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Chronic Flashcards

1
Q

Major areas of ischaemic stroke?

A

Anterior Circulation Stroke (ACS) 70% ofall strokes - MCA = 90% of ACS - ACA = 10% of ACS Posterior Circulation stroke (PCS) 15% of all strokes

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2
Q

What does the NIHSS stand for? What does it measure?

A

national institute of health stroke scale 42 point score; across 11 domains Stroke Severity Repeating test shows improving Prognosticating

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3
Q

What are the 11 domains of the NIHSS?

A

Alertness orientation Gaze Visual capacity Facial strength Upper limb strength Lower limb strength Coordination Sensory Language Dysarthria Neglect

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4
Q

What are the 4 Oxford Classifications for stroke?

A

TACI 9% PACI 48% LACI 29% POCI 14%

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5
Q

What is the minimum blood flow needed to the brain?

A

50ml/min/100g decreased protein synthesis <35ml/min/100g lactic acidosis <20ml/min/100g cell death <11ml/min/100g

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6
Q

What vessels implicated for TACI?

A

Occlussion of of internal carotid artery, 1st division MCA

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7
Q

Clinical manifestations of a TACI?

A

Hemianopia with gaze deviation Unilateral hemiparesis Dominant hemisphere = language problems Non-dominant hemisphere = visual-spatial neglect

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8
Q

TACI initial imaging management?

A

CT brain - dense CT angiogram CT perfusion - determine how much is penumbra (compromised = green) infarcted tissue (red)

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9
Q

What vessel are often involved in PACI?

A

Often M2 of the MCA

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10
Q

A PACI stroke in the Inferior division of M2 causes…

A

Damage to the inferior parietal and temporal lobes - Wernickes dysphasia - Non-dominant parietal lobe = hemi spacial neglect without weakness - Gerstmann syndrome (dominant parietal lobe) □ Agraphia □ Acalculia □ Finger agnosia □ Left-right disorientation

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11
Q

What is Locked Syndrome?

A

Most common cause is ischemic infarction of the ventral pons Patient becomes ‘locked in’ own body limb paralysis loss of speech retained consciousness, alertness, cognition patient uses vertical eye movement and blinking to communicate

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12
Q

What is the biggest risk factor for Intra-cranial haemmorrhage?

A

HT Cerebral amyloid angiopathy others: DM, smoking, low cholesterol?

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13
Q

Common sites of ICH?

A

basal ganglia - 40-50% lobar regions - 20-50% thalamus - 10-15% pons - 5-12% cerebellum - 5-10%

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14
Q

Describe microhaemorrhages

A

Small, aymptomatic bleeds throughout the brain Found only on MRI scanning Subcortical basal ganglia and pons areas = due to HT Lobes cortical areas = due to amyloid

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15
Q

How do Intra-cranial haemmorrhage patients present?

A

Altered levels of consciousness Nausea and vomiting Headaches Seizures (6%) Focal neurological deficits

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16
Q

Management of Intra-cerebral haemmorrhage?

A

ABCs Immediate CT scan Cease all anticoagulants, antiplatelets Reverse anticoagulants Maintain normthermia Maintain hydration Treat hypoglycaemia Prevent aspiration - NBM Prevent DVT/PE Maintian BP <140-160 Antiepileptic medications if seizures Surgery - if hematoma > 3cm and deteriorating patient

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17
Q

Stroke urgent management includes:

A

CT brain BGL O2 saturations

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18
Q

Stroke immediate management includes:

A

ECG blood count EUC Troponin Prothrombin Time and INR E-carin clotting time if on NOACECG blood count

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19
Q

The goal time for CT brain for stroke patient in ED is…

A

within 20min

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20
Q

What is the thrombolysis time for acute stroke?

A

< 4.5 hours

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21
Q

Time parameter for clot retrieval for ICA or M1 or basilar artery occlusions?

A

6-24 hours of symptom onset

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22
Q

What is TPA?

A

Tissue Plasminogen Activator Clot busting medication - tenectaplase age > 18 risk of bleeding? NIHSS score usually > 5

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23
Q

Who should be considered for carotid endarterectomy?

A

Stroke patient with > 50% stenosis on ipislateral side within 7 days

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24
Q

What is the Modified Rankin Score? What does measure?

A

Measures the degree of disability Score is 0 to 6 (6=dead)

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25
What is the ICF model include?
1. Body Functions and Structures (Impairment) 2. Activity (Limitations) 3. Participation (Restrictions) Takes into account the contextual factors, environmental and personal factors
26
Secondary prevention for Stroke: Lifestyle modifications include…(6)
Stop smoking Diet Physical Activity Weight managemtn Alcohol consumption \< 2 SD/day Medication compliance
27
Secondary prevention for Stroke: Medications…
BP management - target 130mmHg ACEi / diuretic therapy Beta-bockers - not first line unless IHD Anti-coagulation therapy - NOACs or warfarin Anti-platelet - aspirin clopidgrel Cholesterol lowering agents Diabetes management - oral hypoglycaemics
28
What does a 'Young Stroke Screen' screen for?
Thrombophilia conditions Antiphospholipid antibodies Lupus anticoagulant Protein C and S levels Anti-thrombin III levels Patent Foramen Ovale
29
Typical dominant stroke impairments?
Aphasia (expressive/receptive) Limb apraxia Apraxia of speech Depression/anxiety Decrease attention span Slowed speed of processing
30
Typical non-dominant stroke impairments?
Inattention / neglect Anosognosia Dressing/constructional apraxia Spatial / perceptual deficits Impulsivity
31
Non-driving period post stroke?
At least 4 weeks personal liscence 3 months for commercial liscence
32
Non-driving period post TIA?
At least 2 weeks
33
What the adverse effects of NSAIDS?
1. Peptic ulceration 2. Platelet dysfunction 3. Bronchospasm 4. Cardiovascular effects MI/HT 5. Renal impairment
34
What classification is used for Spinal Cord Injury?
ASIA Impairment Scale (AIS) Very Precise :) A - complete - no motor or sensory function B - Incomplete - sensory preserved, no motor C - Incomplete - motor function preserved some D - Incomplete - E - normal motor and sensory function
35
Complications associated with Spinal Cord Injury?
Every system affected! Bladder disrupted Autonomic Dysreflexia Skin - pressure ulcers Spasticity Pain
36
What is Autonomic Dysreflexia?
Potentially life-threatening! Parasympathetic symptoms above the lesion --\> Bradycardia, headache, sweating Sympathetic sx below the lesions --\> Increased BP, piloerection
37
Management of Autonomic Dysreflexia?
BP monitor + treat if \> 170mmHg Treat with: --\> GTN (beware phosphdiesterase 5 inhibitors - sildenafil) --\> Nifedipine 10mg crushed --\> Captopril 10 mg S/L
38
What is Traumatic Brain Injury?
…insult to the brain caused by an external force that may produce diminished or altered states of consciousness which results in imparied cognitive abilities or physical functioning'
39
Types of Primary TBI?
Concussion Skull fracture Penetrating injury Contusions/lacerations Haemmorrhages Diffuse axonal injury Diffuse vascular injury Extra-axial collections
40
Types of Secondary TBI?
O2 deprivation cerebral oedema Raised intracranial pressure Cerebral perfusion/ischemia Bleeding Neurochemical
41
What are the grades in severity of TBI in terms of: 1. Initial GCS 2. Duration of LOC 3. Duration of Post-traumatic amnesia
MILD 1. Initial GCS = 13-15 2. Duration of LOC \<30 min 3. Duration of Post-traumatic amnesia \<24 hours MODERATE 1. Initial GCS = 9-12 2. Duration of LOC \>30 min, to \<24 hr 3. Duration of Post-traumatic amnesia = 1-7 days SEVERE 1. Initial GCS = 3-8 2. Duration of LOC \>24 hr 3. Duration of Post-traumatic amnesia = 1-4weeks VERY SEVERE 1. Initial GCS = 3-8 2. Duration of LOC \>24 hr 3. Duration of Post-traumatic amnesia \>4weeks
42
How is the GCS calculated?
EYE --\> spont=4 sound=3 pain=2 none=1 VERBAL --\> Orientated=5 confused=4 inapproriate words=3 incomprhensible sounds=2 none=1 MOTOR --\> obeys commands=6 localises to pain=5 withdraws=4 flexion-abnormal (decorticate)=3 extension-abnormal (decerebrate)=2 none=1
43
What tool is used to measure Post-traumatic Amnesia?
Westmead PTA Scale
44
Physical effects of TBI include…
Sensory loss (smell, taste, hearing, vision) Balance and coordination Dysarthria Swallowing difficulties Motor control (hand function, walking) Seizures Decreased tolerance to drugs and alcohol Headache Sexual dysfunction Sleep disturbance Fatigue
45
Cognitive effects of TBI include…
Short term memory Attention Concentration Distractibility Information processing Slow reaction times Arousal Problem solving Decreased verbal fluency Changed intellectual functioning Difficulties with abstraction/conceptualisation
46
What does the Glasgow Outcome Scale - Extended measure?
The Glasgow Outcome Scale-E, applies to patients with brain damage allowing the objective assessment of their recovery in 8 categories --\>Prediction of the long-term course of rehabilitation to return to work and everyday life
47
Time definition for chronic pain?
Pain \> 3 months
48
Risks associated with Chronic pain?
Increased risk of depression and anxiety 2 x risk of suicide
49
What tool to measure neuropathic pain?
DN4
50
Managaement of chronic pain?
1. Patient-centred goals 2. CBT - Changes in attitude and response to pain - Education about pain - Pt centred goals - Cognitive responses to pain - Behavioural responses to pain - sympathetic response? - Acceptance commitment therapy - ADHERENCE seems to be the key 3. Functional restoration - Avoid deconditioning - Psychologically informed physiotherapy 4. Psychological conditions to be managed - Substance abuse - Depression - Suicide risk x 2 Medications
51
What are would the following walking speeds indicate: 1. \< 0.4m/s 2. 0.4-0.8m/s 3. \> 0.8 m/s
\< 0.4m/s = housebound 0.4-0.8m/s = limited community ambulation \>0.8m/s = community ambulator (eg cross a pedestrian crossing)
52
What is required to walk functionally?
Stability Clearance and swing Landing of foot Adequate step length Energy consumption Gait cycle --\> flexion of hip, knee and ankle
53
Abnormal gait movements for leg length discrepency include:
Circumduction Hiphiking - lift leg up from hip Stepping - ankle not flex Vaulting - of short leg for long leg to clear ground
54
Why do some people walk with a lateral trunk bend?
Moves trunk towards the side of the supportive/stronger limb Less strength and ROM of the opposite hip joint Reduces pain at the hip
55
What is the non-driving periods associated with cardio-arrhythmia/syncope?
4 weeks
56
What is the non-driving periods associated with cardiac arrest?
6 months
57
What is the non-driving periods associated with Acute MI?
2 weeks
58
What is the non-driving periods associated with cardiovascular surgery?
4 weeks
59
What is the non-driving periods associated with PE?
6 weeks
60
What is the non-driving periods associated with DVT?
2 weeks
61
What is the definition of a severe hypoglycaemic event?
a. Not able to administer medication/intervention for the event b. Unconscious c. Not to drive for 6 weeks post severe hypoglycaemic event
62
What are some of the impacts of musculo-skeletal conditions depending on type of vehicle?
Many complex muscle movements needed for driving a vehicle Upper limbs for steering, changing gears, indicators etc Lower limbs for accelerator brakes Neck and torso rotation for looking at things
63
What are the impacts of memory and insight on driving recommendations?
Errors with navigation Decreased concentration and attention Misjudging speed and spatial awareness Confusion with driving controls eg brakes vs accelerator Slowed reaction time Poor hand-eye coordination
64
Which nerve innnervates the external sphincter of bladder and pelvic floor?
Pudendal nerve Voluntary muscle Somatic nervous system
65
Which nerve allows filling of the bladder?
Sympathetic activity via the Hypogastric nerve (T10-L2) Inhibits detrusor muscle contraction (ie promtes relaxation/stretch) during filling Contracts muscles in urethra and bladder neck (internal sphincter)
66
Which nerve allows voiding/emptying of bladder?
Parasympathetic activity via Pelvic nerve (S2-S4) Sacral micturation centre Unopposed impulses result in detrusor contraction
67
Pathophysiology of incontinence due to age...
Decreased bladder capacity Increased post void residual Increased involuntary bladder contractions Increased night time urine production Altered central and peripheral neurotransmitter Altered immune function (UTI)
68
What are the 4 main types of incontinence?
Stress Overflow Urge Functiona
69
Describe Stress incontinence…
Urine escapes due to sudden increase in abdominal pressure Weakened external sphincter and pelvic floor Due to prolonged vaginal labour/delivery, surgery, forceps delivery
70
Describe Urge incontinence…
Involuntary loss of urine accompanied or immediately preceded by urgency Increased contraction activity of detrusor muscle of bladder by irritation from stones, tumor, cystitis.
71
Describe overflow incontinence…
Associated with retention Urine loss when intravesical pressure \> urethral pressure May occur in obstructive bladder (prostate) Hypotonic bladder (spinal cord injury, autonomic neuropathy from diabetes)
72
Functional incontinence…
Inability to get to the toilet in time due to mobility or psychlogical problems
73
What is the mnemonic for causes of transient incontinence?
DIAPPERS D - delirium I - infection A - atrophic urethritis/vaginitis P - psychological P - pharmacologic E - excess urine output R - restircted mobility S - stool impaction
74
What is an example of medication for treatment of urge incontinence?
Anticholinergic or antimuscurinic medications Block parasympathetic neurtransmitters of Ach to muscurinic receptors of detrusor muscle and sphincter Side-effects: urinary retention, dry mouth, confusion
75
Pharmacology management of obstructive symptoms in male with prostate hypertrophy?
1. Alpha-adrenergic antagonist (blockers) Causes relaxation of prostatic smooth muscle Eg. Tamsulosin, prazosin, terazosin 2. Type II 5 alpha reductase inhibitor Also known as dihydrotestosterone (DHT) blockers DHT is a potent androgen steroid that caused epithelial growth of the prostate Blocking DHT, causes reduced prostate enlargement in BPH
76
Main treatment for stress urinary incontinence?
Lifestyle interventions Pelvic floor muscle exercises
77
A cognitive deficit often results from …... sided stroke.
right (dominant)
78
What does the mnemonic KIC MR ILS stand for?
K - knowledge I - involvement C - care plan M - monitoring R - response I - impact L - lifestyle S - upport Used as guiding principles of management of chronic health conditions
79
What is dysarthria?
Disturbance in muscular control of speech mechanism Can be caused by damage to CNS/PNS affecting: - respiratory sufficiency for speech - range, strength and rate of oral musculature - clarity of articulation - voice quality - resonance
80
What is Apraxia?
Impairment of the capacity to program speech muscles and the sequence muscle movements for the production of sounds
81
What is dysphonia?
Impairment in voice quality eg, hoarse, husky etc
82
What is Aphasia?
Disorder of language processing Often caused by right/dominant side. Eg. Wernickes and Broca Expressive vs Receptive
83
Wernickes aphasia is associated with…
Receptive aphasia Patients have difficulty understanding written and spoken language But they are often fluent in their speech
84
Broca's aphasia is associated with …
Expressive aphasia Partial loss of ability to produce language Non-fluent speech
85
What is anomia?
Word finding difficulty
86
What is Zenker's Diverticulum?
Also known as a pharyngeal pouch It is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus) Food can get trapped in the diverticulum
87
What is the difference between penetration and aspiration?
Penetration = past epiglotis into trachea, but not past the vocal cords Aspiration = past both epiglotis and vocal cords
88
What cranial nerves are involved in swallowing? Describe each one's function.
V-trigeminal = mastication; sensation anterior 2/3 tongue VII-facial = taste anterior 2/3 tongue; lip + buccal muscles; hyoid/laryngeal elevation IX-glossopharyngeal = taste posterior 1/3; sensation at soft palate; hyoid/laryngeal elevation X-vagus = palatal elevation/depression; closes laryngeal vestibule; pharyngeal constriction; cricopharyngeal relaxation; initiates peristalsis in oesophagus XII-hypoglossal = tongue movement; bolus transition; hyois elevation
89
What are the swallowing image modalities of FEES and MBS?
FEES = Fibreoptic Endoscopic Evaluation of Swallowing MBS = Modified Barium Swallow (real-time X-ray)
90
What is the eyesight required for driving? VA
VA 6/12 No dipopia VF = horizontal extension \> 110 degrees If VF is \< 110 degrees but \> or equal to 90 degrees (needs conditional liscense)
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