Rosen & Barkin's 5-Minute Emergency Medicine Consult (396 page)

FOLLOW-UP

• Hypoxia (pneumonia or reactive airway disease)
  
• Severe dehydration
  
• Alteration in mental status
  

Most patients will have a short, self-limited course provided they are able to tolerate fluids and antipyretics.

Consultation with infectious disease specialist when uncertain of local disease status, diagnostic uncertainty, local antiviral resistance patterns

Call back for PCR test result.

• Become familiar with online CDC weekly update since flu changes each season.
  
• In most patients, neither testing nor antiviral treatment is necessary.
  
• In patients with respiratory distress or hypoxia, consider concurrent reactive airway disease.
  
• ED policy: Institute respiratory hygiene:
  
  • Etiquette posters and alcohol hand soap available
    

• Call SA, Vollenweider MA, Hornung CA, et al. Does this patient have influenza?
  JAMA
  . 2005;293:987–997.
  
• CDC 2012 flu update:
  http://www.cdc.gov/flu/professionals/index.htm
  
• Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children—diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: Clinical practice guidelines of the Infectious Diseases Society of America.
  Clin Infect Dis
  . 2009;48:1003–1032.
  
• Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008.
  MMWR Recomm Rep
  . 2008;57(RR-7):1–60.
  
• Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza, Bautista E, Chotpitayasunondh T, et al. Clinical aspects on pandemic 2009 influenza A (H1N1) virus infection.
  N Engl J Med
  . 2010;362:1708–1719.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Anthrax
  
• Asthma, Pediatric and Adult
  
• Pneumonia, Pediatric and Adult
  

CODES

• 487.1 Influenza with other respiratory manifestations
  
• 488.02 Influenza due to identified avian influenza virus with other respiratory manifestations
  
• 488.82 Influenza due to identified novel influenza A virus with other respiratory manifestations
  

BASICS

Hemorrhage into brain parenchyma:

• Compression of brain tissues
  
• Secondary injury results from:
  
  • Cerebral edema
    
  • Increased intracranial pressure (ICP)
    
  • Potential of brain herniation
    

Intracerebral hemorrhage can occur spontaneously or from trauma:

• Uncontrolled or acute HTN (most common)
  
• Vascular malformations:
  
  • Arteriovenous malformation
    
  • Venous angiomas
    
  • Ruptured cerebral aneurysms
    
• Neoplasm (particularly melanoma and glioma)
  
• Anticoagulant therapy (warfarin, heparin)
  
• Thrombolytic agents
  
• Illicit drugs (cocaine, amphetamines)
  
• Bleeding disorders (hemophilia)
  
• Cerebral amyloid angiopathy
  
• Traumatic hemorrhage secondary to blunt or penetrating injury
  

DIAGNOSIS

• Severe headache, typically sudden in onset
  
• Seizure
  
• Evidence of head injury
  
• Neck stiffness
  
• Vomiting
  
• Anticoagulation therapy
  
• Altered level of consciousness (may be comatose):
  
  • Altered mental status may occur as late as 24–48 hr after head injury
    

• HTN
  
• Nuchal rigidity
  
• Altered mental status
  
• Variable neurologic deficits depending on site of intracerebral hemorrhage:
  
  • Putamen hemorrhage (35%):
    
    • Contralateral hemiparesis
      
    • Contralateral hemisensory loss
      
    • Occasional dysphagia
      
    • Occasional neglect
      
  • Lobar hemorrhage (30%):
    
    • Variable signs depending on involved area
      
  • Cerebellar hemorrhage (15%):
    
    • Vomiting
      
    • Ataxia
      
    • Nystagmus
      
  • Thalamic hemorrhage (10%):
    
    • Similar to putamen, but may also have eye movement abnormalities
      
  • Caudate hemorrhage (5%):
    
    • Confusion
      
    • Memory loss
      
    • Hemiparesis
      
    • Gaze paresis
      
  • Pontine hemorrhage (5%):
    
    • Quadriplegia
      
    • Pinpoint pupils
      
    • Ataxia
      
    • Sensorimotor loss
      

• Manage airway if indicated
  
• Immediate noncontrast head CT:
  
  • Acute hemorrhage appears as high-density lesion
    

• CBC
  
• Coagulation studies (PT/PTT, INR, platelets)
  
• Electrolytes; BUN, creatinine
  
• Pregnancy test in women of childbearing age
  
• EKG
  
• Consider toxicology screen
  

• CT as above
  
• MRI may be useful but currently not as available or rapid as CT
  

• CT angiography:
  
  • Gaining increasing acceptance as a diagnostic tool in acute setting
    
  • Up to 15% of patients may show an underlying vascular etiology on CTA, potentially changing acute management
    
  • Contrast extravasation (spot sign) may represent ongoing bleeding
    
    • Highest risk of hematoma expansion with poor outcome and mortality
      

• Seizure:
  
  • Todd paralysis
    
• CNS infection
  
• CNS mass
  
• Electrolyte or acid–base abnormality
  
• Intoxication
  
• Wernicke encephalopathy
  
• Migraine headache
  
• Transient ischemic attack
  
• Nonhemorrhagic acute cerebrovascular accident
  
• Air embolism
  
• Differential diagnosis once bleed is seen on CT:
  
  • Spontaneous hemorrhage:
    
    • Hypertensive hemorrhage
      
    • Arteriovenous malformation
      
    • Neoplasm
      
  • Traumatic hemorrhage:
    
    • Subarachnoid hemorrhage
      
    • Subdural hematoma
      
    • Epidural hematoma
      

Additional differential diagnoses include:

• Moyamoya disease
  
• Acute infantile hemiplegia
  

TREATMENT