Emergency & acute med 3 Flashcards
Common causes of seizures? 9
- epilepsy (incl poor compliance to meds)
- drugs (incl recreational)
- alcohol withdrawal
- low sodium or blood sugar
- infection (meningitis, encephalitis)
- high fever (esp in kids)
- head injury / raised ICP (?SAH)
- brain tumours / mets
- pregnancy related - eclampsia etc (consider in women of child-bearing age)
If someone presents after a seizure, what questions should you ask them? (before 2, during 5, after 4)
- important PMH/FHx to ask? 2
- What to ask if had seizure before / known epilepsy?
BEFORE
- Any aura? Changes in smell, taste, headaches, - is this familiar to the patient?
- any triggers? what were you doing?
DURING
- Does it sound tonic-clonic? Were they jerking? describe it (need collateral if poss)
- LOC?
- Tongue biting (tip or side)
- Incontinence
- how long did it last?
AFTER
- Are they sleepy? Drowsy? Confused? Dizzy? Nauseous?
- for how long afterwards
- Headache
- Weakness
- any other injuries?
1) Have you ever had this before?
2) Any FHx of epilepsy
3) What was DIFFERENT from previous seizure? (eg length, type of seizure etc)
What is the difference between:
- simple and complex seizures?
- partial and generalised seizures?
Simple = NO LOC Complex = LOC
partial = focal deficit generalised = whole brain
Types of partial seizure? 3
SIMPLE PARTIAL SEIZURE
- Awareness is unimpaired, there is focal motor, sensory of autonomic symptoms and no post-ictal symptoms
COMPLEX PARTIAL SEIZURE
- Awareness of the period has been impaired. Focal symptoms during an aura. These most commonly arise from the temporal lobe and if there is an aura then this is supportive of this.
Common to have post-ictal confusion in seizures of the temporal lobe but recovery is more rapid in seizures arising from the frontal lobe
PARTIAL SEIZURE WITH SECONDARY GENERALISATION
- 2/3 of patients who have a focal seizure will have a generalising transformation which typically presents as convulsions
Types of primary generalised seizures? 4
PRIMARY GENERALIZED SEIZURES
ABSENCE SEIZURES
Brief pauses where the person stops what they are doing/saying for ten seconds or less and then starts again (make sure you ask about these in the history). These will commonly present in childhood
TONIC-CLONIC SEIZURES
L.O.C. Limbs stiffen (tonic) and then jerk (clonic) in turn. You can have one without the other: there is usually a considerable post-ictal period with confusion and dizziness
MYOCLONIC SEIZURES
Sudden jerk of the limb or the face or the trunk. The patient may fall to the ground or have a violently disobedient limb
ATONIC SEIZURES
Sudden loss of muscle tone and fall to the ground (no LOC)
Triggers of seizures in known epileptics? 7
- poor medication compliance
- lack of sleep
- stress
- missing meals
- alcohol or recreational drugs
- illness / infection
- flashing lights (only 3% of people w epilepsy)
(also menstrual cycle can affect too)
Management of someone having a seizure in the ED:
- Approach?
- positioning and initial 2 interventions?
- when to give medication and options of what to give 1st line?
- 2nd line medication?
- 3rd line medication?
- 4th line medication?
- when to alert anaesthetist? 2
- bloods? 5
- what to make sure to do as part of ‘exposure’? 2
- what other meds to consider giving? 2
A-E approach
- recovery position (and remove tight fitting clothing)
- nasopharyngeal airway
- high flow oxygen
WAIT 5 MINS (time it!)
then give either:
- IV lorazepam
- buccal midazolam
- rectal diazepam
WAIT 10 MINS
- give 2nd dose of benzos (don’t give more than 2 doses as can lead to resp depression)
WAIT 10 MINS
- loading dose then infusion of phenytoin
WAIT 10 MINS
- give propofol or thiopentone (neuroprotective)
ALERT ANESTHETIST
- when GCS <8
- when about to give phenytoin
- ABG
- glucose
- FBC
- UandE
- blood cultures, if pyrexial
(other bloods as well probs - could justify most) - check for rashes or fever (meningitis) or head injury signs
- glucose (if hypoglycaemic)
- pabrinex (thiamine - if suggestion of alcohol abuse or malnutrition)
What are the 2 definitions of status epilepticus?
continuous seizure lasting >30mins
OR
repeated seizures with breaks but GCS stays <15 in breaks
nb it may start tonic clonic then diminish making diagnosis difficult (coma and minimal twitching only )
- can also get non-convulsive status epilepticus - hard to diagnose (need eeg)
Who should get a CT head following a seizure?
Which of these should be done as an emergency?
Following any ‘first fit’
emergency:
- focal signs
- head injury
- known HIV
- suspected intracranial infection
- bleeding disorder
- conscious level failing to improve
What additional test should you do for women of childbearing age who have a seizure?
pregnancy test
as may be sign of pre-eclampsia
if pregnancy-related fit = us IV magnesium sulphate
If patient has a ‘first fit’ - when are they allowed to be discharged? 4
What is the follow-up? 1
what advice must be given in the interim, before follow up? 1
who must be admitted and not discharged?
- normal neuro exam
- normal cardiac exam
- ECG normal
- electrolytes normal
follow up appointment in ‘first fit’ clinic
not allowed to drive until have seen specialist
if multiple seizures, admit
Definition of a stroke?
Acute onset of neurological deficit lasting >24 hours (if it is less then it is a TIA), of VASCULAR origin.
Symptoms/signs of anterior circulation stroke? 6 (also which arteries norm affected)
Symptoms/signs of posterior circulation stroke? 7 (also which arteries norm affected)
ANTERIOR = branches of internal carotids - unilateral limb weakness - unilateral numbness / loss of sensation - unilateral facial droop - speech disturbances - cognitive impairment - visual field disturbances
POSTERIOR = branches of basilar artery (so affect the cerebellum!!) - nausea - dizziness / vertigo - memory loss - lack of coordination - ataxia / loss of balance / gait change - limb weakness - sensory deficits bilaterally
Stroke: examination:
- approach?
- examinations to do? 5
- what else to assess, for safety?
A-E approach (incl GCS)
- Cranial nerve
- UL neuro
- LL neuro
- cerebellar exam
- cardiac exam (carotid bruits, murmurs, AF)
- assess pts swallow, if not okay make NBM
Investigations:
- score to use for TIA? 1
- score to use for stroke? 1
- bedside? 1
- bloods? 3
- imaging? 1
- bloods to consider? 1
ABCD2 score for TIA
Rosier score for stroke
- ECG (looking for AF)
- FBC
- UandE
- glucose (always exclude hypoglycaemia)
CT head (non-contrast) - whether is emergency or not depends on timing of presentation and other factors
ABG (if sats <94%)
Who gets an emergency CT head following a stroke:
- timing of presentation? 1
- other indications? 7
If patient presents WITHIN 4 HOURS of symptoms
- as may be able to thrombolyse
- patient is on anti-coagulant
- severe headache at onset
- fever
- neck stiffness
- GCS <13
- unexplained progressive or fluctuating symptoms
- papilloedema
nb pretty much all patients with a stroke get a CT at some point
Possible management options for stroke? 3
- who is eligible for each?
nb the first two can only be given at places with specialist stroke services!
THROMBOLYSIS (alteplase)
- if can start within 4.5 hours of symptom onset
AND
- if intra-cranial haemorrhage has been excluded by CT
THROMBECTOMY
- if thrombotic stroke of PROXIMAL anterior or posterior circulation confirmed (using CT or MRI angiography)
AND
- presentation within 24hrs
AND
- there is potential to salvage brain tissue, as shown by imaging
ASPIRIN (300mg)
- give to EVERYONE who presents within 24hrs following stroke
AND
- haemorrhagic stroke excluded by CT
- followed by maintenances dose anti-platelet for weeks
- nb give PPI as well if dyspepsia risk factor
sub-arachnoid haemorrhage:
- description of headache?
- other symptoms? 6
- What PMHx and FHx to ask about?
- SUDDEN onset (biggest clue!)
- very severe
- feels localised to back of head
- feels like being hit over back of head with something
- LOC (15% only present with this!)
- neck pain
- photophobia
- VOMITING
- drowsiness and confusion
- unilateral eye pain can occur
nb in 25% of cases, exertional activities precede the event
1) pmhx HTN?
2) Any FHx of aneurysms or strokes?
Sub-arachnoid haemorrhage:
- which examinations to do? 4
- what is most common exam finding?
- what important to look at in the obs? 3
- why?
- cranial nerve exam
- UL neuro
- LL neuro
- cerebellum exam
oculomotor nerve palsy (characteristic of a berry aneurysm in posterior communicating artery)
- increase in BP
- bradycardia
- irregular breathing
= cushings triad / response
= sign of raised ICP
Sub-arachnoid haemorrhage:
- approach?
- bedside investigations? 2
- bloods? 4
- imaging? 1
- what to do if imaging normal? 1
A-E approach
- fundoscopy
- ECG (ischaemic changes)
- glucose
- FBC
- UandE
- CLOTTING
- emergency head CT
if CT normal, do an LP after 12 hours - looking for xanthochromia in the CSF
Sub-arachnoid haemorrhage management:
- what to keep monitoring? 1
- immediate medication? 4
- which teams to involve? 2 (when?)
- monitor O2 sats - give O2 if low
- analgesia
- anti-emetic
- NIMODIPINE (as soon as SAH confirmed - repeat every 4 hrs, prevents vasospasms)
- MANNITOL (if evidence of increased ICP)
- neurosurgical team (once diagnosis confirmed by CT)
- anaesthetist (if GCS <8 or very agitated)
Syncope: definition?
symptoms of vasovagal syncope? (before 5, during 2, after 1)
what other question if it really important to ask in the context of syncope?
ideally what other type of history should you obtain in a pt with syncope?
sudden TRANSIENT LOC with SPONTANEOUS complete recovery
BEFORE - feel unwell / nauseous - feeling warm - light-headed - palpitations - blurred vision / dots in vision DURING - short LOC - no side-tongue biting, may be tip of tongue or myoclonic jerks, esp if person can't get supine AFTER - fast recovery - within 5 mins
WHAT WERE YOU DOING AT THE TIME? (exertional syncope is not a good sign)
get collateral hx - if possible!
Examination for syncope:
- what sort of exams should you do? 2
- what other specific features should you look for? 3
- what causes of syncope must you not miss? 6 (acronym and how to exclude each)
- full cardiac exam
- full neuro exam
- signs of tongue biting
- incontinence
- any injuries
A PEARS
ACS
- ecg and troponin
PE
- risk factors, wells score
Ectopic pregnancy
- ask about abdo pain and vaginal bleeding in women of CBA
Aortic dissection
- BP in both arms
Ruptured AAA
- abdo pain, feel for expansile pulsatile mass in abdomen
SAH
- signs of meningeal irritation
Syncope investigations:
- bedside? 2
- bloods? 3
- ECG
- lying and standing BP
- glucose
- FBC (anaemia big cause)
- UandE
Who to admit to cardiology following syncope? 6
- abnormal ECG (compare to previous)
- heart murmur
- evidence of new heart failure
- LOC of exertion
- aged over 65 with no prodrome
- FHx of sudden death or inherited heart condition
Who can you safely discharge following a syncope? 4
- full recovery
- likely vasovagal
- no new ECG signs
- no other signs or worrying features
nb if frequent episodes, may consider referral to neuro or cardio
Risk factors for falls in the elderly:
- biggest two risk factors?
- conditions affecting mobility and balance? 5
- other co-morbidities? 2
- other risk factors? 3
= aged over 65
= one or more falls in last 12 months
- arthritis
- diabetes
- incontinence
- stroke
- parkinsons disease
- cognitive impairment
- visual impairment
- polypharmacy and / or certain medications
- fear of falling
- physically frail
Which groups of medications increase your risk of falls (esp in elderly)? 8
- opiates
- benzodiazepines
- antipsychotics
- anticonvulsants
- antihypertensives
- antidepressants
- diuretics
- alcohol use!!!
Two tests to assess people’s risk of falling?
what does each involve?
TIMED GET UP AND GO
- person has to get up from chair (without using arms), walk 3m, turn around, return and sit back in chair
- should take <12-15secs
- can do it with normal walking aid
TURN 180 deg TEST
- person has to stand up and step around until they are facing in opposite direction
- risk of falls if person takes >4 steps
Who should be offered a multi-factorial falls risk assessment, ie in specialist falls service? 3
anyone >65 who:
- has had 2 or more falls in last 12 months
OR
- present for medical attention following a fall
OR
- cannot perform, or perform poorly on timed up and go test and/or turn 180 test
Possible interventions to reduce falls in elderly? 7
- medication review
- OT review / home hazard assessment
- physio review / strength exercises
- optimise eyesight / glasses
- give walking aids
- wear sensible shoes
- reduce alcohol intake
amphetamine overdose:
- most common causative drug in the UK?
- little bit of pathophysiology
- early symptoms? 8
- late symptoms? 2
MDMA (aka ecstacy)
-> release of serotonin, cathecholamines, DH secretion -> abnormal thirst and excessive oral intake -> hyponatraemia and cerebral oedema
- euphoria
- agitation
- delirium
- sweating
- palpitations
- fever
- vomiting
- abdo pain
= seizures
= reduced consciousness
Amphetamine overdose, what to ask when doing patient hx or collateral history? 5
- substances ingested
- volume
- route
- timing
- alcohol as well?
Amphetamine overdose:
- findings in obs? 3
- other examination findings? 3
- tachycardia
- hypertension
- pyrexial
- sweating
- DILATED pupils
- hyperreflexia
Amphetamine overdose, serious complications to look out for? 5
- seizures
- metabolic acidosis
- rhabdomyolysis / AKI
- stroke
- MI
Amphetamine overdose: investigations:
- bedside? 2
- bloods? 4
- ECG (looking for ACS)
- urine dipstick (for blood)
- ABG/VBG (acidosis)
- FBC
- UandE (hyponatraemia and AKI)
- glucose
Management of amphetamine overdose:
- approach?
- bedside to do? 2
- medication to consider? 2
- who to inform? 1
A-E assessment
treatment is primarily supportive, no reversal agent available!
- try to cool patient - MAIN AIM!
- restrict fluid intake and give saline hypertonic (2.7%) drip if have hyponatraemia
- activated charcoal (if < hour since ingestion)
- consider benzo to manage agitation and reduce fever
inform ICU if need help!
Opioid overdose main symptoms / signs? 3
- low RR (<8)
- decreased GCS
- pinpoint pupils
What questions to ask during a collateral history of opioid overdose? 6
- what ingested?
- when?
- how much?
- anything else taken? (esp alcohol or benzos)
- recreational or prescribed?
- intentional or accidental?
Investigations / management of opioid overdose:
- approach?
- bedside intervention? 1
- medication to give? 1
- things to be aware of when giving this medication? 2
- what to do before discharging? 2
A-E approach
- give oxygen to correct hypoxia / hypercapnia
NALOXONE
1) in addicts, giving it can precipitate withdrawal symptoms: abdo cramping, nausea, diarrhoea, agitation
2) half-life is shorter than opioids so may need to give more than one dose or set up an infusion
nb if it is someone with chronic pain that is over opiated then may be better to just wean them off as naloxone will make their pain come back!!
either mental health risk assessment if intentional / recreational (incl capacity assessment)
OR
medication review if prescribed / accidental
paracetamol poisoning:
- early symptoms? 3 (incl time frame)
- mid symptoms? 2 (incl time frame)
- late symptoms? 5 (incl time frame)
EARLY <24hrs - nausea and vomiting - sweating - abdo discomfort (nb often get no symptoms though - anything more than N+V is suggestive of liver damage)
MID 24-72 hrs
- RUQ abdo pain (liver capsule stretching)
- more N + V
LATE 3-5 days = symptoms of liver failure - jaundice - coagulopathy (bleeding / bruising) - encephalopathy (confusion, drowsy, agitated, seizures) - low glucose, can -> coma - anuric, renal failure
Taking a history of someone who took a paracetamol overdose:
- medical questions? 7
- psych questions? (6 before, 3 during, 9 after)
- number of tablets taken (and dose)
- when taken (essential!)
- over how long
- anything else taken alongside, other tablets / alcohol
- comorbidities (esp affecting the liver) and mental health history and norm alcohol consumption
- previous deliberate self harm
- DHx (esp anything affecting p450 system)
BEFORE
= any precipitant? (eg argument with partner)
= planned or impulsive?
= where got pills from? stockpiling?
= write a note?
= any precautions against discovery (locking doors, closing curtains, waiting till knew be alone, going somewhere remote)
= was alcohol used?
DURING
= was patient alone
= what was intention? to kill? to harm?
= did you think it would kill you?
AFTER
= what did they do straight after?
= did call anyone? how get to a+e? who were they found by?
= how felt when help arrived?
= do you regret it?
= do you still feel suicidal?
= what would you do if went home today?
= if you were to feel like this again, what would you do?
= what might prevent you from doing this again? anything to live for? (protective factors)
= will they accept treatment?
Investigations for paracetamol overdose:
- bedside? 1
- bloods to consider? 6 (WHEN to do each)
- ECG (may be tachycardic)
- LFT
- VBG
- Clotting
- U+E
- blood glucose
^do all of these on admission to get baseline - PARACETAMOL LEVELS
(do after 4 hours of ingestion)
management of paracetamol overdose:
- what to consult? 1
- what to give if < 1 hour since OD? 1
- what medication give? 1
- what is dose dependant on? 1
- how do you calculate if need to give medication? 1
- who do you always give the medication to? 5
- how do you give the medication and over what period? 3
- other medication to consider giving?
TOXBASE (esp paracetamol graph)
activated charcoal if < 1 hour
acetylcysteine (aka pabrinex)
dose is dependant on weight
take paracetamol blood level 4 HOURS after ingestion
- then plot against paracetamol curve - if blood plasma is ABOVE curve then treat - if not then don’t need treatment
ALWAYS GIVE TO (ie don’t wait the 4 hours):
- any clinical signs of liver damage
- any NEW deranged LFT/clotting (if chronic, discuss with toxbase)
- staggered overdose
- uncertain time of overdose
- overdose was over 8 hours ago
First infusion - over 1 hour second infusion - over 4 hours third infusion - over 16 hours 21 hours in total, the reassess
(dose depends on weight)
GIVE ANTIEMETIC IF NAUSEOUS!
What dose (per kg) is deemed a significant paracetamol overdose, likely to cause harm?
what is the definition of a ‘staggered overdose’?
over 75mg/kg in less than an hour
any overdose taken over longer than 1 hour = staggered
What should you always do before discharging someone that has taken a deliberate paracetamol overdose? 2
What section of the mental health act allows you to detain someone in hospital against their will? for how long?
get mental health team to do a risk-assessment
safety net them for harmful symptoms:
- abdo pain
- N+V
- jaundice of skin or white of eye
- confusion or drowsiness
- difficulty passing urine
section 5.2
- hold someone in hospital for 72 hours!
- mental health has to assess their capacity in this time!
What is the main side effect of the treatment for paracetamol overdose?
anaphylaxis reactions with acetylcysteine (aka pabrinex)
up to 30% of people who receive it
Tricyclic antidepressant overdose:
- normal drug caused by?
- signs and symptoms? 10
amitriptyline
basically anti-cholinergic effects (so fight or flight)
- tachycardia
- hypertension
- dry mouth
- dilated pupils / blurred vision
- urinary retention
- ataxia
- jerky limb movements
- increased muscle tone
- increased reflexes / plantar response
- decreased GCS
Taking a history of someone who took a tricyclic antidepressant overdose:
- medical questions? 7
- psych questions? (6 before, 3 during, 9 after)
- number of tablets taken (and dose)
- when taken
- over how long
- anything else taken alongside, other tablets (esp aspirin)/ alcohol
- comorbidities and mental health history and norm alcohol consumption
- previous deliberate self harm
- DHx
BEFORE
= any precipitant? (eg argument with partner)
= planned or impulsive?
= where got pills from? stockpiling?
= write a note?
= any precautions against discovery (locking doors, closing curtains, waiting till knew be alone, going somewhere remote)
= was alcohol used?
DURING
= was patient alone
= what was intention? to kill? to harm?
= did you think it would kill you?
AFTER
= what did they do straight after?
= did call anyone? how get to a+e? who were they found by?
= how felt when help arrived?
= do you regret it?
= do you still feel suicidal?
= what would you do if went home today?
= if you were to feel like this again, what would you do?
= what might prevent you from doing this again? anything to live for? (protective factors)
= will they accept treatment?
Investigations for tricyclic antidepressant overdose:
- bedside? 2
- bloods? 1
- 12-lead ECG (prolonged PR or QRS, heart block, ventricular dysrhythmias)
- cardiac monitoring
- ABG (for acidosis)
Management of tricyclic antidepressant overdose:
- approach? 1
- medication to consider? 5 (+ when to do so)
- who should you contact?
A-E assessment
OBSERVE CLOSELY
- nb treatment is mainly supportive, treat things as you find them!
- consider activated charcoal (if < 1 hour since)
- consider sodium bicarbonate (if acidotic)
- consider intralipid
- correct hypotension and arrythmias
- give lorazepam or diazepam if seizure
CONTACT TOXBASE!! for help!
What is antidote to benzodiazepine overdose?
when not to give?
flumenazil
(give as part of A-E approach)
don’t give if mixed overdose (ie with other drugs too)
What is antidote to beta-blocker overdose?
glucagon
- give as part of an A-E approach
What resource should you always consult in case of poisoning or overdose of any substance?
What medication can sometimes be used to ‘absorb’ toxins?
TOXBASE!
intralipid
What is the two stage test for assessing capacity?
What things can you do to help someone have capacity? 6
1) Does the person have an impairment of their mind or brain, whether as a result of a mental or physical illness, or external factors such as alcohol or drug use?
2) Is a person able to:
- UNDERSTAND the info relevant to the decision
- RETAIN the info
- WEIGH UP the info as part of the process of making the decision
- COMMUNICATE their decision, verbally or otherwise
- ensure information is easy to understand
- use different types of communication (verbal, non-verbal etc)
- can someone else (carer, family) help with communication
- particular times of day when pts understanding is better
- particular locations where pt may feel more at ease
- can the decision be delayed until they regain capacity?
capacity is TIME and DECISION specific
What is the acronym for people at risk of suicide?
SAD PERSONS
- Sex: male
- Age <19 or >45
- Depression or hopelessness
- Previous attempts or psych care
- Excessive alcohol or drug use
- Rational thinking loss
- Separated / divorced / widowed / single
- Organised / serious attempt
- No social support
- Stated future intent
Doing a self-harm risk assessment following deliberate self harm:
- what to ask about the current episode? (6 before, 5 during, 10 after)
- extra Qs if overdose? 6
- extra Qs if cutting? 6
(see other cards on what else to put in risk assessment)
BEFORE
- precipitant?
- planned or impulsive?
- final acts? (note, will, terminating contracts)
- precautions against discovery? (locking doors, closing curtains, waiting till knew be alone, somewhere remote)
- alcohol used?
- what did you think / hope would happen?
DURING
- what did you do?
- where were you?
- were you alone?
- what was going through your mind?
- did you think it would kill you?
AFTER
- what did you do immediately afterwards?
- did you call anyone?
- how did you get to A+E? who found by?
- how did you feel when help arrived?
- any regret now?
- still feel suicidal?
- if go home today, what would you do?
- if feel like this again, what will you do?
- protective factors? anything to live for?
- will they accept treatment?
IF OVERDOSE:
- what taken? anything else?
- dose? number of pills?
- when did you do it? over how long?
- where get from?
- what take pills with?
- what did you think that amount of pills would do?
IF CUTTING
- where are cuts?
- number of cuts?
- how deep are cuts?
- how did you feel whilst cutting?
- how did you feel when you saw blood?
- what were you hoping the cutting would do?
Doing a self-harm risk assessment following deliberate self harm:
- what to ask about any previous episodes? 3
- psych hx qs? 2 what to do if no hx?
- PMHx qs? 3
- DHx qs? 3
- FHx qs? 2
- SHx qs? (3 major sections, with qs for each)
(see other cards on what else to ask about current episode in risk assessment)
- any self harm in the past? when?
- what methods?
- gain any help as a result?
PSYCH Hx
- any mental health conditions?
- any previous admissions to hospital or psych hospital?
IF NONE:
- screen for:
—- depression (anhedonia, low mood, fatigue)
—- psychosis (are thoughts ever not your own? heard voices?)
—- alcohol dependency
—- anorexia
PMHx
- any relevant to current episode (eg bleeding disorders, liver problems)
- chronic pain?
- others?
DHx
- allergies
- regular meds
- OTC? herbal? (incl st johns wart)
FHx
- any family members attempted or completed suicide?
- any mental health conditions in close fam members?
SHx
LIVING SITUATION
- who with?
- where?
- good support?
- manage ADLs?
- any children? (ask about them)
OCCUPATION
- job?
- if none, how coping financially? any debt?
ALCOHOL and DRUGS
- how much alcohol?
- pattern of drinking?
- any recreational drug use?
- what? how often? how much? who with?
What 3 safeguarding questions should be asked following an episode of self-harm in someone with children?
- are they being neglected?
- do they witness episodes?
- does parent have any thoughts of harm towards children?
symptoms of meningitis:
- three symptoms of meningism?
- other symptoms? 10
- additional symptoms in infants? 3
= headache
= photophobia
= nuchal rigidity (aka neck stiffness - can’t do neck flexion)
- nausea + vomiting
- FEVER
- irritability
- drowsy / reduced GCS
- cold hands and feet
- pale skin
- non-blanching skin rash (late sign)
- muscle or joint pain
- SOB
- seizures
infants
- refuse feeds
- stiff or floppy body
- bulging fontanelle (‘soft spot’)
nb rash only if it’s caused by neisseria meningitidis
nb may start as flu-like illness in elderly or immunocompromised
What are most cases of meningitis caused by?
what’s more serious?
Which 3 age groups are most likely to get meningitis?
normally viral
- bacteria, esp meningococcal, are rarer but more serious!
1) infants and young children
2) young adults
3) older adults
What are the two special tests on examination which you can do to look for meningitis?
how good are they?
KERNIG’S SIGN
- with the pt supine and thigh flexed to 90 deg
- attempts to straighten or extend leg met with resistance
BRUDZINSKI’S SIGN
- flexion of neck cause involuntary flexion of knees and hips
not very sensitive
- only present in 20-50% of cases
- but worth doing as about 90% specific
investigations and management of suspected meningitis:
- approach? 1
- bedside investigations to do? 2
- bloods to do? 7
- imaging to consider? 1
- medications to give immediately? 2
A-E approach
- fundoscopy
- LP (only if no signs of raised ICP)
- ABG
- blood cultures
- FBC
- U+E
- LFTs
- glucose (need this to compare to LP glucose)
- CRP
- clotting screen (do this! as can’t do LP without!)
- CT scan (if suspect raised ICP)
1) IV empirical antibiotics
2) IV steroids
nb if septic shock, do bufalo
Suspected meningitis:
- Which empirical abx should be given to everyone?
- which age groups should have additional empirical abx?
- empirical treatment in penicillin allergy?
- what should be given in out of hospital (eg GP) before transfer to hospital if possible?
EVERYONE
- cefoTAXime - “pay your TAXes so kids don’t die of meningitis”
AGED < 3 months OR > 50 years
- check local guidelines but add in something like ampicillin or amoxicillin
PENCILIN ALLERGY
- chloramphenicol
PRE-HOSPITAL
- IM benzylpenicillin
nb once get lumbar puncture and blood cultures back then can switch abx to most suitable or switch to anti-viral/supportive care if is viral
What are the two main contraindications for doing a lumbar puncture?
- raised ICP
- coagulopathy (hence why do clotting)
Space-occupying lesion:
- socrates description of the headache?
- other possible neuro symptoms? 5
- other symptom? 1
headache
- persistent (had for long period of time)
- always on same side
- dull / achey
- MADE WORSE BY lying down OR straining OR bending forward OR coughing
- associated focal neurological symptoms
- vision changes
- weakness
- sensation changes
- seizures
- personality changes (get collateral hx)
= vomiting (dt raised ICP)
Space-occupying lesion
- examinations to perform? 3
- bedside tests? 2
- blood tests? 3
- imaging? 1
- cranial nerve
- UL neuro
- LL neuro
- FUNDOSCOPY
- ECG
- FBC
- U+E
- glucose
CT head
initial management of space occupying lesion:
- who to refer to?
- medication to consider? 2
- neurosurgery
- analgesics
- dexamethasone (if cerebral oedema)
basically not managed in the acute setting - just keep stable until can be transferred
nb if present with a seizures then manage these in normal way - benzos etc
