Rosen & Barkin's 5-Minute Emergency Medicine Consult (196 page)

• Carboprost tromethamine (Hemabate): 0.25 mg IM q15–60min (up to 2 doses)
  
• Methylergonovine maleate (Methergine): 0.2 mg IM
  
• Oxytocin: 20–40 U IV in 1 L of normal saline infused at 250–500 mL/h IV
  

FOLLOW-UP

• All women with uncomplicated deliveries and no significant postpartum bleeding should be admitted to labor and delivery or postpartum unit for care and monitoring
  
• Obtain pediatric or neonatal consultation and admit to neonatal ICU:
  
  • All infants with respiratory distress
    
  • Gestational age <36 wk
    
  • Weight <5 lb
    
  • Low Apgar scores
    
• Term infants with none of above complications may be admitted to the nursery or with mother to combined maternal–fetal unit
  
• If transferring the mother and infant after delivery, consider using 2 ambulances
  

• After adequate recovery from delivery, patient can be taken labor and delivery or postpartum unit
  
• Patient should not be discharged home from ED
  

• Be ready for complications such as cord prolapse, shoulder dystocia, breech delivery
  
• Be prepared to treat 2 patients after delivery—mother and infant
  

• Enright K, Kidd A, Macleod A. Postpartum emergencies.
  Emerg Med J
  . 2009;26:310.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Mirza FG, Gaddipati S. Obstetric emergencies.
  Semin Perinatol
  . 2009;33:97–103.
  
• Roberts JR, Hedges JR, Chanmugan AS, et al., eds.
  Clinical Procedures in Emergency Medicine
  . 4th ed. Philadelphia, PA: Saunders; 2004.
  

CODES

• 650 Normal delivery
  
• 661.30 Precipitate labor, unspecified as to episode of care or not applicable
  
• V23.7 Supervision of high-risk pregnancy with insufficient prenatal care
  

BASICS

• Progressive deterioration in cognition, behavior, or both without impaired consciousness that is severe enough to interfere with activities of daily living due to alteration in cortical brain function. A chronic and progressive form of organic brain syndrome.
  
• Over 50 different causes, but >60% caused by Alzheimer disease
  
  • Involves increased neurofibrillary tangles and elevated beta amyloid plaques
    
• Prevalence 1% at age 60 yr to 30–50% by age 85 yr
  
• Characterized by gradual decline in cognitive functioning:
  
  • Generally evolves over period of years
    
  • Course is highly variable, months to years in duration
    
  • Rapid decline indicative of other causes, or rare rapid onset causes of dementia (prion diseases, progressive supranuclear palsy)
    
• Variable hereditary
  
  • Increased risk of Alzheimer disease in 1st-degree relatives of patients with Alzheimer
    
  • Apolipoprotein ε4 is the only well-established mutation with late-onset Alzheimer
    

• Primary dementia:
  
  • Cortical (Alzheimer disease, frontotemporal dementia)
    
  • Subcortical (Huntington disease, Parkinson disease, progressive supranuclear palsy)
    
• Secondary dementia:
  
  • Cerebrovascular disease (multi-infarct dementia)
    
  • Toxic, metabolic, nutritional derangements
    
  • Prion disorders (Creutzfelt-Jakob or bovine spongiform encephalopathy and variants)
    
  • Infectious agents (HIV, syphilis, encephalitis)
    
  • Vasculitis (systemic lupus erythematosus, thrombotic thrombocytopenic purpura)
    
  • Traumatic (chronic subdural hematomas, pugilistic dementia)
    
  • Structural (normal pressure hydrocephalus, brain masses)
    
  • Binswanger disease
    
• Reversible (∼15%) causes include normal pressure hydrocephalus, medications, intracranial masses, and alcohol abuse syndromes
  
• Pseudodementia:
  
  • Depression in elderly can present with dementia-like symptoms
    
  • Common in mildly demented patients, look for pin-point event with short duration of symptoms
    
  • Generally with history of psychiatric conditions, emphasis on failures and disabilities
    

DIAGNOSIS

• Insidious onset, with initial complaints of anxiety, depression, frustration, increased forgetfulness
  
• Generally preceded by “mild cognitive impairment,” an intermediate state of cognitive function between normal aging and those meeting criteria for dementia
  
• Can be grouped into 3 categories:
  
  • Early: Difficulty concentrating, memory deficits, difficulty with complex tasks, social withdrawal
    
  • Moderate: Major memory difficulties, need assistance with activities of daily living
    
  • Severe: Minimal ability to speak or communicate, difficulty eating, loss of psychomotor skills
    
• Diagnostic criteria (from American Psychiatric Association):
  
  • Development of multiple cognitive deficits manifested by both:
    
    • Memory impairment
      
    • One (or more) of the following cognitive disturbances: Aphasia, apraxia, agnosia, disturbance in executive functioning
      
  • Cognitive deficits that cause significant impairment in social or occupational functioning and are a decline from prior levels of functioning
    
  • Deficits do not occur during course of delirium
    

• Must include input from family and friends
  
• Complete list of medications
  
• Comorbid diseases
  
• Prior history of similar behavior
  
• Onset and progression
  
• Consider use of Montreal Cognitive Assessment, Short Test of Mental Status (alternative to mini-mental status exam)
  

Full and complete physical exam:

• Head-to-toe evaluation, all organ systems
  
• Meticulous neurologic exam:
  
  • Mental status evaluation
    
  • Cranial nerves
    
  • Reflexes
    
  • Motor, sensory, cerebellar, gait
    

• Must eliminate acute reversible or exacerbating factors
  
• Extent of workup is related to history and course of illness:
  
  • Extensive evaluation for new diagnosis
    
  • Directed evaluation for sudden change of dementia
    
  • Limited evaluation for stable disease previously assessed
    
• Must be able to identify signs and symptoms of the reversible causes of dementia
  

• Extent of evaluation dependent on patient condition and suspected cause
  
• New diagnosis or sudden deterioration:
  
  • CBC
    
  • ESR/CRP
    
  • CMP
    
  • Ammonia
    
  • Urinalysis
    
  • Toxicology screen
    
  • Thyroid-stimulating hormone
    
  • Vitamin B
    ₁₂
    level
    
  • Syphilis serology (RPR)
    
  • HIV
    
  • Blood cultures if fever present
    
  • Urine cultures if fever present
    
  • Antinuclear antibody if SLE suspected
    
• Established diagnosis with stable disease: No tests may be required.
  

• New diagnosis or sudden deterioration in established dementia:
  
  • CXR if infection considered
    
  • Head CT, without and with contrast
    
  • EEG if suspicion of seizure disorder
    
  • Brain MRI/MRA in selected cases
    
  • More advanced imaging (PET, etc.) should be reserved for use by specialists
    
• Established diagnosis with stable disease: Studies may not be required.
  

• Lumbar puncture and CSF analysis, syphilis serology
  
• EEG if seizure suspected
  

• Toxic, metabolic, nutritional abnormalities:
  
  • Narcotics, sedatives, hypnotics
    
  • Alcohol
    
  • Heavy metals
    
  • Dehydration
    
  • Electrolyte abnormalities
    
• Pseudodementia
  
• Delirium (high suspicion for UTI and pneumonia in febrile patients)
  
• Senescent aging
  

TREATMENT