Acute Upper GI Bleeding and Neuro Stuff Flashcards
Draw out the entire management pathway when someone presents with Upper GI Bleeding
1) Resuscitation
2) Risk assessment (Blatchford)
3) Endoscopy (immediately in unstable patients, within 24h in stable patients)
Non-variceal?
= clips with or without adrenaline, fibrin or thrombin with adrenaline, or thermal coagulation with adrenaline
give 40mg omeprazole only during/after endoscopy
Variceal
= Terlipressin 2mg IV, ceftriaxone 1g
Gastric varices
= endoscopic injection (N butyl 2 cyanoacrylate)
or TIPS if that does not work
Oesophageal varices
= band ligation or TIPS if uncontrolled
What is the pre-hospital management of meningitis?
IM benzylpenicillin 1.2mg IM/IV
What are the common organisms that cause meningitis in:
1) 0-3m
2) 3m-6y
3) 6y-60y
4) >60y
5) Immunosuppressed
1) Group B strep, E Coli, Listeria
2) N. meningitidis, S pneumoniae, H influenzae
3) N meningitidis, S pneumoniae
4) S pneumoniae, N meningitidis, Listeria
5) Listeria
What are the early and late features of meningitis?
Early: headache, fever, leg pains, cold hands and feet
Late: meningism, decreased GCS, petechial rash, seizures
What is Kernig’s sign and Brudzinski’s sign?
Kernig’s sign: lay patient down, flex leg to 90, pain will occur = meningism
Brudzinski’s sign: lay patient down, tell them to lift head off bed, they will not be able to unless they flex their knees = meningism
What is the management of suspected meningococcal disease in patients without raised ICP?
ABC (fluid resus if needed, check blood glucose)
Take blood cultures
If no ICP, rash or shock: perform LP <30mins. If delayed by >30mins, give ABx first.
Give dexamethasone 10mg IV if features of meningism
Isolate for first 24h.
What is the management of suspected meningococcal disease in patients with a raised ICP?
If signs of ICP (papilloedema, uncontrolled seizures, focal neurology, GCS <12)
- IV ABx
- Dexamethasone 10mg IV
- Airway support
- Fluid resuscitation
What is the first line management of bacterial meningitis?
Ceftriaxone IV 2g/12h
ADD
Vancomycin (for suspected penicillin resistant pneumococcus)
ADD
Amoxicillin IV 2g/4h (to cover listeria if patients >65, immunocompromised or pregnant)
For meningitis caused by N. meningitides, what is the treatment?
Benzylpenicillin IV 2.4g/4h
For meningitis caused by S. pneumoniae, what is the treatment?
Ceftriaxone IV 2g 12 hourly
For meningitis caused by Listeria, what is the treatment?
Amoxicillin IV 2g/4hourly
AND
Gentamicin IV 5mg/kg
duration: 21 days
For meningitis caused by H. Influenzae, what is the treatment?
IV cefotaxime
What prophylaxis is used for people in contact with meningitis?
Those in contact with a patient within 7 days of them developing the disease should be given prophylaxis with ciprofloxacin
Meningococcal vaccination should be given
What does CSF analysis look like in bacterial meningitis?
Turbid appearance seen Polymorphs seen Cell count: 90-1000 or more Low glucose High protein
What does CSF analysis look like in tuberculous meningitis?
Turbid appearance seen with fibrin web
Low glucose
High protein
What does CSF analysis look like in viral meningitis?
Clear/cloudy appearance
60-80% of plasma glucose
High protein
10-1,000 lymphocytes
How does encephalitis usually present?
Infectious prodrome (fever, rash, lymphadenopathy, cold sores, conjunctivitis) Followed by odd behaviour, focal neurology or decreased consciousness
What are the investigations for encephalitis?
CSF: lymphocytosis, raised protein, decreased glucose. Viral PCR (HSV)
Contrast enhanced CT: focal bilateral temporal lobe involvement (HSV).
Blood cultures
What is the management of viral encephalitis?
Start aciclovir within 30min of patient arriving for 14 days
When should you suspect a cerebral abscess?
What are the signs?
Anyone with raised ICP especially if there is a fever or raised WCC
Signs: seizures, fever, localising signs, or signs of raised ICP. coma. CT/MRI will show a ring enhancing lesion.
Name 4 things that can cause raised ICP
Hydrocephalus
Cerebral oedema
Brain haemorrhage
Status epilepticus
What are the signs and symptoms or raised ICP
Headache worse on coughing and leaning forwards
Vomiting
Drowsiness, irritability
Decreased HR, increased BP
What is the immediate management plan for raised ICP?
ABC
Correct hypotension, treat seizures
Elevate head of bed
If intubated, hyperventilate (causes cerebral vasoconstriction)
Osmotic agents (mannitol)
Dexamethasone 10mg IV (if oedema surrounding tumour)
Fluid restriction
What happens in uncal herniation?
Uncus is pushed towards the midbrain
Oculomotor nerve gets compressed = dilated ipsilateral pupil, then opthalmoplegia
May be followed by contralateral hemiparesis and coma
