CBL_2 headache and coma Flashcards
Differentials for acute single episode of headache
Acute single episode
- meningitis
- encephalitis
- subarachnoid haemorrhage
- head injury
- sinusitis
- glaucoma (acute closed-angle)
- tropical illness e.g. Malaria
Common causes of headache
- tension headache
- cluster headache
- temporal arteritis
- migraine
- medication overuse
Characteristics of migraine
Migraine
- Recurrent, severe headache
- usually unilateral and throbbing
- may be associated with aura, nausea and photosensitivity
- avoidance of, routine activities of daily living (patients often describe ‘going to bed’)
- In women may be associated with menstruation
Tension headache characteristics
Tension headache
- recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
- not aggravated by routine activities of daily living
Characteristics of cluster headache
Cluster headache
- pain typically occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
- intense pain around one eye (recurrent attacks ‘always’ affect same side)
- patient is restless during an attack
- accompanied by redness, lacrimation, lid swelling
- more common in men and smokers
Characteristics of temporal arteritis
Temporal arteritis
- typically patient > 60 years old
- rapid onset (e.g. < 1 month) of unilateral headache
- jaw claudication (65%)
- tender, palpable temporal artery
- raised ESR
Characteristics of headache associated with medication overuse
Medication overuse headache
- present for 15 days or more per month
- developed or worsened whilst taking regular symptomatic medication
- use opioids and triptans are at most risk
- may be psychiatric co-morbidity
Components and scoring in GCS assessment
- *Motor response** 6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None Verbal response 5. Orientated
4. Confused
3. Words
2. Sounds
1. None Eye opening 4. Spontaneous
3. To speech
2. To pain
1. None
Two initial assessments that must be done on an unconscious patient brought to A&E
- ABCDE
- GCS
What bloods and why to perform on an unconscious patient?
Bloods:
- Infection: FBCs, CRP
- Toxicology
- Troponin – to eclude MI
- Creatinine kinase (CK) -> rhabdomyolysis (as person may have been on the floor for too long)
- LFTs -> e.g. paracetamol OD, hepatic encephalopathy
- U&Es -> to check for electrolyte imbalance
What investigations would you like to perform on an unconscious patient?
- ABG -> potential acidosis (DKA, sepsis), to assess oxygen
- ECG -> to exclude cardiac causes
- CXR -> to assess B component of ABC
- CT -> HI, stroke
What may the following indicate :
pinpoint pupils + respiratory depression
Opioid overdose
In cocaine use, what pupils would look like?
Dilation
What’s the definition of coma?
State of unconsciousness and unawareness
What structures are damaged in coma?
Damage to: brainsteam à reticular formations (reticular ascending system)
What (in general) causes coma?
Hypoxia - death of the brain cells
Possible causes of coma
- Sepsis
- Hypoxia
- Hypoglycaemia
- Addison’s crisis
Possible Hx / presentation of subdural haemorrhage
Subdural -> elderly, anti-coagulant, fall -> then confusion weakness etc.
Possible history/ presentation of extradural haemorrhage
- Extradural -> young people, head injury/assault -> LOC , then fine (luicid interval) and then rapid deterioration
What do we examine - neurone wise (what cranial nerve) - in an unconscious patient?
- Pupils -> CN II and III
- CN V -> corneal reflex (in unconscious person)
- CN VIII -> occulo-cephalic: move pt head and if they can fix the eyes on specific point -> then it works; oculo-vestibular: cold water or saline injection into the ears -> if eyes move towards that ear -> then VIII is intact
- CN IX and X -> gag reflex
‘fixed pupils’ - what do they mean?
unreactive pupils
How does ptosis present?
Ptosis down and out -> CN 3 palsy (unopposed action of 4 and 6)
What’s the common cause of ptosis?
Aneurysm at basilar a. or PICA -> 3rd nerve palsy -> dilated, down and out pupil (dilated = aneurysm)
Examinations to perform in a presentation of headache
Examination:
- CN exam, fundoscopy, full neural examinations
What is Kerning’s sign?
Kerning’s sign
positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance). This may indicate subarachnoid hemorrhage or meningitis
*due to irritation of meninges
Two investigations in suspicious presentation of headache
- CT head -> SAH, normal, subdural (if fall and anti-coagulant), trauma (extradural)
- LP -> meningitis, bilirubin (xanthochromia), send off for cultures (to exclude meningitism)
Management of SAH
The treatment -> in accordance with the causative pathology
- intracranial aneurysms -> most coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon
- intil the aneurysm is treated, the patient should be kept on strict bed rest, well controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm
- Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution
- Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt
What condition would we suspect in: stroke-like symptoms and female on OCP?
Venous sinus thrombosis
