Acute Upper GI Bleeding and Neuro Stuff

Question 1

Draw out the entire management pathway when someone presents with Upper GI Bleeding

Answer 1

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

Question 2

What is the pre-hospital management of meningitis?

Answer 2

IM benzylpenicillin 1.2mg IM/IV

Question 3

What are the common organisms that cause meningitis in:

1) 0-3m
2) 3m-6y
3) 6y-60y
4) >60y
5) Immunosuppressed

Answer 3

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

Question 4

What are the early and late features of meningitis?

Answer 4

Early: headache, fever, leg pains, cold hands and feet
Late: meningism, decreased GCS, petechial rash, seizures

Question 5

What is Kernig’s sign and Brudzinski’s sign?

Answer 5

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

Question 6

What is the management of suspected meningococcal disease in patients without raised ICP?

Answer 6

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.

Question 7

What is the management of suspected meningococcal disease in patients with a raised ICP?

Answer 7

If signs of ICP (papilloedema, uncontrolled seizures, focal neurology, GCS <12)

• IV ABx
• Dexamethasone 10mg IV
• Airway support
• Fluid resuscitation

Question 8

What is the first line management of bacterial meningitis?

Answer 8

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)

Question 9

For meningitis caused by N. meningitides, what is the treatment?

Answer 9

Benzylpenicillin IV 2.4g/4h

Question 10

For meningitis caused by S. pneumoniae, what is the treatment?

Answer 10

Ceftriaxone IV 2g 12 hourly

Question 11

For meningitis caused by Listeria, what is the treatment?

Answer 11

Amoxicillin IV 2g/4hourly
AND
Gentamicin IV 5mg/kg

duration: 21 days

Question 12

For meningitis caused by H. Influenzae, what is the treatment?

Answer 12

IV cefotaxime

Question 13

What prophylaxis is used for people in contact with meningitis?

Answer 13

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

Question 14

What does CSF analysis look like in bacterial meningitis?

Answer 14

Turbid appearance seen
Polymorphs seen
Cell count: 90-1000 or more 
Low glucose 
High protein

Question 15

What does CSF analysis look like in tuberculous meningitis?

Answer 15

Turbid appearance seen with fibrin web
Low glucose
High protein

Question 16

What does CSF analysis look like in viral meningitis?

Answer 16

Clear/cloudy appearance
60-80% of plasma glucose
High protein
10-1,000 lymphocytes

Question 17

How does encephalitis usually present?

Answer 17

Infectious prodrome (fever, rash, lymphadenopathy, cold sores, conjunctivitis) 
Followed by odd behaviour, focal neurology or decreased consciousness

Question 18

What are the investigations for encephalitis?

Answer 18

CSF: lymphocytosis, raised protein, decreased glucose. Viral PCR (HSV)
Contrast enhanced CT: focal bilateral temporal lobe involvement (HSV).
Blood cultures

Question 19

What is the management of viral encephalitis?

Answer 19

Start aciclovir within 30min of patient arriving for 14 days

Question 20

When should you suspect a cerebral abscess?

What are the signs?

Answer 20

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.

Question 21

Name 4 things that can cause raised ICP

Answer 21

Hydrocephalus
Cerebral oedema
Brain haemorrhage
Status epilepticus

Question 22

What are the signs and symptoms or raised ICP

Answer 22

Headache worse on coughing and leaning forwards
Vomiting
Drowsiness, irritability
Decreased HR, increased BP

Question 23

What is the immediate management plan for raised ICP?

Answer 23

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

Question 24

What happens in uncal herniation?

Answer 24

Uncus is pushed towards the midbrain
Oculomotor nerve gets compressed = dilated ipsilateral pupil, then opthalmoplegia
May be followed by contralateral hemiparesis and coma

Question 25

What happens in cerebellar tonsil herniation?

Answer 25

increased pressure in posterior fossa causing cerebellar tonsils to go through foramen magnum
ataxia, abducens nerve palsy, upgoing plantar reflexes