YALE NEUROLOGY
RESIDENT SURVIVAL GUIDE
2011-2012
Contributors:
Mary Bailey, MD
Pooia Fattahi, MD
Ben Keung, MD
Imanuel Lerman, MD
Laura Ment, MD
Karin Nystrom, APRN
Imran Quraishi, MD
Katherine Ruzhansky, MD
Anna Sorokin, MD
Editors:
Nicholas A. Blondin, MD
Kumar Narayanan MD PhD
Kamil Detyniecki, MD
Christopher Gottschalk, MD
Kim Robeson, MD
David Greer, MD
1
Table of Contents
Emergencies
IV tPA administration ...................................................................................................... 3
Intracranial Hemorrhage s/p IV tPA ................................................................................. 5
Acute Management of Intracranial Hemorrhage .............................................................. 6
Management of Acute Elevations in ICP ......................................................................... 8
Mannitol Protocol for elevated ICP .................................................................................. 9
Status Epilepticus (adult) ............................................................................................... 10
Guillain Barré Syndrome ............................................................................................... 11
Myasthenic Crisis ......................................................................................................... 12
Chill Alert ...................................................................................................................... 13
Ward Issues
Typical Day ................................................................................................................... 14
Transfers, Computer Systems ........................................................................................ 15
Dictation Instructions Dial 688-6406 ............................................................................. 16
Discharging a patient ..................................................................................................... 17
Lumbar Puncture ........................................................................................................... 18
Common Consults
Ischemic Stroke ............................................................................................................. 19
Young Stroke ................................................................................................................. 20
Seizure .......................................................................................................................... 21
Altered Mental Status .................................................................................................... 22
Coma Exam ................................................................................................................... 23
Headache ...................................................................................................................... 23
Spinal Cord .................................................................................................................... 25
Multiple Sclerosis Exacerbation .................................................................................... 26
Dizziness ....................................................................................................................... 27
Pediatric Seizure Phone Call .......................................................................................... 30
Useful Information
Pediatric Anticonvulsants .............................................................................................. 31
Common Anticonvulsants .............................................................................................. 32
Muscles, Nerves and Roots ............................................................................................ 33
Computer Remote Access .............................................................................................. 34
Phone Numbers.............................................................................................................. 35
2
Emergencies: IV tPA administration
IV tPA Administration
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Review all exclusion criteria and confirm patient is eligible
Review benefits and risks with the patient and family and provide IV tPA
information sheet
Obtain informed consent
Ensure 2 peripheral IV lines or more access
Call the pharmacy (688-1111) with patient information and instructions to
mix and immediately deliver drug to patient location
Make sure pump available to deliver drug
Dose: 0.9 mg/kg body weight (maximum 90 mg)
10% of dose given as a bolus – over one minute
Remainder of dose to be infused over 60 minutes (via pump)
When infusion is complete, attach a NS bag to tPA IV tubing & deliver
remaining drug in tubing to administer full dose
Management of Anaphylaxis
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If stridor, oropharyngeal swelling, urticaria develop, immediately
discontinue tPA infusion.
Administer IV methylprednisolone 125 mg, IV diphenhydramine 50 mg, IV
famotidine 20 mg,
Consider early elective intubation if significant stridor or
oropharyngeal swelling.
Early ENT notification if cricothyrotomy may be needed
Consider medicine consultation if no improvement
Consider CT scan to exclude retropharyngeal hematoma if suspected
Post IV tPA Administration
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Admit to NICU
NPO until patient is screened for dysphagia
Continue cardiac monitoring
Neurochecks q 15 mins x 2 hours, then q 30 mins x 6 hours, then q 1 hour x
16 hours
Rotate blood pressure cuff to avoid excessive bruising
No anticoagulants or antiplatelet agents for 24 hours
DVT prophylaxis
Repeat head CT, labs, U/A and guaiac stools at 24 hours post infusion
from YNHH Stroke Service Policy “Administration of IV t-PA for Acute Ischemic Stroke”
3
4
Emergencies: Intracranial Hemorrhage s/p IV tPA
Administration of blood products will be at the discretion of the stroke attending
After administration of IV t-PA, monitor for following concerning symptoms:
Worsening or new deficits, worsening GCS or NIHSS or decreased level of
consciousness
Nausea, vomiting, sudden severe headache
Seizure
Sudden elevated blood pressure and/or bradycardia
If intracranial hemorrhage is presumed
Immediately discontinue t-PA infusion
Obtain STAT head CT scan
Re-assess the patient’s neurologic status – perform and document NIHSS
Draw labs: type and screen to blood bank ONLY if patient is new to YNHH
-
-
Immediately, upon documentation of intracranial hemorrhage
by CT scan (preliminary read is acceptable):
Call blood bank (688-2443)
Order 10 units (volume approximately 50 mL) of cryoprecipitate
If patient received an antiplatelet agent during the prior 2 weeks, or if an
antiplatelet use during that interval is unknown, also order 8-10 units
platelets (volume approximately 400-500 ml)
Consider pre-medication 30 mins prior to transfusion (acetaminophen 650
mg PO or PR and/or diphenhydramine 25 mg IV)
-
Cryoprecipitate will be administered IV (using a 22 gauge) over 15 mins
Platelets will be administered IV (using a 22 gauge) over 30-60 mins
If the patient exhibits signs of transfusion reaction, immediately stop platelet
infusion
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STAT Neurosurgery consult (370-4492)
Consider Hematology consult (688-2443)
Discuss medical versus surgical therapy
-
Repeat lab draw (PT, PTT, INR, fibrinogen) after administration of
cryoprecipitate
If PT/PTT is elevated, consult heme for further recommendations
If fibrinogen < 150 mg/dl, order and administer additional 10 units
cryoprecipitate
Consider serial CT scans to assess size and change of hemorrhage
-
5
Emergencies: Acute Management of Intracranial Hemorrhage
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Control BP: Goal SBP 100-140
Labetalol 10-20mg IV q1h prn OR Nicardipine drip (5 mg/hr increased by
2.5 mg/hr q15 minutes to max 15 mg/hr)
Arterial line placement while patient is in ED
Check BP q5mins x 1 hr then q15mins x 2hrs then q30mins
If patient is on Coumadin: INR goal <1.4:
o
STAT FFP: 10-20 ml/kg or 4-6 Units, if has CHF, give Lasix
after infusion – send runner to blood bank
o
Vitamin K 10mg IV x 1 (slow push over 5 minutes) (takes 6 hrs
to normalize INR), check PT/INR q6hrs
If patient is on Heparin gtt:
o
Protamine 1mg/100 Units if received heparin in last 3 hours.
o
Check PTT q1hr x 4 hrs then q4hrs
If patient is on Enoxaparin:
o
Protamine 1mg per 1mg of enoxaparin
o
Recheck PTT in 2-4 hrs; if still elevated consider giving
additional 0.5mg of Protamine
If patient received IV tPA < 24 hrs ago then give (see reversal of t-PA
protocol): Cryoprecipitate and Platelets
If patient is on Direct Thrombin Inhibitors (Argatroban, Lepirudin,
Bivalirudin, Dabigatran): There is no specific antidote for these drugs at this
time
Von Willebrand syndrome: Treat with 0.3 mcg/kg DDAVP over 30 min
If platelets are < 100k, transfuse platelets
No need for prophylactic AEDs. No indication for steroids. Osmotic therapy
only if significant edema is present and patient exam compromised.
No data for platelet transfusion if patient was on ASA, Plavix or NSAIDs
(but is often given by neurosurgery). May restart antiplatelets in one week
after ICH
DVT/PE prophylaxis: on admission place patient on SCDs. Patients with
DVT/PE may need to get IVC filter. May start prophylaxis SQ
Heparin/LMWH 48 hours post-ICH
Consult neurosurgery (370 4492) if warranted
Repeat Head CT in 6 hrs or STAT PRN change in neurological exam
Neurochecks q1hrs, HOB 30 degrees
Adopted from http://www2.massgeneral.org/stopstroke/protocolAdultHemorrhage.aspx
6
ICH Volume estimation = (A x B x C) / 2
A = longest diameter
B = diameter perpendicular to A
C = number of slices multiplied by slice thickness in cm
7
Emergencies: Management of Acute Elevations in ICP
ETIOLOGY: variety of causes (tumor, malignancy, stroke, encephalitis, hemorrhage,
hydrocephalus, trauma, global anoxic brain injury)
SIGNS AND SYMPTOMS: headache, nausea / vomiting, somnolence or coma,
hiccups, yawning, focal deficits especially brainstem findings, seizures, anisocoria,
unreactive or blown pupil, posturing, abnormal breathing pattern, Cushing’s triad
[hypertension, bradycardia and irregular respirations]
WORKUP: ABCs, clinical exam and STAT HEAD CT (wheel the patient yourself)
MANAGEMENT (If high suspicion, may want to start treatment on your way to CT)
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ABCs: vital signs and cardiac monitoring, consider intubation
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HOB elevated at 30 degrees, head facing forward
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Consult neurosurgery (370 4492) for possible intervention
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Goal ICP < 20 mm Hg and cerebral perfusion pressure (CPP) > 60 (see
below for equation)
If herniation present:
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STAT mannitol 100 g and then proceed to mannitol protocol (see next
page) OR hypertonic saline
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Hyperventilation: for goal pCO2 ~ 30
If ICP due to tumor:
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dexamethasone 10 mg IV x 1, then 4 mg q6hr
For any patient with a mass lesion, stroke, tumor, hemorrhage, keep goal Na 140-145
(may need to go higher depending on what ICP does). Avoid free water in IVF such as
D5W, ½ NS, D5 ½ NS, LR
CPP = MAP – ICP
MAP ≈ (2DBP+SBP)/3
8
Emergencies: Mannitol Protocol for elevated ICP
For a patient with ICP monitoring: Mannitol 1 g/kg q6hr PRN ICP ≥ X, Hold for Osm
Gap > 10 or Na > 160 or Serum Osm > 320
For a patient without ICP monitoring: Mannitol 1 g/kg q6hr, Hold for Osm Gap > 10 or
Na > 160 or Serum Osm > 320
Check Na, BUN, Cr, Gluc, Osm q6hr, one hour before mannitol dosing
↓
Is Osm Gap >10 or Na > 160 or Serum Osm > 320?
↓
↓
Yes
No
Hold Mannitol
Administer next dose if indicated by ICP
Equations:
Osm Gap = measured Osm – calculated Osm
Calculated Osm = 2(Na) + BUN/2.8 + Glu/18 + 10
Osm gap < 0 may be due to miscalculation or minor variation in lab values;
mannitol may be given if calculation correct
May order hypertonic saline in the presence of a gap
Unexpected gaps may be caused by alcohol or propylene glycol carrier
(lorazepam, diazepam, midazolam, pentobarb and phenobarb)
Adapted from http://www2.massgeneral.org/stopstroke/osmalarGap.aspx
9
Emergencies: Status Epilepticus (adult)
Interventions
Initial Rapid Assessment: Airway, Breathing, Circulation
Record Vital Signs, Monitor 02 saturation, EKG
Establish IV access and have bloods sent: fingerstick, CBC,
electrolytes, BUN/Cr, Ca/Mg/Phos, LFTs, AED levels, tox screen,
ABG, HCG for women of reproductive age
Thiamine 100 mg IV followed by 50% dextrose, 50 cc IV
Lorazepam 0.1 mg/kg IV (<2 mg/min) OR Diazepam 0.25 mg/kg
IV (<5 mg/min)
Phenytoin 18-20 mg/kg IV (50 mg/min) or Fosphenytoin 20 mg/kg
IV (150 mg/min), begin concurrently with benzodiazepine and
monitor EKG, check BP q60 sec
May use Valproic Acid 30 mg/kg IV (150 mg/min) or levetiracetam
50 mg/kg IV (100 mg/min, request *non-formulary*) as alternatives
Perform follow up assessment including history, exam, check labs,
STAT head CT, **STAT EEG** if still seizing or unresponsive,
consider empiric antibiotics / LP if febrile / not known epileptic
If still seizing, then:
Additional phenytoin 7-10 mg/kg IV (<50 mg/min) or
Fosphenytoin 10 mg/kg IV (150 mg/min), monitor EKG, check BP
q60 sec
Send repeat Phenytoin and free phenytoin level 20 min after load
Intubate if not done previously
If still seizing, then:
Phenobarbital 20 mg/kg (75 mg/min)
Establish arterial line for BP monitoring
Initiate EEG monitoring
If still seizing, options for next step include:
Midazolam 0.2 mg/kg IV (loading dose, preferred if BP unstable),
titrate dose (0.1-0.4 mg/kg/hr) to stop electrographic and clinical
seizures. Use fluid or pressor support if needed.
OR
Pentobarbital 5mg/kg IV (loading dose) to obtain burst suppression
on EEG, titrate dose (0.3-9mg/kg/hr, avg=4mg/kg/hr) to maintain
burst suppression on EEG, use fluid to support BP if needed, add
pressor only if fluid fails or not clinically advisable
OR
Propofol 1-2 mg/kg IV (loading dose), 2-10 mg/kg/hr maintenance
drip to stop clinical and EEG seizures or maintain burst suppression
on EEG
Seizure activity
0 min
0-2 min
2-10 minutes
5-10 minutes
10-20 min
30-40 min
30-60 min
50-60
minutes
STAT EEG: daytime – EEG lab 688-3109 / 688-2495; nighttime – attending approval
10
needed; notify technologist in CAVE 688-3269
Emergencies: Guillain Barré Syndrome
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Admit to NICU q 1 hour neuro checks
Place on Telemetry
Watch for autonomic instability, avoid beta-blockers given risk of complete
heart block
Address Code Status while in ED, may need intubation
Check NIF (Negative Inspiratory Force) and FVC q2hrs x 12hrs then q4hrs.
Intubate if NIF < 20 or FVC < 15cc/kg (or 1 liter) or rapid downward trend
Do not go by the O2 sat or ABGs for need for intubation as these patients
will become hypercarbic before hypoxic. Call RRT at the first sign of
respiratory distress
Lumbar Puncture (look for albumino-cytological dissociation)
Check HIV, CMV, Hepatitis panel, Campylobacter in stool
DVT prophylaxis including SCDs
EMG/NCS: absence of ‘F’ waves, conduction block, temporal dispersion
May need Plasmapheresis. Consult IR for placement of the line and consult
Lab Medicine for initiation of Plasmapheresis
May need IVIg 0.4gr/kg/day x 5 days. Check IgA level prior to
administration of IVIg as it may cause anaphylaxis in patients with IgA
deficiency. Give Acetaminophen and Benadryl prior to each IVIg to
decrease HA’s
FEN: swallow eval, aspiration risk
11
Emergencies: Myasthenic Crisis
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Admit to NICU q 1 hour neuro checks
Place on Telemetry
Address Code Status while in ED, may need intubation
Check NIF (Negative Inspiratory Force) and FVC q2hrs x 12 hrs then q4hrs.
Intubate if NIF < 20 or FVC < 15cc/kg (or 1 liter) or rapid downward trend
Do not look at the O2 sat or ABGs as these patients will become hypercarbic
before hypoxic. Call RRT at the first sign of respiratory distress
Rule out infection with panculture
May need Plasmapheresis. Consult IR for placement of the line and consult
Lab Medicine for initiation of Plasmapheresis
May need IVIg 2gr/kg over 2-5 days. Check IgA level prior to
administration of IVIg as it may cause anaphylaxis in patients with IgA
deficiency. Give Acetaminophen and Benadryl prior to each IVIg to
decrease HA’s
Immunomodulatory treatment:
o
Steroids: may acutely worsen weakness, monitor closely,
methylprednisolone 60mg IV daily
o
If steroid ineffective or contraindicated: azathioprine,
mycophenolate mofetil, or cyclosporine
Cholinergics: do not give during crisis.
FEN: swallow eval, aspiration risk
EMG/NCS: decremental response with repetitive stim
Avoid: aminoglycosides, erythromycin, azithromycin, tetracyclines,
ciprofloxacin, clindamycin, phenytoin, lithium, beta-blockers, procainamide,
quinidine and magnesium
12
Emergencies: Chill Alert
CHILL ALERT: called for patients who suffer cardiac arrest and meet a number of
criteria to undergo cooling to decrease the degree of neurologic injury. Neurology is
paged on the stroke alert pager (688-xxxx number tagged with 3333; NOT 688-3333,
which is the pediatric emergency room) and should respond immediately.
Protocol:
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Examine patient. Patient should be comatose, GCS < 8. Patients who are
waking up are not likely to require hypothermia. When in doubt, call the oncall hypothermia attending
Obtain non-contrast head CT if possible, r/o ICH
Obtain emergent portable EEG # 1 during hypothermia (core temperature
32-34 degrees Celsius)
during daytime, contact the EEG lab (688-3109 / 688-2495)
at night needs approval by the on-call critical care EEG attending and
communicated to the technologist in the CAVE (688-3269, pager 412-7557)
Document in your note:
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date / time of initial arrest (if known)
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time to CPR
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date / time of Restoration Of Spontaneous Circulation (ROSC)
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date / time of arrival in the hospital
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date / time of your neurologic exam and whether patient is on sedating or
neuromuscular blockade agents and whether they are intubated
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coma exam (please refer to coma exam under Common Consults section)
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In your assessment and plan, please include the Arctic Sun EEG Protocol
(this can be found in the acronym expander template available in Sunrise.
Go to Preferences ---> Acronym expansion ---> Import from other user --->
Curiale, Gioaccino ---> @arcticsun):
Phase I (initiation of cooling), day 1: EEG (portable, to be done in ICU)
Phase II (rewarming), day 2: EEG (portable)
Phase II (rewarmed), day 3: EEG at temperature >36C normal core body temperature
If non-convulsive status epilepticus is suspected, then please call neurology to obtain
emergent portable EEG
13
Wards Issues: Typical Day
6:15-7:30 AM
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Please arrive no later than 6:15 AM. You may need to arrive earlier depending on
your patient load. Every morning you will be assigned to new patients, so please
factor in the time to repeat a patient history and full exam.

Get sign out from the overnight resident first. If they are not in the resident’s room
then they are probably seeing a consult. Page them (203 370 5298).

Pre-round until 7:30
THINGS TO DO IN ADDITION TO CHECKING ON YOUR PTS
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if you know that a pt is to be discharged make sure all of their paperwork is done
(see note on how to discharge patients)
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ask nightfloat if the patient’s primary care physician was called (if not this needs to
be done prior to rounds begin – even if it is just leaving a message with the
answering service)
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make sure MRI safety sheet has been done
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check on what time all pertinent studies are scheduled for and have this info
available for rounds (TTE, Carotid US, MRI etc)
7:30 – 8:00 AM (Mon, Tues, Thurs, Fri) MORNING REPORT
Please arrive on time
Wednesday is Grand Rounds that begin at 8am and thus there is no AM report.
8:00 – 8:30 AM:
Finish pre-rounding; Write ICU progress notes
8:30 – 11 AM ROUNDS
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Meet in NICU to begin rounds
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We will be doing walk rounds. Please make sure the patient’s nurse is present.
You can get the nurse’s personal phone number from the BA or from the main
patient board.
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Make sure you call all consults very early!
12:00 PM :
Noon conference, refer to schedule. Lunch usually provided
1:00-5:30 PM: Finish the day’s work.
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LPs need to be done no later than 2pm ideally
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Update the sign out daily. Remove non-pertinent information and make sure
family contact info and code status are clearly stated. Please put one line in on
their most updated exam findings.
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Goal is to be ready to sign out to the inpatient night float resident at 5:30 pm.
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Patient discharge: make sure to have all documentation finished the day prior to
anticipated discharge
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All priority dictations need to be done!
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For the weekend: On Fridays please put all daily labs orders for Saturday and
Sunday and note on your sign out that this is done
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14
Wards Issues: Transfers, Computer Systems
Transfers:
When accepting a transfer from another service, or transferring a patient to another
service:
1)
Make sure that the patient has been accepted by the senior resident and attending
on accepting service.
2)
Ensure that the transferring team has provided you with the following in writing
regardless of how long the patient has been on their service:
- Hospital course by organ system. If there are no pulmonary issues, for example,
they must state “no active pulmonary issues.”
- All medications administered and justification for doing such. If a beta blocker
was d/c’d due to bradycardia, for example, this must be communicated to the
accepting resident.
- All Abx, days thereof, and the reason for using one antibiotic versus another must
also be communicated.
- All lines placed must be signed out with dates of placement. If a line was d/c and
then replaced, the transferring teams needs to make us aware.
- After the transferring team has completed their transfer note, they must give
verbal sign out to the accepting resident. The same process is applicable to patients
being transferred to other services from neurology.

When accepting a transfer from an outside hospital, which is done through Yaccess, request the name and contact info of the transfering physician and obtain a
faxed discharge summary in addition to getting a verbal sign out with all of the
above, and request that the patient must be transferred with CDs of their
neuroimaging; an imaging report is not enough. An attending needs to accept any
patient transferred to the service.
Computer Systems: there are multiple systems at Yale for which you need individual
passwords; VA has one
Sunrise Clinical Manager (SCM): inpatient Yale system containing majority of
inpatient info
Centricity / Logician: outpatient Yale system. Will contain clinic notes, and used for
ordering outpatient studies, including if you want to order a test for after discharge. Will
also contain inpatient imaging reports, EEG reports, labs and discharge summaries.
Synapse: Imaging at Yale
ED charts: scanned Yale ED paper charts; username and password are your SCM
username
VA system is CPRS; VistaWeb contains records from outside VAs
15
Wards Issues: Dictation Instructions Dial 688-6406
- enter your dictation ID number _________ followed by the # key
- Enter work type followed by the # key
2 for Discharge summary
4 for Priority discharge summary (for patients being transferred to another facility)
- when prompted, enter patient's medical record number followed by the # key
TO DICTATE:
Press 2 to begin dictation
Press 2 to pause (soft tone is heard in pause mode)
Press 2 again to resume dictating
DISCHARGE SUMMARY MUST INCLUDE THE FOLLOWING:
your name (spell it out) and ID number
attending physician (spell it out)
date of admission and date of discharge
principle discharge diagnosis
secondary diagnoses (list all PMH diagnoses)
operations, if performed during hospitalization. Otherwise state “None”
disposition (home, rehabilitation facility, other hospital, hospice, morgue)
chief complaint / HPI
PMH
medications on admission
Allergies
Family History
Social History
Review of Systems (MUST contain at least 7 systems)
physical exam on admission
hospital course (may want to dictate by system)
pertinent labs and imaging with dates
physical exam on discharge
if patient is being transferred to a facility, discharge plan, also by system
follow up appointments
"please CC this discharge summary to..." and list names and addresses /
phone numbers for patient's follow up physicians including follow up
neurologist, primary care physician and any pertinent specialists
TO END DICTATION OR EXIT SYSTEM: State “this will end dictation. Thank
you.” Press 5 and hang up
TO EDIT: press 2 to stop, press 3 to play back, press 7 to rewind, press 4 to move to end
of dictation
16
Wards Issues: Discharging a patient
Yale:
Discharges at Yale require a few necessary components. Once the patient is ready for
discharge, the following need to be completed:
1) If the patient needs to go home with services, or is going to a facility, please talk to our
care coordinator about this plan. In this case, the patients will need to have a priority
discharge summary dictated and a W-10 filled out in Sunrise
2) Follow up appointments: most patients should be made appointments for follow up
with neurology, and should also be instructed to follow up with PMD in 1-2 weeks as
well as any relevant specialists. Please refer to phone numbers list for follow up clinics.
3) Discharge instructions: This is in a Sunrise template and at minimum should include
follow up appointments made with contact info / clinic address, the medication
reconciliation, and reasons to come to the ED (in the case of stroke or TIA, should
include changes in speech, hearing, vision, balance, numbness, weakness, tingling,
headache, mentation)
4) Medication reconciliation: please reconcile admitting and discharging medications
(you may need to confirm home meds with patient's pharmacy) and perform the
medication reconciliation including giving patient any new prescriptions
5) Performance measures: a separate document on the Sunrise template, needs to be
done before you can put in a discharge order
6) Discharge summary (please refer to dictation sheet as all discharge summaries are
dictated); indicate in dictation to cc patient’s summary to PMD and any follow up
physicians
7) Discharge order
WHVA:
1.
Discharge note
2.
Discharge Medication Reconciliation
3.
Discharge Instructions (Instruction <Patient DC Instruction>)
4.
Fill any new medications at the outpatient pharmacy
5.
Discharge summary to be done in CPRS
6.
Follow up appt with neurology (place consult for Neurology Clinics, call 3118)
and primary care (call appropriate primary care clinic)
17
Procedures: Lumbar Puncture
Materials: LP tray, chlorprep x 4 or iodine solution, extra lidocaine, gown and face
mask, sterile gloves, extra container (urine cup)
Before procedure:
1.
2.
3.
4.
Check Head CT  r/o intracranial mass lesion
Check INR, must be < 1.5
Check Platelets, must be > 100
obtain informed consent and perform “time-out” prior to procedure
After procedure: document procedure via SCM procedure note afterwards, check for
intact leg strength and sensation, instruct patient to lay flat and administer IV fluids
Urgent indication:
Suspected CNS infection (with the exception of brain abscess or a parameningeal
process). Do funduscopic examination and head CT first to rule out raised ICP.
Suspected subarachnoid hemorrhage (SAH) in a patient with a negative CT scan
Potential Contraindications:
Possible raised intracranial pressure: rule out increased ICP by head CT
Thrombocytopenia: if platelet is less than 100k then give platelets prior to LP
Anticoagulation: if INR > 1.5, then give 4 units of FFP, once finished then proceed
with LP
Suspected spinal epidural abscess
Normal CSF pressure is 6-20 cm H20; obese patients may have up to 25cm H20
Bring CSF to the Specimen Drop-Off, Park Street 4th Floor, back of the chemistry lab
What to Order: NOTE that SCM will print the tube number on the label
Tube 1: Cell count
Tube 2: Protein, glucose, FTA-ABS, CSF lyme, Cryptococcus, fungal cx
Tube 3: Viral studies, bacterial culture
Tube 4: Cell count, IgG index, MBP, oligoclonal bands
Extra Tube: Cytology (use specimen cup, ideally 10 cc, at least 5 cc
Evaluate for malignant cells in CSF
Bring to Pathology Drop Off, EP-2 across from back elevators
Extra Tube: Flow Cytometry (use specimen cup, 5 cc)
Evaluate for lymphoma in the CSF
Bring to Flow Cytometry, Park Street 5th floor
Extra Tube: Gene rearrangement analysis (use specimen cup, 10 cc)
Evaluate for lymphoma in the CSF: IgH – B cell, TCR – T cell
High false negative rate with < 50 nucleated cells in CSF
Bring to Molecular, EP 2-631. DO NOT bring to Molecular on Park St
18
Common Consults: Ischemic Stroke
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Right or left handed?
Onset sudden or gradual?
Symptoms at onset and progression in time
Symptoms fluctuating?
Had these symptoms in the past?
Time of onset? If not witnessed, then last seen normal? If awoke with symptoms,
what time were they last awake with no symptoms?
Associated symptoms: headache / neck pain, alteration of consciousness, abnormal
movements
Is the patient on antiplateles / anticoagulation?
Stroke risk factors: HTN, HL, DM, CAD, smoker, illicit drug use, personal or
family history of hypercoagulable states, cardiac arrhythmias, cardiomyopathy,
history of migraines, prior stroke /TIA
EXAM: full physical and neurologic exam paying attention to BP and fingerstick,
cardiac and carotid exam, new or old focal deficits, perform and document NIHSS
WORKUP in the ED:

Non-contrast head CT, labs: PT/PTT/INR, CBC, BMP, urine: UA, urine tox,
CXR, EKG, Consider CTA neck to Circle of Willis (COW)
PLAN: Determine stroke mechanism. Can use stroke order set (type “stroke”).

Admit to neurology; neurochecks, vital sign parameters

Initiate antiplatelet agent

MRI brain w/wo with MRA

TTE with bubble study

Carotid Doppler if no CTA obtained

Telemetry AND 24-hour Holter monitor

PT/OT

AM labs: lipid panel, HgbA1c, ESR/CRP, TSH/T4, cardiac enzymes,
homocysteine, fasting glucose

May consider permissive hypertension if blood pressure dependent exam and flow
limiting lesion seen on vascular imaging; hold antihypertensives and halve betablocker dose

3 oz bedside swallow eval

Fingersticks QID-AC and RISS

Neurosurgery consult if large hemispheric or posterior fossa infarct

Bowel regimen

DVT ppx: heparin/venodynes

Code status
19
Common Consults: Young Stroke
HISTORY: Regular ischemic stroke workup and additionally ask about:

FH of hyper-coagulable states, early heart disease, connective tissue disease

If female, on oral contraceptives? Smoker?
EXAM: same as adult ischemic stroke, include Fundoscopic exam to eval for sinus
thrombosis.
WORKUP:
In addition to the regular stroke w/u, you may check the following:
Hypercoaguable State:
1.
PT, PTT, thrombin time, fibrinogen
2.
“Hypercoagulable panel:” Includes APC Resistance, Antithrombin III, Protein C,
Protein S
3.
Acquired hypercoaguable screening:
Lupus anticoagulant screen (DRVVT) (order in SCM is Dilute Russell
Venom Viper”)
Anti-Cardiolipin antibody
Anti Beta-2 glycoprotein-1 antibody
Anti-phospholipid antibody (APLS) (order in SCM is “Lupus”)
4.
Hemoglobin screen if African American or Mediterranean
5.
Fasting homocysteine (If above 14, check folate, vitamin B12 and MTHFR 677T
gene mutation)
6.
Lipoprotein A
7.
Prothrombin 20210 gene mutation
8.
If suspect metabolic disorder, urine amino and organic acids and lactate and
pyruvate
Rheumatologic Disorders:
1.
ESR, CRP
2.
ANA, ENA, dsDNA, Rheumatoid Factor, ANCA
3.
Antiphospholipid Antibody
4.
C3 (total level), C4 (total level)
5.
Cryoglobulins
6.
Hepatitis Panel
7.
HIV
Imaging:
1.
MRV or CTV brain
2.
TTE with bubble study
3.
TEE
4.
Lower extremity Dopplers (including calves)
5.
MRV of the pelvic veins (order MRA abdomen/pelvis w/ gad and specify
venogram in comments)
6.
CT chest/abdomen/pelvis to look for malignancy
20
Common Consults: Seizure
HISTORY: New onset seizure or known epileptic?
If known epileptic, goal is to determine AED regimen and compliance, seizure
type/frequency and last seizure, epilepsy physician, any recent triggers (see below).
Check AED levels and if low or they are non-compliant, re-load; if not, consider
increasing AED dose. Ask about prior AEDs tried.
If new onset seizures, obtain comprehensive first seizure history:
RISK FACTORS: history of febrile seizures, family history of seizures, prenatal
and perinatal complications, developmental delay, history of head trauma, history
of CNS infection, history of CNS mass
TRIGGERS LOWERING SEIZURE THRESHOLD: medications, antiepileptic
noncompliance, infection, metabolic abnormalities, toxic ingestion, menses, stress,
sleep deprivation, EtOH / benzo withdrawal, bright lights or loud noise
CHARACTERISTICS: aura (visual, auditory, olfactory, epigastric rising
sensation, psychic (déjà vu, derrealization, depersonalization, fear, anxiety), type
of seizure (especially how its starts), eyes open or closed, lateral eye or head
deviation, length of seizure, associated tongue bite or other injury, incontinence,
presence of post-ictal confusion, post-ictal weakness.
SUBTLE SEIZURE SIGNS: history of staring, automatisms, waking up
incontinent or injured (tongue bite). myoclonic jerks.
EXAM: full neurologic exam paying close attention to mental state, post-ictal paralysis
or other focal deficits, subtle signs of ongoing seizures such as abnormal movements,
head or eye deviation, eyelid twitching, pupillary abnormalities or hippus; also check for
tongue bite / other injury, and check meningeal signs
ED WORKUP: AED levels, non-contrast head CT, basic labs including electrolytes and
CBC, infectious workup (UA, CXR), tox screen, LP if concern for meningitis
PLAN:

AED: load and then standing dose if warranted

EEG: for new onset seizure if EEG done within 24-48 hrs has highest yield. Order
sleep deprived if possible.

MRI with and without contrast, seizure protocol if warranted

seizure precautions

ativan IV PRN seizure activity

evaluate medication list to see if anything lowers seizure threshold

code status

no driving for ≥ 3 months per CT state law

Refer to the “First Seizure Clinic.” Kathleen.wilson@yale.edu or 203-785-3582
and leave message with patient contact and demographics
21
Common Consults: Altered Mental Status
HISTORY:
Onset
Any precipitating factor
Baseline level of functioning (history of dementia?)
Recent infectious symptoms (dysuria, diarrhea / vomiting, URI symptoms)
Symptoms to suggest CNS infection (neck stiffness, headache, nausea)
Access to toxic ingestion / illicit substances
Associated focal deficits or abnormal movements
EtOH history
EXAM: full general exam with attention to signs of intoxication, dehydration and
infection, neurologic exam including MMSE and paying close attention to level of
consciousness, focus / concentration, focal neurologic deficits; also check and document
meningeal signs, asterixis and look for subtle signs of seizure
WORKUP: determined by above but typically includes
Fingerstick, Chem-7, Ca/Mg/Phos, BUN/Cr, LFTs, ammonia level, TSH, RPR,
B12
Tox screen and alcohol level
Carefully review medication list for medications that can cause AMS
UA / UCx, CXR
Non-contrast head CT
+/- LP if fever / white count of unknown source, meningeal signs / symptoms,
concern for HSV limbic encephalitis
EEG to r/o non-convulsive status and assess degree of encephalopathy
PLAN:
Determine and treat underlying cause, often multifactorial
Can consider IV thiamine empirically if malnourished or EtOH history
Supportive measures in acute delirium: reorienting (clocks, calendars), familiar
staff / family if possible, encourage sleep-wake cycles, visual and hearing aids if
visually / hearing impaired
Differential of altered mental status:
Drugs
Endocrine, Electrolytes, Ethanol, Emotional, Eyes/Ears
Low O2, Lack of drugs, Liver
Infection
Retention
Intracranial (stroke/hemorrhage/mass), Ictal
Uremia, Under-nutrition, Under-hydration
Metabolic
22
Common Consults: Coma Exam
1.
Determine if patient is on sedating or neuromuscular blockade agents and whether
they are intubated
2.
Check vital signs, determine respiratory rate and pattern.
3.
General physical exam (R/o head trauma, bruit, murmur, rales, ascites, edema)
4.
Neurologic exam:
MENTAL STATUS:
o
spontaneous eye opening
o
obeys verbal command
o
verbal effort
o
eye opening to sounds
CRANIAL NERVES:
o
spontaneous eye movements (conjugate or orienting),
o
blink to visual threat
o
pupillary responses
o
corneal responses
o
oculocephalic reflex
o
cold calorics
o
facial grimace to noxious
o
facial symmetry
o
cough and gag reflexes
MOTOR:
o
tone, arm / leg strength
o
seizures or myoclonus seen
o
Positive Motor: follows commands, localizes pain, flexor
posturing
o
Negative Motor: extensor posturing, no response
SENSORY:
o
eye opening to pain
o
localizes / withdraws from pain in extremities and whether this
is symmetric
REFLEXES:
o
deep tendon reflexes
o
presence of Babinski's or triple flexion response
Glasgow Coma Scale:
Eyes Open
Best Motor Response
Best Verbal Response
Spontaneous
4
Obeys verbal command
6
Oriented, conversant
5
To command
3
Localizes painful stimuli
5
Disoriented, conversant 4
To pain
2
Withdraws
4
Inappropriate words
3
No response
1
Flexion to noxious
3
Inappropriate sounds
2
Extension to noxious
2
No response
1
No response
1
Common Consults: Headache
23
HISTORY:
New headache or personal history of headaches, and is this one different?
Location ? Quality ? Severity ?
Onset (sudden or gradual)?
Preceding aura?
Transient visual obscuration, especially with valsalva?
Associated features (nausea / vomiting / photophobia / phonophobia / diplopia /
tinnitis)?
What and how much have they taken for the headaches?
Worsening factors (e.g. laying down, standing up, straining)?
Diurnal pattern (e.g. worse in the morning)?
OCP or Vitamin A / retinoid use? Recent weight gain?
Any patient recently postpartum or with systemic cancer, HIV, or taking
immunosuppressive drugs should be assumed to have a secondary headache until
proven otherwise
If chronic headache syndrome, ask about family history of headaches and screen for
lifestyle factors: caffeine use, sleep, hydration status, frequency of analgesic use, relation
to menses, stress, relation to weather
If new headache syndrome, screen for red flags: recent head or neck trauma, chiropractor
visits, fevers or chills, recent travel or sick contacts, altered mental state, neck stiffness,
focal neurologic or visual deficits
If associated visual changes in an older person, screen for GCA: fever, weight loss, jaw
claudication, scalp tenderness, proximal limb myalgias, constitutional symptoms
EXAM:
vitals including temp and blood pressure
full neurologic exam including Fundoscopic and visual fields, nuchal rigidity,
focal neurologic deficits including Horner’s syndrome, scalp tenderness
WORKUP: ESR necessary if patient is older (corrected ESR = (age + 10 if female)/2)
PLAN: should be dictated by patient’s history and physical
If no red flags, can start treatment with:
IV hydration
Reglan 10 mg IV (can repeat q6h, benadryl/ativan to reverse akathisia)
Toradol 30 mg IV (can repeat q6h, caution for renal disease)
Magnesium sulfate 2 g IV
Refractory: Depakote 1000 mg IV x 1, Solu-medrol 1 g IV x 1
If red flags present: further workup including LP, neuro-imaging, and ophtho consult
may be warranted
24
Common Consults: Spinal Cord
HISTORY: Timeline and pattern of weakness and numbness, leg heaviness or warmth,
back pain, trauma history, bowel or bladder symptoms, sexual dysfunction, perianal or
saddle anesthesia, recent infectious symptoms, baseline ambulatory status.
EXAM: In addition to standard exam, check pinprick and vibration on both sides of
spine to assess for spinal cord sensory level, palpate / percuss for paraspinal tenderness,
rectal exam for perianal sensation and anal sphincter tone, palpate bladder,
bulbocavernosus reflex (pull Foley or squeeze glans, S1-3), carefully assess muscle tone,
skin exam for rash if you suspects an inflammatory disorder, pay attention to DTRs
(triceps C6-7, biceps C5-6, brachioradialis C5-6, knee L2-4, ankle S1) and cutaneous
reflexes (upper abdominal T8-10, lower abdominal T10-12, plantar L5-S1) as well as
check Hoffman’s and Clonus
DIFFERENTIAL: Herniated disc, myelitis, spinal tumor, AIDP (if reflexes are lost),
neuropathy, neurosarcoidosis, syringomyelia.
CORD SYNDROMES:
Brown-Sequard: Hemisection leading to ipsilateral dorsal column signs, contralateral spinothalamic
signs, usually spared bladder function.
Central cord: Segmental pain and temperature loss, segmental DTRs lost, segmental weakness/atrophy,
UMN signs below the lesion, urinary urgency
Extrinsic compression: Segmental symptoms indicate nerve root involvement, long tract findings
(UMN signs, numbness, weakness, urinary urgency) indicate cord involvement. Pain and temperature
loss begins sacrally.
Spondylotic myelopathy: From disc disease or osteophytes, begin with segmental findings such as
dropped reflexes at the level of the lesion and spastic weakness with hyperreflexia below the lesion,
sensory findings usually come later.
Conus medullaris: Sudden, bilateral, symmetric, spastic distal lower extremity weakness, loss of ankle
jerks, low back pain, perianal numbness, early onset of urinary retention and overflow incontinence,
impotence.
Cauda equina: Flaccid lower extremity weakness, urinary retention late in the disease, decreased anal
tone, occasional sexual dysfunction, saddle anesthesia, loss of knee and ankle reflexes, severe radicular
pain, presentation may be asymmetric and gradual.
CORD TUMORS: Extramedullary (outside cord) may be intradural (meningiomas and schwannomas)
or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas).
Intramedullary are rare and usually gliomas (astrocytomas or ependymomas), in children usually lowgrade astrocytomas.
WORKUP :
1. PVR with bladder scan or catheter for urinary retention
2. If you suspect acute cord compression, conus or cauda equina syndrome – this is a surgical
emergency! Give dexamethasone 10 mg IV x 1, call spine service immediately (alternates between
trauma and neurosurgery) for decompression, get STAT imaging
3. MRI spine w/wo, choose appropriate level; include diffusion if you suspect ischemia
4. Based on above, consider: Brain MRI for MS plaques; serum RPR, copper, B12, NMO Ab,
ACE, ESR, ANA, Lyme, HIV, HTLV-1, Mycoplasma, hep panel; CSF for basic studies and AFB / TB
cx, crypto ag, fungal stain/cx, viral PCR, Lyme, VZV, EBV, CMV, enterovirus, ACE, HHV-6/7, WNV
25
Common Consults: Multiple Sclerosis Exacerbation
HISTORY:
Symptoms (onset, duration, progression)?
If suspected MS, other neurologic symptoms they may have had in the past which
resolved?
Recent signs of infection (fever, chills, URI symptoms, dysuria)?
If known MS, have they ever had these exact symptoms before? This may suggest
recrudescence due to systemic issue
If known MS, MS history:
when and how they were diagnosed
type of MS (RRMS, PPMS, SPMS, NMO, etc.)
what MS medication are they on and compliance
last exacerbation, last round of steroids
baseline deficits or character of their past flares
EXAM:
Vitals, full physical looking for signs of infection and full neurologic exam and
specifically looking for APD / optic nerve pallor, INO, Lhermitte’s sign, spasticity /
hyper-reflexia
ED WORKUP: obtain UA / Ucx, CXR, basic labs
PLAN:
If suspected exacerbation:
admit to neurology
may need to consider changing or starting a disease modifying agent (discuss on
rounds with attending)
Make sure to call there neurologist if they are private
consider steroids (solumedrol 1gram IV daily x 5 days) or IVIG
if starting steroids, also start on PPI / H2 blocker and insulin sliding scale
MRI with and without contrast of pertinent areas (brain, spine)
PT/OT
If suspected new diagnosis:
Full differential needs to be considered and ruled out, possible further testing
includes MRI brain and spine w/wo, ACE, Lyme, anti-NMO, RPR/VDRL,
vasculitic and autoimmune panel, CSF for basic studies and oligoclonal bands,
myelin basic protein, IgG index, Lyme, ACE
26
Common Consults: Dizziness
HISTORY:
Onset?
Description of symptoms (lightheadedness, room spinning, walking on a boat)
Severity
Duration (brief episodes, long episodes, or constant)
Worse with head turning or getting up?
Nausea or vomiting?
Headache or neck pain?
Chest pain or palpitations?
Recent head or neck trauma or neck manipulations?
Associated ear pain, URI symptoms, aural fullness, tinnitus?
Hydration status?
Able to walk?
Feel off balance or pulled to one side?
Associated neurologic deficits, especially ataxia and brainstem symptoms (diplopia
or other visual changes, tongue heaviness, taste changes, changes in voice, trouble
chewing or swallowing
EXAM: orthostatics if indicated, physical exam including otoscopic exam, full
neurologic exam including detailed brainstem exam (include taste, LT and PP sensation
of face, gag, tongue and uvula deviation, skew deviation of eyes), nystagmus (direction,
extinguishing or not), head impulse test, Dix-Hallpike test, as well as cerebellar testing
and gait exam
WORKUP: to be dictated as above
If there are red flags or you cannot rule out central etiology, obtain neuro-imaging such as
non-contrast head CT, CTA neck up to circle of Willis, and admission to rule out
posterior circulation stroke. Following admission, obtain MRI to rule-out stroke.
If no red flags and symptoms suggest BPPV or other benign etiology:
IV fluids
Meclizine (25-100 mg/day in divided doses) or Valium (5-10 mg q3-4 hr PRN)
Antiemetic (raglan or zofran)
Teach Epley maneuver and give them a handout or PT for vestibular rehab
27
EPLEY Maneuver for BPPV - Right
28
EPLEY Maneuver for BPPV - Left
29
Common Consults: Pediatric Seizure Phone Call
1. Look up patient info
Does patient have epilepsy?
Most recent EEG?
Most recent neuro-imaging?
Med list
Most recent note
2. Call parent to get history
is patient sick or having a fever?
any recent sleep problem, dehydration, or other provoking factor?
what meds is patient on?
when did patient get most recent drug levels checked?
what is the pt's current weight?
Tell parent you need to discuss case with a colleague, and that you will call them
back with recommendations
3. Call senior resident, discuss case
4. Develop action plan:
Does patient need to come to ED? (usually not)
Check levels soon
Increase AED dose for weight (as most kids gain weight)
Consider another EEG or MRI
Follow-up appointment
5. Call back parent
Give them recommendations
Tell them that pediatric neuro office is closed, but they will be contacted with an
upcoming appt on the next business day
6. REMEMBER TO CALL Gerry at the pedi neuro office at 785-5708, ext 6, or Sheryl at
737-3654, to make the follow-up appointment.
7. Route note to appropriate pediatric neurology attending for review
30
Information: Pediatric Anticonvulsants
Anticonvulsant
Load
Maintenance
Level
(mg/kg)
(mg/kg/d)
(ug/ml)
Carbamazepine
15 – 20
6 – 12*
Ethosuximide
15 – 30
40 – 100*
5 – 15**
Lamotrigine
Levetiracetam
4 – 16*
20 - 40
10 – 30
Oxcarbazepine
Phenobarbital
15 - 20
5
15 – 30
Phenytoin
18 - 20
5
10 – 20
Topiramate
10 – 30
Valproic acid
15 – 30
Zonisamide
4–8
50 – 150*
10 – 40
* check trough levels
** if child on VPA, maintenance 1 – 5 mg/kg/d
31
Information: Common Anticonvulsants
Medication
Carbamazepine
(CBZ)
Side Effects
Diplopia, blurred vision,
lethargy, liver failure,
SIADH, aplastic anemia
Interaction
PHT, PB, VPA – decrease levels
Diltiazem, verapamil,
cephalosporins, antifungals –
increase levels
None
Gabapentin
(GPN)
Levetiracetam
(LEV)
Lamotrigine
(LMG or LTG)
Lethargy, ataxia, weight
gain
Lethargy, dizziness,
depression, psychosis
Insomnia, rash (severe)
Oxcarbazepine
(OXC)
Hyponatremia, nausea,
rash
Phenobarbital
(PB)
Lethargy, sedation,
depression
VPA
Phenytoin (PHT
or DPH)
Nausea/vomiting,
dizziness, sedation, ataxia,
gingival hyperplasia, liver
failure, osteoporosis
CBZ, PB – decrease levels
None
PHT, PB, OCPs – decrease levels
VPA – increase levels
CBZ, PB, PHT, VPA, verapamil –
decrease levels
VPA – increase levels
Decrease OCP effectiveness
Topiramate (TOP
or TPM)
Valproic Acid
(VPA)
Zonisamide
(ZNS)
Cognitive impairment,
dizziness, metabolic
acidosis, kidney stones,
hypohidrosis
PHT, CBZ, VPA – decrease levels
Weight gain,
hepatotoxicity,
hyperammonemia, tremor,
rash
PHT, PB, TOP, CBZ – decrease
levels
Sedation, rash, kidney
stones, hypohidrosis
PHT, CBZ, PB – decrease levels
Decrease OCP effectiveness
Elavil – increase levels
32
Information: Muscles, Nerves and Roots
Muscle
Action
Nerve
Root
Deltoid
abduction & elevation of arm
axillary
C5, C6
Biceps
flexion & supination of forearm
musculocutaneous
C5, C6
Brachialis flexion of elbow
musculocutaneous
C5, C6
Triceps
extension of forearm
radial
C6-8
Brachioradialis flex. of elbow, forearm mid position radial
C5, C6
Ext. Carpi Radialis wrist extension & radial deviation radial
C6, C7
Abd. Poll. Brev. abduction of thumb
median
C7, C8
Pronator teres
pronation of forearm
median
C6, C7
Flexor Carpi Radialis wrist flexion & radial deviation median
C6, C7
Palmaris longus
median
C7-T1
Opponens Pollicis draws thumb forward and medially median
C8, T
Ext. Dig. Comm. extension of fingers
posterior interosseous
C7, C8
Ext. Carpi Ulnaris wrist extension & ulnar deviation posterior interosseous C7, C8
First Dors. Inter. abduction & adduction of fingers ulnar
C8, T1
Flexor Carpi Ulnaris
wrist flexion & ulnar deviation ulnar
C7-T1
Abd. Digiti Minimi
abduction of 5th digit
ulnar
C8, T1
Teres minor external rotation of arm
axillary
C5, C6
Supraspinatus
abduction arm
suprascapular
C5, C6
Infraspinatus
external rotation of flexed arm suprascapular
C5, C6
Levator scapulae
dorsal scapular
C4, C5
Rhomboideus elevation & retraction of scapula dorsal scapular
C5
Teres major
internal rotation, add., & extension subscapular
C5-C7
Serratus anterior arm rotation of scapula, abduction long thoracic
C5-C7
Pectoralis major arm adduction & internal rotation anterior thoracic
C5-C8
Pectoralis minor
anterior thoracic
C6-C8
Latissimus dorsi arm adduction, int. rotation & ext. thhoracodorsal
C6-C8
Tibialis Anterior dorsiflexion & inversion of foot deep peroneal
L4, L5
Ext. Digit. Brevis extension of toes
deep peroneal
L5, S1
Ext. Hallucis Longus
extension of great toe
deep peroneal
L5, S1
Gastrocnemius
plantar flexion
tibial
S1, S2
Tibialis Posterior inversion and plantar flexion tibial
L4, L5
Soleus
plantar flexion
tibial
L5-S
Flexor Hall. Longus flexion of great toe
tibial
L5-S2
Vastus medialis
leg extension at knee
femoral
L2-4
Iliopsoas
flexion of hip
femoral
L2, L3
Rectus Femoris knee extension & hip flexion
femoral
L2-4
Gracilis
knee flexion, leg internal rotation
obturator
L2-4
Adductor Magnus adduction of the thigh
obturator
L2-4
Gluteus Medius abd. & int. rotation of thigh
superior gluteal
L4-S1
Gluteus Maximus extension of hip
inferior gluteal
L5-S2
Biceps Femoris
hip extension, knee flexion Sciatic trunk, peron. div.L5-S2
33
Information: Computer Remote Access
How to access the Yale desktop while at the VA:
1. Logon to the VA desktop
2. Go to My Computer > M:\
3. Double click on "scan.rdp" found near the bottom of the file list, click "Connect"
4. Logon to the VA desktop
5. Double click the "mstsc" icon
6. In the Remote Desktop Connection box, enter VHACONTMS5, then click "connect"
7. Logon to the VA desktop
8. Start menu > Internet Explorer
9. Enter the web address https://cag.ynhhs.org
10. Logon to the Yale portal with your Synapse (Novell) username and password
How to get Synapse at Home:
1. Go to Yale ITS Software Library - http://www.yale.edu/its/software/
2. Enter netID and password, select operating system
3. Download synpase
4. Login as you would at YNHH
How to get SCM and Yale Desktop at Home:
1. Download Citrix XenApp client (formerly Metaframe Server) onto home PC
2. Obtain remote access privileges: Contact ITS Helpdesk at 688-4357 for current
application forms
34
Information: Phone Numbers
YNHH 20 York St. 06510
8=688 5=785 7=737
Neurology Consult Pager 370 5298
RADIOLOGY
MRI Inpt Scheduling 200-5142/5143 / 5144
/ 5145
MRI Suite 200-5130
Neuroradiology fellow: reading rm 2003181
Pager days: 688-3175; nights: 688-6180
CT Inpt Scheduling 82749 / 85639
CT Outpt Scheduling 84572 / 82433
CT Scanner (for Stroke Code) 85952
CT ED 82749
CT 2nd floor 85639
ED/night/weekend reading Rm 86180
CTAngio 86215
Holter lab 8-4134
Ultrasound Scheduling 200-5600; 200-5684
Ultrasound Reading Rm 200-1923
ECHO Scheduling 81296
ECHO appt 7411 / 54629
ECHO read 89404 / 89228 / 89359
X-Ray Tech 83515
Nuclear Med 2005610
CXR Reading Rm Weekdays 86170
Portable Xray 86172 / 86170
Fluoro LP: phone 86215, fax 85319
Youngson: 737-2691; 370-1359
Angiogram 88441 /85127
IR 85358; IR consults: 370-0915
Film Library 86054 Ballroom 688-3363
Conscious Sedation 688-5608
CALLING A STROKE CODE
go to www.myairmail.com username:
Stroke1, password: Yale; pick
Mastergroup1 and send your text page
OR
Send text page via myairmail to:
203 370 6660
CLINICS - NEUROLOGY
Page Operator 83111
Stroke Phone 688-7111
NEUROPHYSIOLOGY
EEG/EMG Scheduling 82495
EEG reading room 54380
EEG tech on-call pager 412-7557
Tamara (EEG tech) c: 782-9174
LABS
Chemistry 82444 Heme 82434
Immuno 82440 Micro 82460
Virology 83524 / 81872
Cytology 55430 Flow cytometry
82437
Surg path 52788
Blood Bank 55406
ADD ONS: Fax to 688-8281 or 8-8569
NEUROLOGY UNITS 6-3 and 6-2
Neuro Consult Pager 370-5298
SP6-3 82342
NICU 6-2
82341
6-3 Fax 81322
Neuro Residents Rm 87524 / 87451
CAVE: 83269, 83976
Geoff (OT) 128-3076
EMERGENCY ROOM
ED Bubble 82222
AB-Side 85213 C-Side 84713
Pediatric ED 83333
CIU (Psych ED) 8-1616
Pharmacy
Amber- 688-9946; 128-4933
Pharm Inpt 81111
Stroke Pharm 82212 / 82213 / 82215
Pharm Nonformulary 766-8652
CONSULTS
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General Neuro, Epilepsy, Movement,
Headache, Neuromuscular – 800 Howard
Ave, YPB LL; 785-4085 / 785-5783
Email (weekends/holidays)
tanya.smith@yale.edu
MS Clinic – 40 Temple st, 785-5684
Stroke Clinic – 800 Howard Ave, YPB LL;
737-1057, e-mail (weekends/holidays) at
stroke1@email.med.yale.edu
First Seizure Clinic – 800 Howard Ave,
YPB LL; 785-3582 or
kathleen.wilson@yale.edu
Pediatric Neuro Clinic - 785-5708 or 7854081
Dr. Baehring Clinic – Smilow Cancer
Center, 8th flr, contact 785-7284
Yale Health Plan, Dr. Machado, 432-0038
Hearing and Balance Center, Dr.
Navaratnam, 800 Howard ave, YPB, 7852467
Yale Primary Care Clinic 85555, 82471
Hill Health Clinic 503-3698 / 3000 / 3010
Coumadin Clinic 85102; 766-1552
Ophtho Clinic 785-2020; 54629
Dr. Lesser-neurophtho New Haven 7892020
Dr. Lesser-neurophtho Waterbury 5979100
Dental Clinic 82464
Fair Haven Health 777-7411
Nathan Smith Clinic 8-5303
Neurosurgery Clinic 785-2802
PT/OT 8-6811
MISCELLANEOUS
Sue Fanning (Gaylord) 203-741-3348
CT Public Health 860-509-8500
Interpreter Services 8-7523
Alternative Therapy 200-6129
Cindie Peterson 5-6054
LOCAL NEUROLOGISTS
Neurosurg beeper 370-4492
General Surgery 128-2199
Med Consult 128-2330
Anesthesia 4444
Dermatology 2454
Speech/Language Heather 128-3377
Speech/Swallow Dr. Leder 128-3104
Gaylord- Dave Rosenblum 741-3348;
284-2400
ID consult 860-260-7101
Psych consult 52618; 860-340-4213
Diabetic Service 412-4559
PICC service 766-6507
IR PEG Consult 370-0915
IR PEG Scheduling 85127
Plasmapheresis 200-4707
MEDICAL RECORDS
East Pavilion Ground 82231 / 82224
Dictation Line 86406
ADMISSION/BED ASSIGNMENT
Admission 82221
Bed Assignment 85051 / 128-2712
Care Coordinators
NICU- Pam 412-0747
FLOOR/HOSPITAL OFFICE
NUMBERS
Hospitalist 84748
Rehab 8-8 82175
9W 87993
Dialysis 8-2407
Hospitalist Coverage 766-7633
Hospitalist Admission 766-7416
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Norman Werdiger office 624-7893
Door Codes: Res Room 4-3-1
Supply room 6-3: 1-2-4
WEST HAVEN VA HOSPITAL 932-5711
NEURO DEPT
General Number 932-5711
Neuro VA Call Pager 784-1222
Neuro Residents Rm 2657 (code 4951*)
Neuro Call Rm 2143 (code 4951*)
Neuro Office (George Gregoire) 4724
Fax Neuro office 937-3464
Specialty Clinic/Debbie 3118
IR 2940 / 2941
6th Floor Conf. Rm. 2657
HOSPITAL/WARDS/ED
EEG/Jean 2653
Admission: 3966 / 3967
Gloria
(transfers) 2667
Nursing Supervisor 1006
Bed Mgr:
477-1581
Medicine Paging 203 688 6569 xxxx
PT 2887 (inpt) / 2885 (outpt)
ED 4777
Sue - Care Coordinator: 3626
Psych ED 4471
Psych consult 867-3291 / 1048
Psych Inpt Unit 4481
LABS
Phlebotomy 2906 / 3925
Chem lab. 2929, 2931 Cytology 2972
Heme lab. 4476
Urinalysis 2926
Micro lab: 2917 / 2918
Door Codes
4E Supply room 6875*
4W Supply room 2931*
MICU supply room (23) + (51)
SDU Supply room 2351*
Josh Hasbani o 562-8071
6-5 Call room: 4-2-5
CAVE: 1-5-3
RADIOLOGY
Neuroradiology 7466
CT 4646 / 2948 / 4187 / 4188
MRI 2983
Inpt ECHO 2774
IR 2940 / 2941 / 5595
U/S 5444 / 5594 / 5595
MRI tech 7467 / 2983
MRI Copy 2939
Ash (neurorads) 477 4735
Nuc Med 4684
PET 4403
Bed Management (day) 477 1581
Pharm inpt : 4498
Pharm outpt : 4708, 7227
MICU 3976 / 3980 / 3979
SW 477-2567
Yale RadED 688-6180
4E : 4441 / 4442
4W : 4451 / 4452
SDU 3155 SDU charge nurse 1020
Surgery consult 1003
Cyto 2972 Blood Bank 2924
Add-ons 2931
Surg Path 2974
Printers
Resident room: NEU6
4th floor work room: med 21
5th floor work room: med 22
Clinic: AMB35
Labels:
4E: nur43
4W: nur44 SDU: nur29
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