Rosen & Barkin's 5-Minute Emergency Medicine Consult (510 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Phimosis
  
• Priapism
  

CODES

605 Redundant prepuce and phimosis

BASICS

• Gradual progressive neurologic disorder of middle or late life
  
• Degeneration of dopaminergic neurons in the substantia nigra
  
• Development of Lewy bodies in the residual dopaminergic neurons
  
• Accelerated cortical atrophy
  
• Can begin unilaterally, but generalizes to symmetric
  
• Affects 1% of people >60 yr; 4% >80 yr
  
• May have symptoms 20 yr prior to diagnosis
  
  • Nonspecific:
    
    • Fatigue
      
    • Constipation
      
    • Hyposomia
      

• Sporadic or idiopathic
  
• Disorders presenting with parkinsonism:
  
  • Drug induced:
    
    • Parkinsonism-hyperpyrexia syndrome (dopaminergic drug withdrawal)
      
    • Amphotericin B
      
    • Chemotherapeutic drugs
      
    • Neuroleptic treatment induced
      
  • Toxins:
    
    • Carbon monoxide
      
    • Methanol
      
    • Cyanide
      
    • Organophosphate poisoning
      
    • 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine
      
  • Brain lesions:
    
    • Basal ganglia stroke
      
    • Midbrain lesions
      
    • Hydrocephalus
      
  • Infections:
    
    • Mycoplasma
      
    • Viral encephalitis
      
  • Other:
    
    • Central pontine myelinosis
      
    • Encephalitis lethargica (autoantibodies against basal ganglia antigens)
      

DIAGNOSIS

• Nonmotor vs. motor symptoms:
  
  • Nonmotor:
    
    • Orthostatic hypotension
      
    • Constipation
      
    • Delayed gastric emptying
      
    • Dysphagia
      
    • Pain sensory dysfunction
      
    • Depression
      
    • Hallucinations
      
    • Dementia
      
    • Sleep disorders
      
• Motor symptoms:
  
  • “Pill-rolling” resting tremor
    
  • “Cog-wheel” rigidity due to increased muscular tone
    
  • Stooped posture and instability of posture
    
  • Bradykinesia: Extreme slowness in movement
    
  • “Masked face” appearance
    

• Sudden change in baseline motor function or mental status:
  
  • May be the only indication of systemic disease such as infection
    
• Noncompliance (sudden withdrawal) of dopaminergic medications can lead to parkinsonism-hyperpyrexia syndrome:
  
  • Rigidity, pyrexia, reduced consciousness
    
  • Complications:
    
    • Acute renal failure
      
    • Venothrombosis
      
    • Disseminated intravascular coagulation
      
    • Rhabdomyolysis
      
    • Autonomic instability
      

• Cog-wheel rigidity:
  
  • Jerking movements when a muscle is passively stretched
    
• Stooped posture
  
• Pill-rolling tremor
  

• History is of primary importance:
  
  • Diagnosis is made based on clinical findings
    
• Important historical information includes:
  
  • Onset of symptom, whether gradual or sudden
    
  • History of potential causes of a Parkinson-like syndrome
    
  • Patients with established Parkinson disease (PD):
    
    • Sudden change in baseline motor function
      
    • Change in mental status
      
    • Should prompt workup for infectious process
      

• No specific or recommended lab studies necessary to confirm the diagnosis
  
• Disorders presenting as PD may require directed lab studies as appropriate for suspected cause
  
• Directed labs if suspect parkinsonism-hyperpyrexia syndrome
  

• CT and MRI are not required to diagnose PD but are often elements of evaluation for dementia
  
• CXR may be indicated for any signs of respiratory tract infection
  

• Benign familial tremor
  
• Major depression
  
• Wilson disease
  
• Huntington disease
  
• Alzheimer disease
  
• Creutzfeldt–Jakob disease
  
• Carbon monoxide poisoning
  
• B
  ₁₂
  deficiency
  
• Hydrocephalus
  
• Multi-infarct dementia
  
• Essential tremor disorders
  
• Hypothyroidism
  
• Dementia with Lewy bodies
  

TREATMENT

• Treatment with antiparkinsonian medications can be initiated in the ED to alleviate symptoms
  
• Consultation with neurology for recommended medication regimens and ongoing support and monitoring is prudent
  
• For patients with mild disease, no medication may be required
  
• For moderate disease, anticholinergic medications and dopaminergic medications should be used
  
• Treat underlying infection, if present
  
• Treat parkinsonism-hyperpyrexia syndrome:
  
  • Replace levodopa or bromocriptine
    
  • Supportive
    
  • Treat complications
    

• PD:
  
  • Amantadine: 100 mg BID
    
    • Stimulates dopamine release
      
  • Benztropine: 0.5–1 mg TID
    
    • Anticholinergic
      
    • Limited use in tremor-dominant PD
      
  • Carbidopa/levodopa: 25/100 mg TID
    
    • Carbidopa lessens peripheral side effects and increased levodopa CNS bioavailability
      
    • Levadopa is direct precursor to dopamine
      
  • Entacapone: 200 mg PO BID–QID
    
    • Adjunct therapy; should be administered concomitantly with carbidopa/levodopa
      
    • Increases CNS levadopa bioavailability
      
  • MAO inhibitors
    
    • May be used in mild disease as first-line therapy
      
  • Selegiline: 5 mg qam and noon
    
  • Rasagiline: 1–2 mg QD
    
  • Dopamine agonists:
    
    • Pramipexole: 0.5–1.5 mg PO TID
      
    • Ropinirole: 3–6 mg PO TID
      
    • Apomorphine: 0.2–0.6 mL SQ PRN
      
• Parkinsonism-hyperpyrexia syndrome:
  
  • Levodopa: 50–100 mg IV over 3 hr
    
  • Bromocriptine: 7.5–15 mg PO TID
    

Carbidopa/levodopa

FOLLOW-UP

• Patients with previously diagnosed Parkinson with infections, trauma, cardiovascular emergencies, cerebrovascular emergencies, GI emergencies, electrolyte disturbances, altered mental status, or other medical problems
  
• Depression with intent to do self-harm
  
• Confirm diagnosis and levodopa responsiveness
  
• Medication complications (parkinsonism-hyperpyrexia syndrome)
  
• Management of motor fluctuations and dyskinesias
  
• Inability to go home secondary to elder abuse
  
• Complications from deep brain stimulation devices (e.g., headache, infection, mental status change)
  
• Failure to thrive