Disability Notes 2 Flashcards
When should a patient have imaging for suspected stroke within 1 hour?
- indications for thrombolysis/ early anticoagulation treatment
- on anticoags
- known bleeding tendency
- GCS <13
- unexplained progressive, fluctuating symptoms
- pappiloedema, neck stiffness or fever
- severe headache at onset
What patients warrant thrombolysis in stroke?
What score can be used and what does a score >0 mean?
- time of onset <4.5 hours and ROSIER score >0
- ROSIER score, high likelihood of stroke
What are the parameters of the Rosier Score?
- Assymetric facial/ elg/ arm weakness (1 each)
- speech disturbance
- visual field defect
- -ve points for syncope and seizures
What are the contraindications to thrombolysis?
- Seizure at onset of stroke
- symptoms suggesting SAH
- stroke in last 3 months
- major surgery/ trauma in last 2 weeks
- previous intracranial haemorrhage
- intracranial neoplasm
- aneurysm
- bleeding in last 3 weeks from anywhere
- INR>1.7
What bloods/ investigations would you order?
- ECG
- FBC
- U+Es
- Cholesterol
- Glucose (rule out hypo)
What risk factors are there for stroke?
- Previous stroke/ TIA
- Hypertension
- Diabetes
- PVD, IHD
- AF
- current/ ex- smoker
- hyperlipidaemia
After CT how should these patients be managed?
- Alteplase 0.9mg/kg
- 10% given as bolus, 90% infusion
Aspirin 300mg OD for 2 weeks if NO bleed, then clopidogrel 75mg OD for life
- Statin
- Monitor RFs
If the patient has AF how should management change?
What anti-coagulant should they get?
Offer anti-coagulation if:
- Male + CHA2DS2-VASc score of 1 or more
- Female + CHA2DS2-VASc score of 2 or more
- NOACs: Dabigatran, rivaroxaban, apixaban
What is the CHA2DS2S VASc score breakdown?
- Congestive heart failure
- Hypertension
- Age >75
- Diabetes
- previous Stroke/ TIA (2)
- Vascular disease
- Age 65-74
- Sc Sex category- (female 2)
How would you assess bleeding risk in patients with AF who are anticoagulated? Explain it
- HAS BLED score
- Hypertension
- Abnormal liver/ renal function
- Stroke
- Bleeding
- Labile INR
- Elderly (age> 65)
- Drugs/ Alcohol
What are the common organisms causing meningitis?
- N meningitides/ Strep pneumoniae
- listeria in young and old
What signs can be elicited?
- headache, neck pain, photophobia, seizures
- tachycardia, hypotensive, pyrexial, reduced GCS,
- non blanching, petechial rash
- Brudzinskis (neck flexing)
- Kernig’s sign (knee extension)
What is the treatment for Meningitis?
- Community: IM benzylpenicillin 1.2g
- Hospital: ceftriaxone 2g IV
What bloods would you do in meningitis?
- (FBC/ U+Es/ LFTs, CRP, BM, clotting, blood gas)
What investigations would you do apart from bloods in meningitis?
- Blood cultures
- throat swab
- PCR
- CT scan
- LP
What is the glucose like in bacterial, viral and TB lumbar punctures?
What components of WCC are high in bacterial and then viral meningitis?
- low, normal, low
- neutrophils >1000
- lymphocytes
- LP turbid means bacterial
Name causes for seizures.
- Epilepsy,
- hypoglycaemia, hyper/ hyponatraemia, hypoxia, hypercalcaemia
- hypertension/ eclampsia
- stroke, alcohol withdrawal
- meningitis, encephalitis
What is defined as status epilepticus?
- Convulsive seizure, continued for >30 mins
- OR continued one after the othern
What is the management of elipesy?
- ABCDE, recovery position
- manage CAUSE of seizure
- If seizure >5mins, call for senior help, attach cardiac monitor and one of:
- IV lorazepam (4mg stat) repeat every 10 mins
- PR diazepam 10mg. Can repeat every 10 mins up to 30 mg
- Buccal midazolam 10mg
What is the management of epilepsy cont.
- If seizure lasts >20 mins:
- call the anaesthetist
- phenytoin- 20mg/kg IV at <50mg/min
- (phenobarbitol if taking phenytoin)
if seizure lasts >40 mins:
- manage on ICU with thiopentone/ propofol infusion
What bloods would you get in epilepsy?
- FBC, U+Es, LFTs, Ca, glucose, blood cultures
What are the symptoms of alcohol withdrawal?
- tremor, sweating
- N and V
- anxiety, psychomotor agitation
- headache, insomnia
- malaise, weakness
- hallucinations
- grand mal convulsions
- tachycardia/ hypertension
When does delirium tremens set in?
What is it characterised by?
- 1-3 days post alcohol cessation
- symptoms of alcohol withdrawal and hallucinations involving insects/ small animals
how is delirium tremens managed?
What is the CIWA-Ar score out of? When does the patient start to get out of control, aggressive and angry?
- Reducing dose of chlordiazepoxide
- IV pabrinex 1+2 (PO thiamine and vitamin B co-strong)
- CIWA-Ar score
- around 20
