LGI see rare antidotes)
      • Can help reverse AChe blockage
      • Earlier the better and may take a long time
  • Types of Agent
    • G agents – volatile evaporate quick, onset fast offset fast
    • V agents – stable, onset slower, off set slow
    • OP agents (pestersides) – v slow


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