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!Final Year > Acute Care and Trauma (3) > Flashcards

Acute Care and Trauma (3) Flashcards

1
Q

What is spinal cord injury also known as?

A

Acute cervical spine trauma: encompasses a wide range of potential injuries to ligaments, muscles, bones, and spinal cord that follow acute incidents (ranging from a seemingly innocuous fall to a high-energy motor vehicle accident)

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2
Q

How are patients with spinal cord injury managed?

A

All patients with suspected trauma should be assessed and stabilised using the Advanced Trauma Life Support protocol (A to E approach)

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3
Q

What are the risk factors for cervical spine injury?

A
  1. Age 18-25 (higher velocity injuries) or >65
  2. Dangerous mechanism of injury (fall from a height, an axial load to the head)
  3. Traumatic injuries
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4
Q

What are the features of a spinal cord injury?

A
  1. Concordant mechanism of injury in history
  2. Neck pain (cervical injuries)
  3. Reduced level of consciousness
  4. Paraesthesia in the limbs
  5. Motor weakness
  6. Sensory loss
  7. Bowel or bladder dysfunction
  8. Priapism (prolonged erection in men)
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5
Q

What is the first line investigation for spinal cord injury?

A

Urgent CT scan of the cervical spine

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6
Q

What test should be performed after a CT scan for spinal cord injuries if there is a neurological abnormality on examination?

A

MRI: this is regardless of whether there is an abnormality evident on CT scan

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7
Q

What is the management of spinal cord injuries following initial assessment and imaging?

A

Patients with clinical signs of a spinal cord injury (i.e. an abnormal neurological examination) should be referred to a neurosurgeon or a spinal surgeon

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8
Q

What is chronic spinal cord injury?

A

A term generally used when elements of a spinal cord injury have been present for at least 1 year

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9
Q

What is the aetiology of chronic spinal cord injury?

A

Can result from a variety of pathologies:
1. Acute mechanical trauma
2. Compression by a space-occupying lesion
3. Infection
4. Vascular insult
The injury may be exacerbated by ischaemia or inflammation

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10
Q

What are the common features of chronic spinal cord injury?

A
  1. Bladder and/or bowel dysfunction
  2. Pain (neurogenic and musculoskeletal)
  3. Gait disturbances
  4. Soft tissue contractures
  5. Sexual dysfunction
  6. Cardiovascular dysautonomia (including autonomic dysreflexia)
  7. Development and/or progression of long-term neurological complications e.g. syringomyelia
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11
Q

What is autonomic dysreflexia?

A

A clinical syndrome that occurs in patients who have had a spinal cord injury at or above T6 spinal level

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12
Q

What is the pathophysiology of autonomic dysreflexia?

A
  1. Afferent signals (most commonly triggered by faecal impaction or urinary retention) cause a sympathetic spinal reflex via a thoracocolumbar outflow
  2. The usual centrally mediated parasympathetic response is prevented (due to spinal cord injury)
  3. As a result there is an unbalance physiological response
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13
Q

What is the unbalanced physiological response characterised by in autonomic dysreflexia?

A
  1. Extreme hypertension
  2. Flushing and sweating above the level of the spinal cord lesion
  3. Agitation
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14
Q

What can develop in untreated, severe cases of autonomic dysreflexia?

A

Consequences of extreme hypertension e.g. haemorrhagic stroke

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15
Q

What is the management of autonomic dysreflexia?

A
  1. Removal or control of the stimulus
  2. Treatment of any life-threatening hypertension and/or bradycardia
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16
Q

What are the investigations for chronic spinal cord injury?

A
  1. MRI spine
  2. EMG
  3. Urodynamic studies/ bladder ultrasound (if bladder dysfunction)
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17
Q

What is the management of chronic spinal cord injury?

A
  1. Intensive rehabilitation: optimise mobility and hand function
  2. Prevention of complications
  3. Bladder and bowel management
  4. Analgesia
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18
Q

What is the prognosis of spinal cord injuries?

A
  1. Full recovery of neurological function is unlikely
  2. Patients have a decreased life expectancy compared with the general population
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19
Q

What are the complications of chronic spinal cord injury?

A
  1. Dysphagia
  2. Venous thromboembolic conditions (DVT)
  3. Soft tissue and joint contractures
  4. Pressure injuries
  5. Orthostatic hypotension
  6. Low bone mass or oestopenia/osteoporosis
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20
Q

What conditions result in motor only lesions of the spinal cord?

A
  1. Amyotrophic lateral sclerosis (ALS)/ MND: both upper and motor neurones
  2. Poliomyelitis: affects anterior horns resulting in lower motor neurone signs
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21
Q

What conditions result in a combined motor and sensory spinal cord lesion?

A
  1. Brown-Sequard syndrome
  2. Subacute combined degeneration of the spinal cord (Vit B12 and E deficiency)
  3. Friedrich’s ataxia
  4. Anterior spinal artery occlusion
  5. Syringomyelia
  6. Multiple sclerosis
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22
Q

What condition results in only sensory spinal cord lesions?

A

Neurosyphilis

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23
Q

What are some of the different diseases that affect the vertebral column?

A
  1. Ankylosing spondylitis
  2. Scheuermann’s disease
  3. Scoliosis
  4. Spina bifida
  5. Spondylolysis
  6. Spondylolisthesis
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24
Q

What are the main causes of spinal/ vertebral fracture?

A
  1. Osteoporotic vertebral fracture
  2. Trauma
  3. Stress fractures (caused by repetitive force often from overuse: can lead to spondylolisthesis
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25
Q

What are osteoporotic fractures in the spine (vertebra)?

A
  1. Fragility fractures from osteoporosis
  2. Osteoporosis is where bone gradually decreases in bone mineral density
  3. Fragility fractures: fractures that occur as a result of mechanical forces that would not usually lead to a fracture
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26
Q

What are the risk factors for osteoporotic fractures?

A
  1. Advancing age (major RF)
  2. Previous history of a fragility fracture
  3. Frequent or prolonged use of glucocorticoids
  4. History of falls
  5. FH of hip fracture
  6. Alternative causes to secondary osteoporosis e.g. Cushing’s, hyperthyroidism, CKD
  7. Low BMI
  8. High alcohol intake
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27
Q

What is the epidemiology of osteoporotic fractures?

A
  1. Osteoporosis is far more common in women
  2. One of the most common sites of osteoporotic fractures is the spine
  3. The prevalence of vertebral osteoporotic fractures is difficult to determine, as not all patients present to a clinician and fractures may not always be clearly identifiable on X-ray
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28
Q

What are the presenting symptoms of an osteoporotic fracture?

A
  1. Asymptomatic: may be diganosed through an incidental finding on an x-ray
  2. Acute back pain
  3. Breathing difficulties: change in shape and length of vertebrae can lead to compression of organs including lungs
  4. Gastrointestinal problems
  5. Minority of patients will have a history of a fall/ trauma
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29
Q

What are the signs of an osteoporotic fracture of examination?

A
  1. Loss of height: compression of the spinal vertebrae therefore a reduction in overall length of the spine
  2. Kyphosis: curvature of the spine
  3. Localised tenderness on palpation of the spinous processes at the fracture site
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30
Q

What is the first line investigation for osteoporotic fractures?

A

X-ray of the spine: may show wedging of the vertebra due to compression of the bone (may also show old fractures - sclerotic appearance)

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31
Q

What are some of the other investigations for osteoporotic fractures?

A
  1. CT spine: more detailed view of the bone structure, therefore can visualise the extent/features of the fracture more clearly
  2. MRI spine: Useful for differentiating osteoporotic fractures from those caused by another pathology e.g. a tumour
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32
Q

What is the management of osteoporotic fractures?

A
  1. Pain relief
  2. Temporary use of an orthosis (e.g., Jewett/Lumbar brace or thoracolumbosacral orthosis)
  3. Walking aids (e.g., stick, elbow crutches, all-terrain rollator)
  4. Follow up (every 6 weeks for 3 months after injury)
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33
Q

What is important in osteoporotic fractures?

A
  1. The stability of the spine is not compromised with this type of fracture
  2. These fractures are traditionally considered benign injuries that heal without complications
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34
Q

What should be carried out to assess the risk of future fractures following an osteoporotic fracture?

A
  1. Risk factors are taken into account and a dual-energy X-ray absorptiometry (DEXA) scan should be performed
  2. According to NICE, the FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture
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35
Q

What is spondylolisthesis?

A

When one vertebra is displaced relative to its immediate inferior vertebral body

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36
Q

What will traumatic spondylolisthesis show on plain x-ray of the spine?

A

‘Scotty Dog’ appearance

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37
Q

What is the management of spondylolisthesis?

A
  1. Depends upon the extent of deformity and associated neurological symptoms
  2. Minor cases may be actively monitored
  3. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation
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38
Q

What is spinal cord compression?

A

EMERGENCY

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39
Q

What are the features of spinal cord compression?

A
  1. Back pain (earliest and most common): may be worse on lying down and coughing
  2. Lower limb weakness
  3. Sensory changes: loss and numbness
  4. Neurological signs depend on level of lesion
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40
Q

What are the neurological signs of spinal cord compression?

A
  1. Depend on level of lesion:
    a. Above L1: usually result in UMN signs in the legs and sensory level
    b. Below L1: usually cause LMN signs in the legs and perianal numbness
  2. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
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41
Q

What is the investigation of choice for spinal cord compression?

A

Urgent MRI: whole MRI of spine within 24 hours of presentation

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42
Q

What is the management of spinal cord compression?

A
  1. High dose oral dexamethasone
  2. Urgent oncological assessment: extradural compression accounts for the majority of cases, usually due to vertebral body metastases, patient may need surgery or radiotherapy
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43
Q

What are the common cancers which can lead to neoplastic spinal cord compression?

A

Lung, breast and prostate cancer (usually extradural compression from vertebral body metastases)

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44
Q

What is cauda equina syndrome?

A

Rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed

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45
Q

In which patients should cauda equina syndrome be considered in?

A

Any patient who presents with new/worsening back pain

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46
Q

What is the main concern with cauda equina syndrome?

A

Late diagnosis may lead to permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence

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47
Q

What are the main causes of cauda equina syndrome?

A
  1. Most common cause: central disc prolapse (L4/5 or L5/S1)
  2. Tumour: primary or metastatic
  3. Infection: abscess, discitis
  4. Trauma
  5. Haematoma
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48
Q

What are some of the possible features of cauda equina syndrome?

A
  1. Low back pain
  2. Bilateral sciatica (50% of cases)
  3. Reduced sensation/ pins and needles in the perianal area
  4. Decreased anal tone (should check this in patients with new onset back pain)
  5. Urinary dysfunction e.g. incontinence (this is a late sign and may indicate irreversible damage)
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49
Q

What is the investigation of choice for cauda equina syndrome?

A

Urgent MRI

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50
Q

What is the management of cauda equina syndrome?

A

Surgical decompression

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51
Q

What is a stroke?

A
  1. The rapid permanent neurological deficit from cerebrovascular insult
  2. Also defined clinically, as focal or global impairment of CNS function developing rapidly and lasting >24 h
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52
Q

What can stroke be divided into?

A
  1. Ischaemic: caused by vascular occlusion or stenosis
  2. Haemorrhage: caused by vascular rupture, resulting in intraparenchymal and/or subarachnoid haemorrhage
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53
Q

What is the most common type of stroke?

A

Ischaemic (85%)

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54
Q

How can ischaemic strokes be further divided?

A
  1. Thrombotic: thrombosis from a large vessel e.g. carotid (atherosclerosis)
  2. Embolic: a blood clot from fait, air or bacteria (AF is an important cause of this)
55
Q

What are the risk factors for ischaemic strokes?

A

General risks for cardiovascular disease:
1. Age
2. Hypertension
3. Smoking
4. Hyperlipidaemia
5. Diabetes mellitus
For cardioembolism: AF

56
Q

What is the proportion of haemorrhagic strokes?

A

15%

57
Q

How can haemorrhagic strokes be further divided?

A
  1. Intracerebral: bleeding within the brain
  2. Subarachnoid haemorrhage: bleeding on the surface of the brain
58
Q

What are the risk factors for haemorrhagic strokes?

A
  1. Age
  2. Hypertension
  3. Arteriovenous malformation
  4. Anticoagulation therapy
59
Q

What are the features of a stroke?

A

Sudden onset, usually unilateral:
1. Motor weakness
2. Speech problems (dysphasia)
3. Swallowing problems
4. Visual field defects: homonymous hemianopia
5. Gait/ balance problems

60
Q

How can strokes be classified?

A

Based on the initial symptoms using the Oxford Stroke Classification

61
Q

What are the three main criteria used in stroke classification?

A
  1. Unilateral hemiparesis and/or hemisensory loss of face, arm and leg
  2. Homonymous hemianopia
  3. Higher cognitive dysfunction e.g. dysphasia
62
Q

What is a total anterior circulation infarct?

A
  1. Involves the middle and anterior cerebral arteries
  2. All three of the main criteria are present:
    a. Unilateral hemiparesis and/or hemisensory loss
    b. Homonymous hemianopia
    c. Higher cognitive dysfunction
63
Q

What is homonymous hemianopia?

A

Vision loss on the same side of the visual field in both eyes

64
Q

What is a partial anterior circulation infarct?

A
  1. Involves the smaller arteries of the anterior circulation e.g. upper or lower division of the middle cerebral artery
  2. Two of the main criteria are present
65
Q

What are lacunar infarcts?

A
  1. Involves the perforating arteries around the internal capsule, thalamus and basal ganglia
  2. Presents with one of the following:
    a. Unilateral weakness (and/or sensory deficit of face, arm, leg)
    b. Pure sensory stroke
    c. Ataxic hemiparesis
66
Q

What are the signs of lacunar infarcts on examination?

A
  1. Internal capsule or pons: Pure sensory or motor deficit (or combination of both)
  2. Thalamus: Loss of consciousness, hemisensory deficit
  3. Basal ganglia: Hemichorea, hemiballismus (movement disorder), Parkinsonism
67
Q

What are the signs of multiple lunar infarcts on examination?

A
  1. Vascular dementia
  2. Urinary incontinence
  3. Gait apraxia (marche a petits pas, shuffling small-stepped gait, with upright posture and often normal or excessive arm-swing)
68
Q

What are lacunar infarcts strongly associated with?

A

Hypertension

69
Q

What is a posterior circulation infarct?

A
  1. Involves the vertebrobasilar arteries
  2. Presents with one of the following:
    a. Cerebellar or brainstem syndromes
    b. Loss of consciousness
    c. Isolated homonymous hemianopia
70
Q

What are some features of an anterior inferior cerebellar infarct?

A
  1. Vertigo
  2. Ipsilateral ataxia
  3. Ipsilateral deafness (or tinnitus)
  4. Ipsilateral facial weakness
71
Q

What are some features of a posterior inferior cerebellar infarct?

A

This is also known as Lateral medullary syndrome:
1. Wallenberg’s syndrome
2. Ipsilateral:
a. Ataxia
b. Nystagmus
c. Dysphagia
d. Facial numbness
e. Cranial nerve palsy e.g. Horner’s
3. Contralateral limb sensory loss

72
Q

What are the signs of a haemorrhagic stroke on examination?

A
  1. Headache
  2. Meningism
  3. Focal neurological signs
  4. Signs of raised ICP e.g. papilloedema
  5. Seizures
73
Q

What is the screening tool used to assess strokes that is widely known?

A

FAST: Face/ Arms/ Speech/ Time

74
Q

What does FAST stand for in an acute stroke setting?

A

F- facial dropping
A- arm weakness
S- speech difficulties
T- time (narrow therapeutic window as stroke is a permanent condition)

75
Q

What screening tool is used to assess strokes in secondary care settings?

A

ROSIER score
Exclude hypoglycaemia first, then asses the following:
1. Loss of consciousness or syncope (-1)
2. Seizure activity (-1)
3. New, acute onset of:
a. Asymmetrical facial weakness (+1)
b. Asymmetrical arm weakness (+1)
c. Asymmetrical leg weakness (+1)
d. Speech disturbance (+1)
e. Visual field defect (+1)

76
Q

What is the ROSIER score for a stroke being likely?

A

If > 0

77
Q

What is the first line radiological investigation for suspected stroke?

A

Non-contrast CT head scan: this is to determine if the stroke is ischaemic or haemorrhagic

78
Q

What are the findings of an acute ischaemic stroke on non-contrast CT Head?

A
  1. May show areas of low density in the grey and white matter
  2. Can take time to develop
  3. Other signs: ‘hyperdense artery’ sign corresponding with the responsible arterial clot - this tends to visible immediately
79
Q

What are the findings of an acute haemorrhagic stroke on non-contrast CT head?

A

Typically show areas of hyperdense material (blood) surrounded by low density (oedema)

80
Q

What is the management of acute stroke?

A
  1. Determine if ischaemic or haemorrhagic stroke
  2. Maintain blood glucose, hydration and oxygen within normal limits
  3. Do not lower blood pressure in acute phase (unless hypertensive encephalopathy)
  4. Options of thombolysis or thrombectomy for ischaemic strokes
81
Q

What should be given as soon as possible to patients once a haemorrhagic stroke has been excluded?

A

Aspirin: 300mg orally or rectally

82
Q

What is the guidance regarding acute stroke and atrial fibrillation?

A

Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke

83
Q

What is the risk of ischaemic strokes?

A

The risk of haemorrhagic transformation

84
Q

What medication is given in thrombolysis for acute ischaemic stroke?

A

Alteplase

85
Q

When should thrombolysis be given in patients with acute ischaemic stroke?

A
  1. Administered within 4.5 hours of onset of stroke symptoms
  2. Haemorrhage has been definitively excluded (i.e. confirmed on imaging)
86
Q

What are the relative contraindications to thrombolysis in acute ischaemic stroke?

A
  1. Concurrent anticoagulation (INR > 1.7)
  2. Active diabetic haemorrhagic retinopathy
  3. Suspected intracardiac thrombus
  4. Major surgery/ trauma in the preceding 2 weeks
87
Q

What are the absolute contraindications to thrombolysis in acute ischaemic stroke?

A
  1. Previous intracranial haemorrhage
  2. Seizure at onset of stroke
  3. Intracranial neoplasm
  4. Suspected SAH
  5. LP in preceding 7 days
  6. Stroke or traumatic brain injury in preceding 3 months
  7. Active bleeding
  8. Pregnancy
  9. Uncontrolled hypertension > 200/120mmHg
  10. Oesophageal varices
88
Q

What is mechanical thrombectomy in the management of an acute ischaemic stroke?

A
  1. Exciting new treatment
  2. Require confirmed occlusion of the proximal anterior circulation on CT or MR angiography
  3. Can be given alongside thrombolysis in specific scenarios
89
Q

What is involved in secondary prevention for an ischaemic stroke?

A

Anti-platelet therapy:
1. Clopidogrel is now recommended by NICE (first line)
2. Combination use of aspirin plus modified-release (MR) dipyridamole is recommended only if clopidogrel is contraindicated or not tolerated
3. MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated
Statin:
1. If the cholesterol is > 3.5 mmol/l patients should be commenced on a statin
2. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

90
Q

What is the management of haemorrhagic strokes?

A
  1. Control hypertension and seizures
  2. IV mannitol and hyperventilation helps lower intracranial pressure
  3. Evacuation of haematoma or ventricular drainage may be required
    For all strokes: Multidisciplinary rehabilitation: Speech and language
    therapy, occupational therapy, physiotherapy and neuropsychology
91
Q

What is a transient ischaemic attack (TIA)?

A
  1. A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
  2. Fully resolving within 24h
  3. Bought on by a transient decrease in blood flow
92
Q

How long does a TIA typically last for?

A

Less than an hour (but fully resolves within 24h)

93
Q

What are the clinical features of a TIA?

A

Similar to that of a stroke but, rather than persisting, the features resolve, typically within 1 hour:
1. Unilateral weakness or sensory loss
2. Aphasia or dysarthria
3. Ataxia, vertigo or loss of balance
4. Visual problems:
a. Amaurosis fugax: sudden transient loss of vision in one eye
b. Diplopia
c. Homonymous hemianopia

94
Q

What are the NICE recommendations for suspected TIA?

A
  1. Immediate antithrombotic therapy: aspirin 300mg
  2. Specialist review
95
Q

When should a patient with suspected TIA not be given aspirin 300mg?

A
  1. Patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
  2. Patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
  3. Aspirin is contraindicated: discuss management urgently with the specialist team
96
Q

What is the time frame for specialist review for suspected TIA dependent on?

A
  1. Urgent admission and observation with stroke specialist: if the patient has had more than 1 TIA (‘crescendo TIA’) or has a suspected cardioembolic source or severe carotid stenosis
  2. Urgent assessment (within 24 hours) by a specialist stroke physician: if the suspected TIA was in the last 7 days
  3. Specialist assessment as soon as possible within 7 days: if the suspected TIA occurred more than a week previously
97
Q

What advice should be given a patient with a suspected TIA whilst awaiting specialist review?

A

Not to drive

98
Q

What imaging is used in the investigation of a TIA?

A
  1. First line is usually MRI (should be done on same day as specialist review):
    a. including diffusion-weighted and blood-sensitive sequences
    b. determines the territory of ischaemia, or to detect haemorrhage or alternative pathologies
  2. Carotid imaging: Due to risk of atherosclerosis, all patients should therefore have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy
  3. CT head should not be done ‘unless there is clinical suspicion of an alternative diagnosis that CT could detect’
99
Q

When should a carotid endarterectomy be considered in the management of a TIA?

A
  1. Recommend if the patient has suffered stroke or TIA in the carotid territory and is not severely disabled
  2. Should only be considered if
    carotid stenosis > 70% according European Carotid Surgery Trialists’ Collaborative Group criteria or > 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria
100
Q

What is the secondary prevention management for TIAs?

A
  1. Antiplatelet therapy to follow on from initial aspirin therapy:
    a. Clopidogrel is recommended first-line (as for patients who’ve had a stroke)
    b. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
  2. Lipid modification:
    high-intensity statin (such as atorvastatin 20–80 mg daily) - the aim of statin therapy is to reduce non-HDL cholesterol by more than 40%
101
Q

What are the complications of strokes?

A
  1. Cerebral oedema (raised ICP and local compression)
  2. Immobility
  3. Infections (e.g. pneumonia, UTI, from pressure sores)
  4. DVT
  5. Cardiovascular events (arrhythmias, MI, cardiac failure)
  6. Death
102
Q

What is the prognosis of strokes?

A
  1. 10% mortality in first month
  2. Up to 50% of those who survive remain dependent
  3. 10% have a recurrence in 1 year
  4. Generally, poorer for haemorrhagic than for ischaemic
103
Q

What is a Subarachnoid Haemorrhage?

A

Arterial bleeding into the subarachnoid space and is a medical emergency

104
Q

What type of haemorrhage is a SAH?

A

An intracranial haemorrhage: defined as the presence of blood within the subarachnoid space, i.e. deep to the subarachnoid layer of the meninges

105
Q

What are the two types of subarachnoid haemorrhage?

A
  1. Most common: traumatic SAH from head injury
  2. In the absence of trauma: spontaneous SAH
106
Q

What are the causes of spontaneous subarachnoid haemorrhage?

A
  1. Intracranial aneurysm (saccular ‘berry’ aneurysm): accounts for 85% of cases
  2. Arteriovenous malformations
  3. Pituitary apoplexy
  4. Mycotic (infective) aneurysms
107
Q

What are berry aneurysms associated with?

A
  1. Hypertension
  2. Polycystic kidney disease
  3. Ehlers-Danlos syndrome
  4. Coarctation of the aorta
108
Q

What are some of the risk factors for subarachnoid haemorrhage?

A

Hypertension, smoking, excess alcohol intake

109
Q

What are the presenting features of a subarachnoid haemorrhage?

A
  1. Sudden onset of severe headache: ‘thunderclap’, ‘hit with a baseball bat’, ‘worst of my life’
  2. Nausea and vomiting
  3. Photophobia and neck stiffness
  4. Reduced level of consciousness/ coma
  5. Seizures
110
Q

What are the signs of a subarachnoid haemorrhage on examination?

A
  1. Meningism:
    a. Photophobia and neck stiffness
    b. Kernig’s sign (resistance or pain on knee extension when hip is flexed) because of irritation of the meninges by blood
  2. Reduced GCS
  3. Raised ICP:
    a. Papilloedema
    b. Cranial nerve palsy
    c. Ophthalmoplegia
  4. Hypertension and bradycardia
111
Q

What is the first line investigation for subarachnoid haemorrhages?

A

Non-contrast CT Head

112
Q

What are the findings of a subarachnoid haemorrhage on a non-contrast CT head?

A

Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system

113
Q

What is the next investigation/ step in management if the CT head shows evidence of a subarachnoid haemorrhage?

A
  1. Referral to neurosurgery (as soon as SAH is confirmed)
  2. CT intracranial angiogram: identify aneurysm/ AVM
  3. ± Digital subtraction angiogram: catheter angiogram
114
Q

What is the next investigation for subarachnoid haemorrhage if the CT head is normal?

A

Depends on timing of CT Head:
1. If done within 6 hours of symptom onset:
a. Do not perform an LP
b. Consider an alternative diagnosis
2. If done more than 6 hours after symptom onset:
a. Perform an LP
b. LP should be performed at least 12 hours following onset to allow development of xanthochromia (result of RBC breakdown)
c. SAH have a normal or raised opening pressure

115
Q

What is the management of a confirmed subarachnoid haemorrhage caused by an anuerysm?

A
  1. Supportive:
    bed rest, analgesia, VTE prophylaxis and discontinuation of anti-thrombotics
  2. Medical: oral nimodipine to prevent vasospasm
  3. Surgical:
    a. Intracranial aneurysms are at risk of rebleeding- need promt intervention within 24 hours
    b. Usually a coil by interventional neuroradiologists
    c. Minority of patients need a craniotomy and clipping
116
Q

What are the complications of a subarachnoid haemorrhage?

A
  1. Re-bleeding:
    a. 10% of cases
    b. Most common in first 12 hours
    c. If suspected: arrange a repeat CT head
    d. Associated with high mortality = up to 70%
  2. Hydrocephalus: can be treated temporarily (external ventricular drain) or long-term (ventriculoperitoneal shunt)
  3. Vasospasm:
    a. Delayed cerebral ischaemia
    b. Typically 7-14 days after
    c. Ensure euvolaemia and give vasopressors if symptoms persist
  4. Hyponatraemia (from SIADH)
  5. Seizures
117
Q

What are important predictive factors in subarachnoid haemorrhages?

A
  1. Conscious level on admission
  2. Age
  3. Amount of blood visible on CT head
118
Q

What is a pituitary apoplexy?

A

Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction

119
Q

What are the precipitating factors for pituitary apoplexy?

A
  1. Hypertension
  2. Pregnancy
  3. Trauma
  4. Anticoagulation
120
Q

What are the features of pituitary apoplexy?

A
  1. Sudden onset severe headache (similar to SAH)
  2. Vomiting
  3. Neck stiffness
  4. Visual field defects: classically bitemporal superior quadrantic defect
  5. Extraocular nerve palsies
  6. Features of pituitary insufficiency e.g. hypotension/hyponatraemia secondary to hypoadrenalism
121
Q

What is the investigation and management of pituitary apoplexy?

A
  1. MRI is diagnostic
  2. Required urgent steroid replacement due to loss of ACTH
  3. Careful fluid balance
  4. Surgery and hormone replacement
122
Q

What is compartment syndrome?

A

A particular complication that may occur following fractures (or following ischaemia reperfusion injury in vascular patients)

123
Q

What is compartment syndrome characterised of?

A

Raised pressure within a closed anatomical space: will eventually compromise tissue perfusion resulting in necrosis

124
Q

What are the two main fractures that carry the complication of compartment syndrome?

A
  1. Supracondylar fractures
  2. Tibial shaft injuries
125
Q

What are the features of compartment syndrome?

A
  1. Pain:
    a. Especially on movement, even passive
    b. Excessive use of breakthrough analgesia
  2. Paraesthesia
  3. Pallor may be present
  4. Arterial pulsation may still be present (necrosis occurs due to microvascular compromise)
  5. Paralysis of the muscle group
126
Q

What is important to remember when examining a patient with suspected compartment syndrome?

A

The presence of a pulse doe not rule out compartment syndrome

127
Q

How is compartment syndrome diagnosed?

A

Measurement of intracompartmental pressure measurements:
a. pressures in excess of 20mmHg are abnormal
b. >40mmHg is diagnostic

128
Q

Why are x-rays not indicated in the investigation of compartment syndrome?

A

Not typically show any pathology

129
Q

What is the mainstay management of compartment syndrome?

A

Prompt and extensive fasciotomies: surgery to relieve swelling and pressure in a compartment of the body (cut tissue that surrounds the area)

130
Q

What are some considerations of managing compartment syndrome?

A
  1. In the lower limb: the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
  2. Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
  3. Where muscle groups are frankly necrotic at fasciotomy: they should be debrided and amputation may have to be considered
  4. Death of muscle groups may occur within 4-6 hours
131
Q

What is urinary catheterisation?

A

A flexible tube used to empty the bladder and collect urine in a drainage bag

132
Q

What are the indications for urinary catheterisation?

A
  1. Surgery: to empty the bladder before, during and after and to help perform certain tests
  2. Obstruction in the urethra e.g. scarring or prostate enlargement
  3. Bladder weakness or nerve damage that affects your ability to urinate
  4. Drain bladder during childbirth- epidural anaesthetic
  5. Monitor urine output e..g in sepsis
  6. Deliver medicine directly into the bladder, such as during chemotherapy for bladder cancer
  7. A last resort treatment for urinary incontinence when other types of treatment have been unsuccessful
133
Q

What are the possible complications for a urinary catheterisation?

A

Main complication is UTI
Others:
1. Bladder spasms
2. Leakages
3. Blockage and/or damage to the urethra

134
Q

What are the different types of upper limb fractures?

A
  1. Colles’ fracture
  2. Smith’s fracture
  3. Bennett’s fracture
  4. Scaphoid fracture
  5. Radial head fracture

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