Emergencies

Question 1

Components of the Glasgow coma scale

Answer 1

Eyes max 4
Verbal max 5
Motor max 6

Question 2

Metabolic causes of a coma

Answer 2

Hypoglycaemia
Diabetic ketoacidosis
Hepatic encephalopathy
Ureamia
Wernicke's encephalopathy/thiamine deficiency.
Hypoxia
Carbon monoxide poisoning
Addisonian crisis.

Question 3

Definition of a coma

Answer 3

Defined via GCS. Unrousable unresponsive

Question 4

Neuro causes of a coma

Answer 4

Trauma
Infection - meningitis, encephalitis
Tumour/SOL
Vascular stroke
Epilepsy - post-ictal.

Question 5

Management of a coma

Answer 5

ABCDE
Support circulation - IV fluids
Oxygen
Protect cervical spine
Treat cause if identifiable - naloxone, IV midazolam, glucose, Pabrinex (thiamine)
Urgent head CT

Question 6

Mild, moderate or severe head injury on GCS

Answer 6

Mild = 13-15
Moderate = 9-12
Severe = 8 or less.

Question 7

Acute headache differentials

Answer 7

Subarachnoid haemorrhage
Raised ICP
Venous thrombosis
Giant cell arteritis
Meningitis
Acute glaucoma

Question 8

First, worst thunderclap headache ∆ and management.

Answer 8

Subarachnoid haemorrhage.
A-E resuscitation, neurosurgical referral ASAP.
Insert peripheral and consider central lines.
0.9% saline 500ml STAT.
Nifedipine to prevent vasospasm
CT scan
Surgical clipping or endovascular coil embolisation.

Question 9

Unilateral headache and eye pain differentials and managements.

Answer 9

Cluster headache - high flow oxygen + subcut sumatriptan.

Acute glaucoma - ophthalmology referral, lie flat, pilocarpine eye drops.

Question 10

Cough-initiated, worse on lying down (in morning) and bending forward headache differentials and managements.

Answer 10

Raised ICP - A to E resuscitation. IV mannitol.

Venous thrombosis.

Question 11

Headache with fever and neck stiffness differentials and managements.

Answer 11

Meningitis - IM benzylpenicillin, IV ceftriaxome.

Subarachnoid haemorrhage - CT head + nifedipine + surgical clipping.

Question 12

Status epilepticus definition

Answer 12

Single seizure lasting longer than 30mins or repeated seizures without full regain of consciousness

Question 13

Management of status epilepticus

Answer 13

ABCDE
Open airway, recovery position, intubate if necessary. 100% oxygen plus suction if require.
IV access and bloods (FBC, LTF, U+E, Calcium)
- Pre-hospital buccal midazolam
- IV lorazepam in hospital
- If seizure continues - IV infusion of phenytoin or diazepam.

Question 14

Causes of raised ICP

Answer 14

Tumour - primary or metastatic
Haemorrhage
Hydrocephalus
Infection - meningitis, encephalitis, brain abscess
Cerebral oedema

Question 15

Signs of raised ICP

Answer 15

headache - worse on bending forward, lying down and cough.
Altered GCS
Vomiting
Pupil change
Papilloedma
Cushing’s response = falling pulse and rising BP

Question 16

Cushing’s response

Answer 16

Falling HR and rising BP

Question 17

Spinal cord compression ∆ and management

Answer 17

Cancer patients, spine trauma, intervertebral disc herniation.
Acute onset of back pain, numbest + paraesthesia in lower limbs, weakness, bowel and bladder dysfunction, hyper-reflexia of knee and ankle.
TREAT BEFORE INVESTIGATING - IV dexamethasone, immobilisation, MRI spine.

Question 18

Spinal injury approach

Answer 18

• CABCDE - catastrophic haemorrhage, C-Spine injury.
• Canadian C-Spine high risk = aged over 65yrs, dangerous mechanisms of injury, paraesthesia of limbs.
• Maintain full in-line spinal immobilisation.
• Analgesia - IV morphine.
• MRI or whole body CT

Question 19

Name a mild traumatic brain injury, ∆ and management

Answer 19

Concussion = closed head injury due to a direct blow to head, or deceleration from an impulse force. Changed mental status.
S+S = headache, dizziness, memory dysfunction, nausea, feeling foggy/confused/slow.
Ix = Head CT if fits NICE guidance.
Rx = physical rest, analgesia.