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POEM > Disability > Flashcards

Disability Flashcards

1
Q

List the differential diagnosis for the unconscious patient.

A

GCS <8:

  • head injury
  • overdose of sedating drugs
  • non-traumatic coma: post-ischaemic; systemic infection; and metabolic derangement e.g. hypoglycaemia
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2
Q

Outline the AGED mnemonic for disability in ABCDE assessments.

A 
A = AVPU
G = capillary blood glucose
E = pupillary reflexes
D = drug kardex
(+ temperature)
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3
Q

Outline the presentation of head injury.

A
  • Pain
  • Reduced GCS <13
  • Amnesia of event or leading up to injury
  • Confusion and disorientation
  • Headache
  • Dizziness
  • Blurry vision
  • Nausea and vomiting (esp. if more than once)
  • Seizure
  • Changes in behaviour
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4
Q

Outline the signs of a head injury.

A

Base of skull fracture:
• Panda/raccoon eyes (peri-orbital
• bruising behind the ear (Battle’s sign)
• Blood/CSF from the ear canal or nose

Anterograde amnesia:
• Extent of loss correlates to severity of injury

Assess risk of C-Spine w/ CT:  
•  Plain X-rays are suspicious 
•  GCS <13 
•  LOC +/- >65yo, focal deficit, RTC 
•  If no risk factors and has been ambulatory since w/ no pain: rotate head 45 degrees each way
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5
Q

Describe the aetiology of head injury.

A
  1. Direct trauma
  2. Cerebral contusion: rupture of capillaries at site of trauma; or ‘contra-coup’ recoil
  3. Diffuse axonal injury: shearing force creates petechial haemorrhages in white matter, and tearing or shearing of axons and myelin sheath
  4. Cerebral oedema/swelling
  5. Intracranial haemorrhage: intracerebral; sub-dural; extra-dural; can lead to herniation
  6. Hydrocephalus: early after head injury; obstruction of fourth ventricle by blood or swelling in posterior fossa; or as a result of SAH blocking the arachnoid granules
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6
Q

Outline the appropriate investigations in head injuries.

A
  • Bloods (FBC, U&E, CRP)
  • Glucose
  • Blood alcohol
  • Toxicology screening
  • ABG
  • Coagulation
  • Head trauma CT series immediately if:
GCS < 13
Focal deficits/seizure
Suspected #BOS
Vomiting > once
LOC > 5 minutes
RTC
Anterograde amnesia
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7
Q

How is head injury managed?

A
  • ABCDE
  • Spinal immobilisation
  • GCS < 8 = intubate
  • Refer to neurosurgery
  • *high dose mannitol useful in pre-operative management of acute intracranial haematomas (reduce cerebral oedema and ICP)
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8
Q

What is status epilepticus?

A

Status epilepticus is defined as:

  • a single seizure lasting >5 minutes, or
  • > = 2 seizures within a 5-minute period without the person returning to normal between them

This is a medical emergency. The priority is the termination of seizure activity, which if prolonged will lead to irreversible brain damage.

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9
Q

Outline the management of status epilepticus.

A

Management:

  • ABCDE
  • airway adjunct
  • oxygen
  • check blood glucose
  • in the prehospital setting diazepam may be given rectally
  • in hospital IV lorazepam 4 mg is generally used. This may be repeated once after 10-20 minutes
  • If ongoing (or ‘established’) status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion
  • If no response (‘refractory status’) within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.
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10
Q

How does sub-arachnoid haemorrhage usually present?

A
  • Sudden onset occipital headache (thunderclap headache)
  • Rarely get nausea and vomiting/meningism (neck stiffness/photophobia)
  • Vision changes
  • Neurological symptoms such as speech changes, weakness, seizures and loss of consciousness
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11
Q

What is a sub-arachnoid haemorrhage?

A

An intracranial bleed. Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.

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12
Q

How is SAH investigated?

A
  1. CT head is the first line investigation. Immediate CT head is required. Blood will cause hyperattenuation in the subarachnoid space.
  2. Lumbar puncture is used to collect a sample of the cerebrospinal fluid if the CT head is negative. CSF can be tested for signs of subarachnoid haemorrhage:
    • Red cell count will be raised. If the cell count is decreasing in number over the samples, this could be due to a traumatic lumbar puncture.
    • Xanthochromia (the yellow colour of CSF caused by bilirubin)
  3. Angiography (CT or MRI) can be used once a subarachnoid haemorrhage is confirmed to locate the source of the bleeding
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13
Q

How is SAH managed?

A
  • Coiling of aneurysm by interventional radiologist
  • Vasospasm avoided by giving 21 day course of nimodipine
  • Hydrocephalus treated with shunt
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14
Q

What are some common complications of SAH?

A
  • Re-bleeding
  • Vasospasm
  • Hyponatraemia (due to SIADH - common MCQ)
  • Seizures
  • Hydrocephalus
  • Death
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15
Q

Outline the components of the Glasgow Coma Scale.

A

Eye opening (4)

Spontaneous
To sound
To pressure
None

Verbal response (5)

    Orientated
    Confused
    Words
    Sounds
    None

Motor response (6)

    Obey commands
    Localising
    Normal flexion
    Abnormal flexion
    Extension
    None
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16
Q

How is hypoglycaemia managed?

A

A dangerous medical emergency.

  1. Unconscious = 150 mL 10% glucose IV STAT (repeat if necessary)
    - Glucagon 1 mg IM if no IV access (repeat 1-2 times if necessary)
    - Check CBG 10 mins later
  2. Conscious but unable to swallow = 1.5-2 tubes glucose gel around teeth if mild and patient conscious
    - Check CBG 10 mins later and give long-acting carbohydrate when able to swallow
  3. Can swallow = 15-30 g fast-acting carbohydrate (e.g. 5-7 glucose tablets; 150 mL fruit juice)
    - AND long-acting carbohydrates (e.g. biscuits/toast)
  4. ALL = correct underlying cause
17
Q

What are the causes of coma with focal signs?

A
  • No meningism — stroke, space occupying lesions (e.g. tumor, hemorrhage, abscess), injury, inflammation
  • Meningism (Neck stiffness, headache, photophobia, Kernig’s sign) — meningoencephalitis, subarachnoid haemorrhage (SAH)
18
Q

What is Kernig’s sign?

A

Patient supine with hip flexed 90 degrees, cannot fully extend knee (demonstrating meningitis)

19
Q

What are the systemic causes of coma WITHOUT focal signs?

A 
Mnemonic: TOMES
•  Toxins 
•  Organ failures 
•  Metabolic — check COATPEGS (CO2, O2, ammonia, temperature, pH, electrolytes, glucose) 
•  Endocrine  
•  Seizures
20
Q

What is the underlying cause when pupils are dilated bilaterally and unreactive?

A

Brainstem injury

POEM (11 decks)

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