allergy and confusion and alcohol confusion

Question 1

what is delirium

Answer 1

delirium is an acute, transient reversible confusional state with often underlying organic cause

Question 2

types of delirium

Answer 2

hyperactive agitation - agressive , wandering , hallucination

hypoactive delirium - lethargy and sleep, inattentive and normal tasks take long

mixed

Question 3

mini AMTS score/ PADY

Answer 3

place
age
DOB
year

Question 4

where can you look for signs of infection

Answer 4

chest
skin
abdo
GU
head and neck

Question 5

bloods would you do
other ix

Answer 5

haematology - purple
FBC
coag - baseline and sepsis

biochem - yellow
U and E
bone ca
TFT
haematinics - B12 and folate
glucose

blood cultures
blood gas look for lactate

CT head

have a low tolerance for sepsis

Question 6

alcohol withdrawal syndrome
2 of the following to be dx

Answer 6

insomnia
agitation
seizures
hallucinations
N and V
tremor
autoimmune dysfunction - tachyc and sweating

Question 7

when is the peak incidence of delirium tremens and what sx

Answer 7

peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 8

peak incidence of seizures in alcohol withdrawal

Answer 8

peak incidence of seizures at 36 hours

Question 9

what is AWS due to and what happens normally

Answer 9

Alcohol withdrawal syndrome (AWS) occurs due to an overabundance of the excitatory neurotransmitter NMDA.

In normal brain function the inhibitory GABA and excitatory NDMA neuroreceptors balance out. AWS develops due to the imbalance between these neuroreceptors. Chronically, ethanol acts on GABA receptors increasing their inhibitory effects. Therefore the body reacts by down regulating GABA and upregulating NDMA to reset the balance. When ethanol is not present there is an overabundance of NDMA due to the down regulation of GABA. This causes a hyper-excitability and the clinical features of alcohol withdrawal.

Benzodiazepines will reduce these effects.

Question 10

pt with hepatic failure but is the best drug for alcohol withdrawal

Answer 10

Lorazepam may be preferable in patients with hepatic failure

Question 11

first line for alcohol withdrawal

Answer 11

benzos - diazepam or chloradizpozide

Question 12

mechanism of how benzos treat alcohol withdrawal

Answer 12

bind to benzo receptors between the alpha and gamma subunits of GABA-A receptor

therefore increasing the frequency of the chloride ion channel opening and therefore increasing the inhibitory effects of GABA

Question 13

short half life benzo 2-6hr

Answer 13

midazolam

loraz 6-24

24-72 diazepam and chlordiazepoxide

Question 14

CIWA is what

Answer 14

scoring system for withdrawal from alcohol - determines does of chlordiazepoxide – amount required to prevent withdrawal

Question 16

confusion, ataxia, horizontal nystagmus and opthalmaplegia

Answer 16

wernickes

Question 17

confabulation , neuropathy peripheral, ataxia, dementia

Answer 17

Korsakoff

patient feel gaps of knowledge with made up stuff

Question 18

the increased ammonia in the liver in hepatic encephalopathy does what

Answer 18

inhibitory effects via GABA as well as causing cerebral oedema presenting with drowsy and flapping tremor progressing to coma

Question 19

how does lactulose work in hepatic encephalopathy

Answer 19

clears the gut of ammonia producing bacteria with an aim of producing 2-4 soft stools a day

Question 20

what causes the bronchospasm in anaphylaxis

Answer 20

histamine release from mast eclls

increased cap permeability causing rash
decreased vascualr tone dropping blood pressure

Question 21

hereditary angioedema

Answer 21

C1 esterase insufficiency

only really get airways sings and will not respond to adrenaline

Question 21

are there such things as biphasic anaphylactic reactions

Answer 21

yes in 4-5% of people they can have a second attack one after the first

Question 22

sx of anaphylaxis

Answer 22

airway problems
lip and tongue swelling
angioedema
nasal congestion and sneezing
tightness of throat
hoarse voice
stridor
tachyp
bronchospasm with wheeze
increased mucous secretions

late signs
exhaustion hypoxia confusion and arrest, low BP , tachy c arrhythmia and MI

skin changes hives, linear excoriation

it can present as just hypotension

Question 22

managment of anphylaxis

Answer 22

A-E - if A call for help give adrenaline and oxygen
lie patients flat - improve venous return , pregnancy lie on left side

Question 23

how do you lay pregnant women in these scenarios

Answer 23

on left side to avoid compression of the vena cava

Question 23

how long between doses in anaphylaxis

Answer 23

5 mins

Question 24

adrenaline dose for anaphylaxis in adult

Answer 24

0.5ml/500mcg for children older than 12 year 1:1000

Question 25

what do we call pt who do not recover after two IM doses of adrenaline

Answer 25

refractory anaphylaxis

get senior help

Question 26

when to give IV fluids in anaphylaxis

Answer 26

give after 2nd dose of adrenaline

500ml bolus in an adult
or
10ml/kg in a child

Question 27

adrenaline mech in anaphylaxis

Answer 27

alpha action causes vasoC
beta action helps with airway dilation

Question 28

when can you give antihistamines in anaphylaxis

Answer 28

given once life threatneing features have resolved - non sedating like cetrizine for sx mx of rash and itch

Question 29

can you use salbutamol in anaphylaxis

Answer 29

yes in sx wheeze especially in asthamtics

Question 30

when do you take mast cell tryptase samples

Answer 30

one immediately
second 1-2 hours
3rd 24hours

confirms anaphylaxis

Question 31

criteria for a 2hr observation post shock

Answer 31

good response to single dose
complete resolution of sx
pt has adrenaline auto-injector
adequate supervision post discharge

Question 32

criteria for keeping pt 6 hours after shock

Answer 32

two doses of adrenaline needed
previous biphasic reaction

Question 33

12hour observation needed for pt

Answer 33

over 2 doses
pt severe asthma and resp compromise
ongoign allergen absorption
pt presents late at night or may not be able to respond
pt lives in area where emergency care difficult to access

Question 34

on discharge of anaphylactic pt what do we need to make sure

Answer 34

2 adrenaline autoinjectors and knows how to use them
verbal and written advice
referral to allergy clinic if first presentation
ensure auto injectors are in date

Question 35

try that cause delirium (9)

Answer 35

Tricyclic antidepressants e.g. amitryptilline
Antimuscarinics e.g. oxybutynin
Antihistamines e.g. cetirizine, loratadine, hydroxyzine
H2 receptor antagonists e.g. ranitidine
Opioids e.g. codeine
Benzodiazepines e.g. lorazepam
Gabapentin
Theophylline
Hyoscine

Question 36

if alcohol abuse or withdrawal is suspected what do you need to remember to prescribe alongside the benzo

Answer 36

parenteral thiamine