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Anaesthetics > Disorders of Conciousness > Flashcards

Disorders of Conciousness Flashcards

1
Q

Someone’s mental status is defined by 2 components. What are they?

A

Level of consciousness and cognition

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2
Q

What is the difference between arousal and awareness?

A

Arousal is the degree of wakefulness
Awareness/alertness is the degree of responsiveness to external stimuli

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3
Q

Define a confused level of consciousness

A

One that is disoriented in time/place/person

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4
Q

Define a delirious level of conciousness

A

Disoriented (in space/time/person) + restless + sometimes hallucinating

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5
Q

What levels of consciousness are typically seen in delirium

A

Hyperalert in hyperactive delirium
Delirious in delirium lol

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6
Q

What is the difference between a somnolent and a lethargic level of conciousness?
Vs. Obtunded?

A

Somnolent = sleepy
Lethargic = reduced alertness
Obtunded = reduced alertness + slow responses (awareness)

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7
Q

Present (correct formatting) the GCS score of someone who Obeys commands, is oriented in space/time/person when asked but only opens their eyes to pain?

A

GCS: 2/4, 5/5, 6/6

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8
Q

Present (correct formatting) the GCS score of someone who flexes their arm to pain, is cussing at you, and opens eyes spontaneously

A

4/4, 3/5, 3/6

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9
Q

Present (correct formatting) the GCS score of someone who extends their arm to pain, is confused, and opens eyes only to your voice

A

3/4, 4/5, 2/6

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10
Q

Present (correct formatting) the GCS score of someone who elicits no response to pain and is only mumbling

A

1/4, 2/5, 1/6

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11
Q

Present (correct formatting) the GCS score of someone who localizes to pain, is not making any sounds and eyes closed unless their is pain.

A

2/4, 1/5, 5/6

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12
Q

Present (correct formatting) the GCS score of someone who withdraws their arms to pain, is rambling about their sad days.

A

4/4, 4/5, 4/6

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13
Q

Give 5 intracranial and 5 extracranial causes of reduced conciousness

A

Intracranial = TBI, stroke, space-occupying lesion, subarachnoid hemorrhage, hematoma, infection (meningitis, encephalitis), Seizures, non-convulsive status epilepticus, Wenicke’s encephalopathy
Extracranial = Cardiac (shock), Resp (Any cause of T1 or T2RF), Renal failure (hypernatremia), endocrine (glucose/thyroid), pH disturbances, alcohol withdrawal, sedatives, poisons and toxins.

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14
Q

Quick history on loss of conciousness

A

First collateral history going through the course of LOC (before, during, after) including
focal signs before,
seizure activity,
head trauma,
when last seen well
Drug/medication hx with potential for OD/poisoning?
Past psych hx

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15
Q

What are the clinical features of a patient presenting with brain injury?

A

Reduced GCS: Altered consciousness
Raised ICP: Headache, vomiting, hypertension, bradycardia
Seizures

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16
Q

What part of the ECG is particularly important when suspected of OD?

A

QRS complex and QT length

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17
Q

When ordering a toxic screen what should you make sure is included other than the typical drugs?

A

Paracetamol and salicylates as they are one of the most common ODs

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18
Q

What is the first line imaging for all LOC?

A

Neuroimaging - non-contrast CT

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19
Q

What investigations would you order

A

If having trouble, its very easy if you ensure youre checking for all your causes
Bedside: Glucose (seizure), urinalysis (UTI), ECG (QRS and QT length imp in OD), ECG (QRS and QT length)
Lab: Bloods (FBC, UandE - renal failure, coag screen -TBI, LFTs (hepatic encephalopathy), Toxic screen (INCLUDE PARACETAMOL and SALICYLATES)
ABG
Blood/urine cultures and viral swabs (sepsis, meningitis and encephalitis) - LP if high suspicion
Neuroimaging: NON-CONTRAST CT (mass effect, hematoma, hemorrhage stroke, TBI)
Endocrine (TFTs)

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20
Q

The general management of LOC is via ABCDE and treatment of the underlying cause. Treat the following underlying causes appropriately with correct dosages and methods of administration.
Hypoglycemia
Hypoglycemia with alcohol abuse history
Infection
Opioid toxicity
Increased ICP (pharmacological dw the rest will come)

A

Hypoglycemia: IV 50 ml 50% glucose followed by IV 100mg Thiamine
Hypoglycemia with alcohol abuse history: IV 100mg Thiamine followed by IV 50ml 50% glucose
Infection: Antibiotics (Ceftriaxone)
Opioid toxicity: Naloxone
Increased ICP: Mannitol/Hypertonic saline

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21
Q

Most seizures resolve spontaneously within 2 minutes. In an emergency requiring ABCDE approach. How would you manage outside the typical ABCDE approach.

A

1) IV thiamine 100mg
2) IV 50% glucose 50ml
3) If longer than 2 minutes: IV Lorazepam (0.1mg/kg max 4mg) can be repeated once. If no IV access Buccal Midazolam (10 mg if >40kg) or Rectal Diazepam (0.2-0.5mg/kg max=20mg) as second line
4) If longer than 5 minutes => ongoing status => Alert anesthetics and ICU where they will administer IV phenytoin/phenobarbitone
5) Refractory Status, nothing is working => General anesthesia (Propofol)

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22
Q

When is a Bag-mask indicated over a non-rebreather mask?

A

If RR<8

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23
Q

In an emergency situation, when is intubation indicated?

A

GCS 8 or lower

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24
Q

Many drugs and poisons have a high risk of dysrhythmias. How would you treat it in an acute setting?

A

4As: Adenosine, adrenaline, amiodarone, and atropine

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25
Q

What is the relation of cerebral blood flow to CO2 and PO2?

A

Cerebral blood flow increases when CO2 increases => Vasodilation
Cerebral blood flow decreases when PO2 increases => Vasoconstriction

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26
Q

In an emergency situation, it is often essential to get the substance out of the system as quickly as possible. How would you acutely increase elimination?

A

Gastric/gut lavage, Activated charcoal, and Hemodialysis (in this order)

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27
Q

In terms of poisoning/OD, it is typically difficult or impossible to know the exact substance ingested in an acute setting. In an emergency situation with the ABCDE approach, go through every step

A

1) Get data from first responders (pre-hospital) and put on PPE to prevent exposure to some
2) Toxidrome-oriented physical examination looking for patterns of signs consistent with groups of agents
3) ABCDE approach
A: Often difficult to keep open reliably => intubation with consideration of rapid sequence intubation (RSI) if needed
B: 100% Non-rebreather mask 15L/min and Bag mask if GCS<8
C: Treat hypotension with fluid bolus IV 500ml normal saline and Vasopressors (norepinephrine, vasopressin).
Treat Dysrhythmias with 4As: Adenosine, adrenaline, amiodarone, and atropine
D: Treat hyperglycemia with 100mg Thiamine IV and 50% 50mg Glucose IV (alcohol suspicion) + Reverse known agents as appropriate (e.g. naloxone 400mg for opioid)
E: Exposure and elimination: Correct hyperthermia with paracetamol and look for any marks, swellings, IV marks for drugs etc…
ELIMINATION: Gastric/gut lavage, Activated charcoal, and Hemodialysis (in this order)

REFERRAL TO TOXBASE

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28
Q

A patient presents in the emergency department with increased HR and BP, high body temp, dilated pupils, no bowl sounds and anhidrosis. What is the most likely group of drugs? Give 2 examples

A

Anticholinergic: Atropine, antihistamines

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29
Q

A patient presents to the emergency department with pinpoint pupils, normal bowel sounds and diaphoresis. What is the most likely group of drugs? Give 2 examples

A

Cholinergic: Pilocarpine, mushrooms

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30
Q

A patient presents to the emergency department with low HR, BP, RR, and body temp. They have pinpoint pupils , no/reduced bowel sounds, and anhidrosis. What is the most likely group of drugs? Give 2 examples

A

Opioid: Tramadol, fentanyl, oxycodone, codeine, morphine…

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31
Q

A patient presents to the emergency department with reduced HR, BP, RR, and body temp. They have reduced bowel sounds and anhidrosis. What is the most likely group of drugs? Give 2 examples

A

Can be opioid or Sedative/hypnotic. We would need to check the pupils. If they are constricted then its probably opioid: Tramadol, fentanyl, oxycodone, codeine, morphine…
If there is no change and the pupils are normal then it is probably a Sedative Hypnotic: Anti-anxiety medications, anti-epileptics, benzos, parasympathetics

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32
Q

A patient presents to the emergency department with increased HR and BP, high body temp, and dilated pupils. A colleague suggests an anti-cholinergic overdose such as atropine. You disagree. What is your alternative and what additional characteristics differentiate it from an anti-cholinergic overdose? Give 2 examples

A

Sympathomimetic: Cacaine, ritalin, LSD, Caffeine, MDMA, ecstasy
Here, there would be increased HR (normal in anti-cholinergic), presence of bowel sounds (constipation in anticholinergic), and diaphoresis (anhidrosis in anticholinergic obviosiously)

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33
Q

What is the difference between a primary and secondary injury in TBI (traumatic brain injury)

A

Primary is the direct initial insult. Secondary injury are the factors that exacerbate or worsen the primary injury.

34
Q

How would you grade the severity of a TBI?

A

GCS scoring.
Mild 13-15
Moderate 9-12
Severe <9

35
Q

What is the normal range of ICP and at what ICP would you treat it in a TBI?

A

Normal = 7-15mmHg
Treat if >22mmHg

36
Q

At what GCS score do we intubate in TBI?
At what GCS score do you intubate anyways?

A

TBI <9 = severe TBI which is the same as normal which is 8 or less :)
Intubation also occurs in TBi if SPO2<90

37
Q

What is Cushing’s triad in trauma?
What is its significance?

A

Bradycardia, hypertension (widened pulse pressure), and irregular respirations
Classic sign of intracranial hypertension

38
Q

What is the aim of pre-hospital care in TBI? What does this entail?
What would then be performed on arrival to the hospital?

A

Prevent respiratory failure (hypoxia and hypercapnia)
1) Intubate if GCS<9, SPO2<90%, or if unable to maintain airway
2) Establish normocapnia and normotension
3) C-spine immobilization. Treat every TBI as if it is an upper spinal fracture

In hospital: ATLS protocol
1) Intubate if needed according to same criteria if haven’t done yet
2) Full neuro assessment and monitor for Cushing’s Triad (bradycardia, hypertension -widened pulse pressure, irregular respirations)
3) Bloods: Blood gas, FBC with differentials (esp platelets) , U&E, glucose, RFT (creatinine and eGFR), LFT, coag screen, calcium, magnesium
Transfer to ICU if needed

39
Q

How is ICP monitored in TBI?
What are the indications to monitor ICP in TBI?
What is the cutoff to begin treatment?
What are all the lines of management?

A

Monitored via a probe most commonly inserted intraventricularly. Others include intraparenchymal, subarachnoid, and epidural
Indications for monitoring: Either
1) GCS <8 + CT evidence of Mass effect
2) Normal CT and 2 of: age>40, systolic <90, Motor posturing

Treatment for increased ICP in TBI is indicated when ICP >22mmHg
1) Drainage of CSF
2) Sedation (lowers metabolic demands)
3) Hyperosmolar therapy (mannitol - osmotic diuretic, hypertonic saline)
4) Surgical measures e.g. Craniotomy, drainage of hematoma, Burrholes, ventricular drain, Decompressive craniectomy (bad quality of life in the long-term)

40
Q

What is the most common location to monitor ICP in TBI? Why is it the preferred one? What are some others?

A

Intraventricular is the most common as it also allows for drainage of CSF as is the first line management. Others include intraparenchymal, subarachnoid, and epidural

41
Q

What is the target BP in ICU for TBI patients?
What is the target PaO2 and PaCO2 in these patients?

A

15-49 >110mmHg systolic. 50+ >100 systolic
PaO2 >8kPa and PaCO2<4kPa

42
Q

What is Cerebral perfusion pressure?
What is the normal amount?
What would happen if it is reduced?

A

CPP = MAP (ABG) - ICP (Probe)
Normal = 60-70 mmHg
Reduced = secondary ischemia

43
Q

How does Hypoventilation and hyperventilation both lead to secondary ischemia in TBI?

A

Hypoventilation -> increase in CO2 => vasodilation => increased ICP => reduced CPP => secondary ischemia
Hyperventilation -> reduced CO2 => Vasoconstriction => reduced ICP (only temporarily) => secondary ischemia

44
Q

How would you determine bleeding risk and coagulopathy? What are the normal values. What would be considered a risk?

A

Coagulopathy screen/INR
Normal <1.2
High >1.5

45
Q

What are the contraindications to VTE prophylaxis?
What would you give as VTE prophylaxis typically in a TBI patient?
Why would you wait 24-48 hours before administering?
What would you give as VTE prophylaxis before surgery?

A

Contraindications: High risk of bleeding, coagulopathy (INR>1.5), Thrombocytopenia, bleeding disorders, pregnancy, recent TBI…
Normally: LMWH, apixaban, riveroxaban
Surgery: Clexane or any of the others
We wait 24-48 hours to ensure we will not delay clotting to prevent further hemorrhage before administration.

46
Q

What is the aim of ICU care in TBI? What does the ICU care of TBI entail? (10)

A

Aim: prevent secondary injury
1) Fluids: Achieve Euvolemia via saline bolus
2) Achieve BP target: 15-49 >110mmHg systolic. 50+ >100 systolic
3) Cerebral perfusion Pressure b/w 60-70 mmHg
4) Oxygenation/ventilation: Keep PaO2 >8kPa and PaCO2<4kPa to prevent hyper/hypoventilation to prevent secondary ischemia.
5) Seizure management: Seizure post-TBI is common, Phenytoin is given prophylactically
6) Coagulopathy Screen and VTE prophylaxis: In those without contraindications, VTE prophylaxis via LMWH, Apixaban… may be used 24-48 hours after injury.
7) Glycemic control
8) Normothermia (manage high temp)
9) Nutrition (enteric feeding best if possible)
10) Manage ICP

47
Q

Give the likely diagnosis/finding of Loss of Consciousness + the following symptoms:
tachycardia + hypotension:
tachycardia + Hypertension + Hyperthermia:
Bradycardia + Hypertension + Papilloedema on fundoscopy:
Bradycardia + Widened pulse pressure + irregular respirations:

A

tachycardia + hypotension: Shock (any type)
tachycardia + Hypertension + Hyperthermia: Anticholinergic toxicity
Bradycardia + Hypertension + Papilloedema on fundoscopy: Raised ICP
Bradycardia + Widened pulse pressure + irregular respirations: Cushing’s triad/Intra cerebral hypertension

48
Q

Give 2 diagnoses for each
Constricted pupils
Dilated pupils
unequal

A

Constricted pupils: Opioid or cholinergic
Dilated pupils: Anticholinergic or sympathomimetic
unequal: Herniation or Stroke

49
Q

What is ecchymoses?

A

Bruising (evidence of mild internal bleeding)

50
Q

Finding many areas of petechiae and ecchymoses would make you suspicious of

A

Bleeding disorder or coagulopathy

51
Q

You find isolated petechiae around the neck on a patient in the ED. What are you suspicious of in the context of loss of consciousness.

A

These isolated petechiae are actually a sign of raised central venous pressure. In this context, this occurs with post-convulsive seizures which have that

52
Q

Jaundice and LOC whatre we concerned about?

A

Hepatic encephalopathy

53
Q

Neck stiffness in a patient in the ED with no fever. Whatre we concerned about?

A

Subarachnoid hemorrhage
2nd: meningitis

54
Q

You are asked to conduct a focused neuro exam on a patient in the ED with Loss of consciousness. What are the 3 main parts to focus on?

A

1) level of conciousness GCS
2) Motor responses (movement reflexes, tone)
3) Brainstem reflexes

55
Q

You attempt to assess the brainstem reflexes of a patient who is comatosed. You find it impossible to assess most of the criteria. What will you do instead?

A

Fundoscopy for papilloedema

56
Q

What do you expect to see on an FBC of a patient who experienced a hemorrhage or chronic bleeding (e.g. IBD)

A

reduced Hb

57
Q

When should C-spine stabilisation be implemented?

A

When there is any suspicion of trauma to the head

58
Q

A patient presents to the ED with tachypnea, signs of increased work of breathing and is vomiting. Their SpO2 reading is 98%. What is your most likely diagnosis?

A

Carbon monoxide poisoning. It can trick the SpO2 monitor into giving elevated readings.

59
Q

Brain death is a clinical diagnosis but if clinical tests cannot be performed, there are confirmatory tests that can be used. What are these tests (3)?

A

4 vessel cerebral angiography
CT-Angiogram
Radionucleotide imaging

60
Q

What is considered to be normotension?

A

SBP>90 or MAP>60

61
Q

What are the conditions that preclude the diagnosis of braindeath? (3)

A

If these conditions are met, there will be no preclusion to the diagnosis of brain death:
1) Patient is observed to have fixed, dilated pupils and absent cranial nerve responses for 4 hours
2) Documented underlying neurological diagnosis which caused the severe neurological injury and accompanying loss of brain stem reflexes
3) Exclude reversible causes of coma:
a) No drugs/toxins/sedatives/muscle relaxants (must say all)
b) Normothermic and normotension (SBP>90 or MAP>60)
c) Absence of severe electrolyte, metabolic, or endocrine disturbances
d) Must be able to perform brain reflex testing (one eye and one ear) and Apnea Test (not if in ARF or cervical spine injury)

62
Q

You are asked to conduct brain reflex testing to confirm brain death. The preconditions have been met. List all 8 tests and what you would do after

A

1) Absent Motor Responses
2) No pupillary response to light
3) Corneal reflex
4) Oculovestibular reflex
5) Oculocephalic Reflex (if #4 unable to be performed)
6) Pharyngeal reflex
7) Laryngeal reflex
8) Apnea test
I will need to complete this test on 2 separate occasions to declare the patient dead
Only at this stage is the decision of organ donation discussed with the family

63
Q

How would you assess absent motor responses for brain death

A

Pressure on supraorbital notch (trigeminal nerve distribution). Should elicit extreme pain but if brain dead, no response

64
Q

How would you assess pupillary response to light for brain death?

A

Dim room. Pupils should be >4mm in diameter. Then shine light and assess reflex (brisk constriction). If brain dead, not change in pupil size

65
Q

How would you assess corneal reflex

A

Touch cotton wool on cornea to elicit blink reflex. No blinking if brain dead

66
Q

How would you assess the oculovestibular reflex?

A

Before testing, I must ensure that there is no damage or obstruction to the tympanic membrane or canal as well as no base of skull fracture. Otherwise I will conduct the Oculocephalic Reflex (must include)
For the test, I will irrigate the canal with 50ml of ice cold water. There should be slow movement of the eyes towards the ear. Any movement of the eye will exclude brain death

67
Q

How would you assess the Oculocephalic Reflex?

A

This test would be skipped if the oculovestibular reflex was conducted. To perform this test, you must also ensure that there is no cervical spine injury (must include)
For the test, Turn the head to one side. This should elicit the eyes to turn in the direction opposite to the head. In brain death, there is no movement of the eyes=> eyes will “move” in the direction of the head.

68
Q

How would you assess the Pharyngeal reflex?

A

Using a tongue depressor, stimulate each side of the oropharynx looking for any palatal or pharyngeal movement. No movement if brain death

69
Q

How would you assess the Laryngeal reflex?

A

A suction catheter is introduced into the ET tube to stimulate the Carina to elicit the cough reflex. No cough in brain death

70
Q

Where is the carina located

A

It is located at the bifurcation of the bronchi

71
Q

How would you conduct the Apnea test?

A

This must be the last test performed.
1) Pre-oxygenate the patient to ensure normal levels of PaCO2 or if not possible, establish the patient’s baseline
2) Disconnect the patient and attach to C-circuit for provision of oxygen. This C-circuit has a reservoir bag which is used to easily monitor any resp effort.
3) ABGs are checked at 5 minute intervals until pH <7.3 and PaCO2>8kPA (or2.7kPa above baseline)
4) If despite hypercapnia/hypercarbia and acidemia, there is no attempt at spontaneous ventilation, this is consistent with brain death

72
Q

What are the absolute contraindications to organ donation? Give 6

A

Age 85 or over
Primary intracerebral lymphoma and any secondary intracerebral tumour
Any active cancer with evidence of spread outside affected organ within 3 years of donation
Melanoma except if completely excised when in stage 1
Any active hematological malignancies (myeloma, leukemia, lymphoma)
Active and untreated Tb
West Nile Virus
HIV disease (not infection)
History of Ebolavirus infection
Suspected case or familial case of Human TSE (transmissible spongiform encephalopathy)
Neurodegenerative diseases a/w infectious agents

73
Q

What is the warm ischemia time? When do you start timing it?
How would you describe the warm ischemia time in brain death organ recovery?

A

The warm ischemia time is the amount of time that an organ remains at body temp after its blood supply has stopped or been reduced. Different organs can withstand different warm ischemia times.
Timing begins once the BP falls <50mmHg systolic
In brain death organ recovery, once support is ceased, the heart stops at the same time and hence the organs are cooled => warm ischemia time is very minimal. In cardiac death it is longer as activity hasn’t ceased completely

74
Q

When withdrawing treatment after the diagnosis of death. What is also stopped?

A

We also stop analgesia and anxiolytics

75
Q

Who makes the decision to withdraw support?

A

Primary physician/surgeon + intensivist
with second opinion from neurologist and second intensivist

76
Q

What are the preconditions that must be met for donation after cardiac death? (2)

A

1) Must be a ventilated patient from whom treatment is withdrawn
2) Death is likely to occur in less than 60-90 minutes post-withdrawal of tx. The estimation is based on whether the patient breathes spontaneously after withdrawal

77
Q

When do you decide to reinstate life-saving measures after decision to withdraw treatment has executed?

A

If the patient hasnt died within 90 minutes

78
Q

After withdrawing treatment, when do you pronounce the patient dead, and when do you begin the organ donation process?

A

After 5 minutes of continuous asystole on the ECG, the patient is pronounced dead
An additional 5 minutes is waited to ensure no spontaneous return of circulation. Organ donation is then initiated

79
Q

After the diagnosis of brain death has been made and the decision to donate the organs has been discussed, what is done next?

A

Treatment is then oriented towards optimizing the organs that may be transplanted rather than the protection of the brain. This is done to allow potential improvement in reversible organ dysfunction. This treatment is a multi-system management. (details in notes, ill add a notecard if necessary). Following this, the donor is taken to the theatre where organ retrieval is commenced.

80
Q

A previously fit and healthy 18 year old male is in a motorbike accident on presentation he is eye opening to verbal stimulus, making incomprehensible sounds confused, withdrawing from painful stimuli.

You are the intern on call for ED and you are asked to review this patient by nursing staff prior to his CT scan as he is agitated, and the nurse wonders if he will need sedation to lie still.

What is most appropriate action :
A - Accompany the patient to the CT scanner, bringing IV sedation with you in case it is needed
B - Call the ICU registrar to establish secure airway- intubate & ventilate
C - Call radiology to urgently expedite his scan
D - Call your registrar to give the patient the benzodiazepine Midazolam 5mg prior to the scan
E - Give analgesia – Oxynorm 5mg

A

D - Call for senior help and give benzo to sedate the patient

Anaesthetics (6 decks)

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