Isaac Lamb, MD Profile picture
Mar 4, 2023 10 tweets 5 min read Read on X
I'm a collector, a neurology nerd, and a history fan by nature. The result of all of those is that I now own every major type of #neurology reflex hammer, and I've done the work for you to rank them.

Check out my reasoning below.

#neurotwitter #medtwitter
Tromner (S)
It's simultaneously the Cadillac and the Toyota Camry of reflex hammers. Most (American) neurologists carry one for a simple reason: it's the best. Best length, best weight, pointed tip for Babinski sign... There's really nothing negative to say.
Berliner (A)
Doesn’t get enough love. Has a great weight and pointed tip. It's slightly shorter and thinner so it can fit in your pocket. While the shorter handle and off-balance head are actually advantageous, I can't deny that it doesn't feel as good in your hand as a Tromner.
Déjerine (A)
Good length, great striking surface. It's got the weight and feel of a Tromner, but it looks more "balanced" without the little hammer on the side. It lacks a pointed tip for getting a Babinski, though.
Buck (B)
It's a little too short and a little too light, although not as light as a Taylor. It's small enough to fit in a pants pocket, which is nice, but it's double-headed so it usually gets stuck.
Babinski (C)
Good weight, great striking surface, good length, and has a point for checking a, well, Babinski. The round head makes it a little harder to store in your pocket. The handle is also too skinny and it tends to roll off the table. Telescoping versions feel gimmicky.
Queen Square (C)
Brits can get on my level: your hammer is just not good. Sorry, not sorry. The handle is so long it constantly gets snagged on stuff. See my complaints about the Babinski above. Popular doesn’t mean good. See also: the Taylor hammer.
Taylor (D)
The standard American 60 gm Taylor just sucks. It’s too light, too short, and has a weird striking surface. Generations of medical students think they can’t get a brachioradialis reflex because all they’ve used is the Taylor that came with their stethoscope.
Finger method (D)
I’m not actually recommending this strategy, but… it actually works decently well, at least on the wards. You’ll look like a neurology god when you do it. Attendings love it. EM docs SHOULD love it. But they’ve given their hearts, for some reason, to…
Stethoscope (F)
Checking reflexes with a flexible stethoscope is like playing billiards with a rope. Just use your fingers, it’s easier and more accurate.

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More from @IsaacLamb01

May 18
FIRST TIME SEIZURE

Anyone who spends time on an inpatient neurology service knows this is one of our top 5 consults/admits. This thread will break down the workup and the decision of who needs to be on antiseizure medication (ASM).

#neurology #FOAMed #neurotwitter
The first step: was it really a seizure?

Common mimics of seizures:
- Syncope (esp convulsive syncope)
- PNES/functional seizures
- Behavioral staring spells (esp in kids)
- Stroke/TIA
- Movement disorder
History elements suggestive of seizure:
- Duration (usually 1-3 minutes)
- Postictal period
- LATERAL tongue biting
- Description of movement (eg tonic-clonic, etc)

Tongue tip biting, urinary incontinence, and convulsive activity without note of duration are all nonspecific.
Read 13 tweets
Feb 8
What is Romberg’s sign and how should it be used?

I often see this sign misused to suggest a cerebellar ataxia. But it’s the exact opposite - the test exists to point AWAY from central cause!

Explanation below ⬇️
HISTORY
Moritz Heinrich Romberg was a pioneering German neurologist who’s focused on one of the most important diseases of the time: syphilis. Without effective treatments, syphilis could cause tabes dorsalis, a degenerative disease of the spinal dorsal columns.
Romberg developed his characteristic test of station to differentiate sensory ataxia (ie proprioception, from a peripheral neuropathy or dorsal column issue) from cerebellar ataxia.
Read 8 tweets
Dec 9, 2023
INPATIENT STROKE WORKUP
Pt 3: Cardioembolic strokes

In a cardioembolic stroke, a blood clot starts in or passes through the heart but ends up in the brain. It’s managed differently than the other two types we’ve covered. Let’s jump in!
#neurotwitter #neurology #MedEd #FOAMed
PATHOPHYSIOLOGY

Cardioembolic strokes are generally caused by the other two corners of Virchow’s triad: stasis (eg afib) and hypercoagulability (eg paradoxical embolus from a DVT). Overactivity of secondary coagulation results in a thrombus which can embolize. Image
Some of the more important causes include:
- afib/aflutter
- paradoxical embolism via patent foramen ovale (PFO)
- ventricular thrombus
Read 17 tweets
Dec 5, 2023
INPATIENT WORKUP OF STROKE
Pt 2: Small vessel disease

If there’s large vessel (atherosclerosis), you know there must be a small vessel category. Join me as we work through another major category of stroke!

#neurology #MedEd #FOAMed #neurotwitter #tweetorial
As before, we will be following the TOAST framework. While the trial itself bears little significance today, the framework it used to categorize strokes is a very helpful cognitive tool and has been repeatedly used in subsequent research. Image
PATHOPHYSIOLOGY

Small vessel occlusions refer to ischemic strokes impacting vessels too small to have names. These small perforating arteries are at right angles to larger vessels and primarily supply the basal ganglia, thalami, white matter, and brainstem. Image
Read 14 tweets
Dec 3, 2023
INPATIENT WORKUP OF STROKE

To many, stroke admissions are not very exciting: it’s formulaic with the same tests ordered every time. But if you understand the reason behind the tests, it becomes much more interesting! Let’s explore together.

#neurology #meded #stroke #FOAMed
Back in the 1990s, there was a study called the TOAST trial that categorized strokes by mechanism. That framework is very helpful to this day and I’ll be using it here.

This thread will focus on the most common cause: large artery atherosclerosis (LAA) Image
PATHOPHYSIOLOGY

LAA is caused by the same common pathway that often causes other vascular diseases including MIs and PVD: atherosclerosis.

Risk factors include anything that causes vessel trauma: HTN, diabetes, smoking, FHx, and of course high LDL. Image
Read 13 tweets
Nov 12, 2022
PSA: don't withhold a QT prolonging drug just because the computer calculated a QTc above 450-460 ms. The computer correction is usually (>50% by the study below) very inaccurate. And it only takes 15 seconds to do it right (or at least better).

PMID: 27317349
#MedEd #tweetorial
Background: QT intervals change depending on HR. To compare them, one can correct for HR using many different formulas:
- Bazett
- Hodges
- Fridericia
- Framingham
- Rautaharju Image
Here's a graph comparing how each formula compares at different heart rates (technically 1/HR). You want the line to be flat. None are perfect, but you'll notice that one performs nearly as poorly as not correcting at all: Bazett. Image
Read 9 tweets

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