Emergency Medicine 3rd year 2nd semester TLOC Flashcards

Question

FAST vs. NIHSS A naturopathic doctor is evaluating a patient with suspected stroke in the clinic. Which of the following clinical assessment tools should be used for a quick screening before calling EMS? a) NIH Stroke Scale (NIHSS) b) Glasgow Coma Scale (GCS) c) FAST (Face droop, Arm weakness, Speech difficulty, Time to call EMS) d) Canadian CT Head Rule

Answer 1

**(c) Correct – FAST is the quick, office-based screening tool for stroke recognition and immediate EMS activation.** Explanation: (a) Incorrect – NIHSS is more detailed but not used in-office; it is performed in a hospital setting. (b) Incorrect – GCS is used for assessing level of consciousness, not stroke. (d) Incorrect – Canadian CT Head Rule is for head trauma, not stroke assessment. **CEREBROVASCULAR ACCIDENTS (CVA) – ISCHEMIC VS. HEMORRHAGIC STROKE** Stroke Assessment in Office: FAST vs. NIHSS * You are not expected to conduct a full NIH Stroke Scale (NIHSS) in-office. * However, recognizing key neurological deficits (e.g., facial droop, limb weakness, speech difficulty) helps guide appropriate and timely referral. Use FAST for In-Office Screening * Face drooping * Arm weakness * Speech difficulty * Time to call EMS

Answer 2

**(b) Correct – tPA (alteplase) is the first-line treatment for ischemic stroke if within 4.5-hour window and no contraindications. Explanation:** (a) Incorrect – Aspirin should not be given until hemorrhagic stroke is ruled out with a CT scan. (c) Incorrect – IV heparin is not used acutely in stroke treatment. (d) Incorrect – Neurosurgery is typically needed for hemorrhagic strokes, not ischemic ones. CEREBROVASCULAR ACCIDENTS (CVA) – ISCHEMIC VS. HEMORRHAGIC STROKE When to Refer Immediately * If FAST is positive, or patient shows: ◦ Unilateral limb weakness ◦ Slurred or absent speech ◦ Vision changes ◦ Decreased level of consciousness NIHSS >4 often qualifies for thrombolytic therapy (tPA) → Early EMS activation is critical **Management of Ischemic stroke:** - IV tPA (alteplase) if within 4.5-hour window and no contraindications.

Answer 3

**(b) Correct – BP control and neurosurgical consultation are key for managing hemorrhagic strokes.** Explanation: (a) Incorrect – tPA is contraindicated in hemorrhagic stroke because it increases bleeding. (c) Incorrect – Aspirin worsens bleeding and should be avoided. (d) Incorrect – Carotid endarterectomy is for ischemic stroke prevention, not hemorrhagic stroke treatment.

Answer 4

**(c) Correct – Opioid overdose presents with pinpoint pupils, respiratory depression, and decreased LOC.** Explanation: (a) Incorrect – Stroke typically presents with focal neurological deficits, not pinpoint pupils and respiratory depression. (b) Incorrect – Hemorrhagic stroke may cause LOC but not pinpoint pupils. (c) Correct – Opioid overdose presents with pinpoint pupils, respiratory depression, and decreased LOC. (d) Incorrect – Vasovagal syncope involves brief LOC with rapid recovery, not respiratory depression **INTOXICATION (DRUG OR ALCOHOL OVERDOSE) Etiology** * Common substances causing LOC include opioids, benzodiazepines, alcohol, sedatives, and stimulants. Key Signs & Symptoms * Opioid toxicity: Pinpoint pupils, respiratory depression, decreased consciousness. * Alcohol intoxication: Slurred speech, unsteady gait, altered mental status. * Benzodiazepines: Lethargy, confusion, respiratory depression. * Stimulants (cocaine, methamphetamine): Agitation, tachycardia, hypertension, hyperthermia.

Answer 5

**(c) Correct – Vasovagal syncope is triggered by emotional distress and causes brief LOC with rapid recovery. Explanation:** (a) Incorrect – Seizures usually have postictal confusion and jerking movements, which are absent here. (b) Incorrect – Stroke does not present with a transient LOC and rapid recovery. (d) Incorrect – Cardiac syncope is usually sudden without warning and does not have an emotional trigger.

Answer 6

**(c) Correct – Systolic BP <90 mmHg is a high-risk factor in SFSR and requires further evaluation.** Explanation: (a) Incorrect – Vasovagal syncope is low risk. (b) Incorrect – A normal ECG suggests low risk. (d) Incorrect – Quick recovery without confusion suggests a benign cause like vasovagal syncope.

Answer 7

**✅ Correct Answer: (b) NIHSS >4 🔹 Explanation: NIHSS >4 typically indicates a moderate stroke and is often the threshold for considering IV tPA (alteplase) therapy, provided the patient is within the 4.5-hour window and has no contraindications.** Lower NIHSS scores (e.g., 2 or below) suggest mild stroke, where risks of tPA may outweigh benefits. Higher NIHSS scores (≥10) may indicate a severe stroke, potentially requiring mechanical thrombectomy if a large vessel is occluded. **NIHSS Includes Assessment of:** 1. Level of Consciousness (LOC) ◦ Alertness, ability to answer questions, follow commands 2. Gaze ◦ Normal vs. gaze palsy (eye movement) 3. Visual Fields ◦ Hemianopsia (vision loss in one side) 4. Facial Palsy ◦ Weakness on one side of the face 5. Motor Function (Arms & Legs) ◦ Strength in limbs (each side tested separately) 6. Limb Ataxia ◦ Coordination testing 7. Sensory Loss ◦ Numbness or decreased sensation 8. Language ◦ Ability to name objects, speak clearly 9. Dysarthria ◦ Slurred or impaired speech 10. Extinction/Inattention ◦ Neglect or unawareness of one side of the body Key Point: NIHSS >4 typically indicates moderate stroke severity and may qualify for thrombolytic therapy (tPA) if within the 4.5 hour treatment window.

Answer 8

**✅ Correct Answer: (b) It reduces perfusion to the brain, worsening ischemia 🔹 Explanation:** In hemorrhagic stroke, the goal is controlled BP reduction, but lowering BP too aggressively can lead to hypoperfusion of surrounding brain tissue, causing secondary ischemic damage. Option (a) Increased intracranial pressure (ICP) is a major issue in hemorrhagic stroke, but BP lowering itself does not increase ICP. Option (c) Reflex tachycardia occurs in BP fluctuations but isn’t the key issue here. Option (d) Preventing clot stabilization isn’t correct; clot stabilization is more relevant in anticoagulant reversal therapy. **CEREBROVASCULAR ACCIDENTS (CVA) – ISCHEMIC VS. HEMORRHAGIC STROKE ND Management in Clinic (While Waiting for EMS)** * Perform FAST exam (Face droop, Arm weakness, Speech difficulty, Time to call EMS). * Do not give aspirin if hemorrhagic stroke is suspected. * Keep patient upright at 30 degrees to reduce ICP. Initial Hospital Care * For ischemic stroke: tPA administration if eligible, or thrombectomy for large vessel occlusion. * For hemorrhagic stroke: BP control, neurosurgical intervention if needed.

Answer 9

**✅ Correct Answer: (c) Severe headache with nausea and vomiting 🔹 Explanation: Severe headache, nausea, and vomiting are more indicative of hemorrhagic stroke because the bleeding increases intracranial pressure (ICP), causing irritation of the brain and meninges.** Options (a), (b), and (d) are common in both ischemic and hemorrhagic strokes, but a sudden, severe headache ("thunderclap headache") is more characteristic of hemorrhagic stroke.

Answer 10

**✅ Correct Answer: (b) A 60-year-old with a history of heart failure and an abnormal ECG 🔹 Explanation: The San Francisco Syncope Rule (SFSR) identifies high-risk syncope patients.** History of congestive heart failure (CHF) and abnormal ECG are both high-risk criteria, indicating a potential cardiac cause (e.g., arrhythmia or structural heart disease). Option (a) and (c) describe vasovagal syncope, which is typically benign. Option (d) suggests a low-risk case with no red flags. **VASOVAGAL SYNCOPE (MOST COMMON REFLEX SYNCOPE) San Francisco Syncope Rule (SFSR)** Purpose: Predicts risk of serious outcomes in patients presenting with syncope High-Risk Criteria: * History of congestive heart failure (CHF) * Shortness of breath (Dyspnea) * Systolic blood pressure <90 mmHg * Abnormal ECG (New ischemic changes, conduction block) * Hematocrit <30% VASOVAGAL SYNCOPE (MOST COMMON REFLEX SYNCOPE) San Francisco Syncope Rule (SFSR) Application: * High-risk (any criterion met): Refer to ED for further evaluation * Low-risk: Discharge with outpatient follow-up * At bedside, apply the rule to stratify syncope risk: * Any high-risk factor present? → Refer to ED (e.g., history of CHF, abnormal ECG, SBP <90 mmHg) * All criteria absent? → Consider outpatient workup and reassurance.

Answer 11

The ischemic stroke treatment window is 4.5 hours correct? Yes, the standard treatment window for IV thrombolysis (tPA, alteplase) in ischemic stroke is 4.5 hours from symptom onset. However, there are some additional considerations: 🔹 0–3 hours: Ideal window for tPA, with the best outcomes. 🔹 3–4.5 hours: Still eligible, but with additional exclusions (e.g., patients >80 years, history of prior stroke & diabetes, severe stroke NIHSS >25). 🔹 Up to 24 hours: Mechanical thrombectomy can be considered for large vessel occlusion (e.g., ICA/MCA occlusions) based on CT perfusion or MRI findings.

Answer 12

**✅ Correct Answer: B) Naloxone Explanation: Naloxone is a competitive opioid antagonist that rapidly reverses opioid-induced respiratory depression.** ❌ Incorrect Answers: A) Flumazenil: Used for benzodiazepine overdose, but rarely due to the risk of seizures. C) IV Fluids: Supportive care but does not directly reverse opioid toxicity. D) Diazepam: Used for seizures or anxiety, not opioid toxicity.

Answer 13

✅ Correct Answer: B) Administer naloxone Explanation: Pinpoint pupils and respiratory depression are classic signs of opioid overdose, requiring immediate naloxone administration. ❌ Incorrect Answers: A) IV fluids: Helps with hydration but does not reverse opioid toxicity. C) Flumazenil: Used for benzodiazepine overdose, not opioid overdose. D) Observe: Delaying treatment could be fatal.

Answer 14

✅ Correct Answer: B) Emotional stress Explanation: Vasovagal syncope is triggered by vagal activation due to emotional distress, prolonged standing, or dehydration. ❌ Incorrect Answers: A) Arrhythmia: Can cause syncope but is not vasovagal in origin. C) Hypoglycemia: Causes syncope but through metabolic dysfunction, not vagal response. D) Seizure: Causes LOC but with postictal confusion, unlike vasovagal syncope.

Answer 15

✅ Correct Answer: C) Shortness of breath Explanation: Dyspnea is a high-risk factor, as it may indicate underlying heart failure or pulmonary embolism. ❌ Incorrect Answers: A) Vasovagal syncope: A benign cause of syncope, not high-risk. B) Normal ECG: Only abnormal ECG findings are high-risk. D) Age <30 years: Younger patients usually have benign syncope causes.

Answer 16

✅ Correct Answer: B) Orthostatic hypotension Explanation: Orthostatic hypotension occurs due to a sudden drop in blood pressure upon standing. ❌ Incorrect Answers: A) Vasovagal syncope: Typically triggered by emotional stress, prolonged standing, or pain. C) Seizure: Seizures usually have postictal confusion and tonic-clonic activity. D) Cardiac arrhythmia: Arrhythmias usually cause sudden, unpredictable LOC.

Answer 17

✅ Correct Answer: B) Non-contrast CT Head Explanation: Non-contrast CT is the fastest and most effective way to detect acute hemorrhage. ❌ Incorrect Answers: A) MRI Brain: More sensitive but not the first-line test for acute bleeding. C) X-ray Skull: Cannot detect intracranial bleeding. D) EEG: Used for seizure evaluation, not SAH.

Answer 18

✅ Correct Answer: B) Drug or alcohol intoxication Explanation: Slurred speech and ataxia are classic signs of intoxication. ❌ Incorrect Answers: A) Seizure: Would likely have postictal confusion, not slurred speech. C) Vasovagal syncope: Causes brief LOC but does not cause confusion/ataxia. D) Hypoglycemia: Can cause confusion but not slurred speech.

Answer 19

Explanation: A) Incorrect – While Flumazenil has a short half-life, this is not the primary reason for its limited use. B) Correct – Flumazenil can trigger seizures, especially in chronic benzodiazepine users who are physiologically dependent. C) Incorrect – Flumazenil is effective at reversing benzodiazepine-induced sedation, but its risks often outweigh the benefits. D) Incorrect – Hypotension is not a major side effect of Flumazenil; the main risk is seizure precipitation.

Answer 20

**B) Correct – A new-onset headache in someone over 50 raises suspicion for giant cell arteritis or other serious causes.** Explanation: A) Incorrect – A chronic tension-type headache is usually benign. C) Incorrect – Benign headaches often improve with rest. D) Incorrect – Stress headaches are usually tension-type and not life-threatening.

Answer 21

Correct Answer: C Why? Patients with history of CHF and abnormal ECG are at high risk for cardiac syncope, which can be life-threatening. These patients require hospital admission. Wrong Answers: (A) A normal ECG and BP suggest a low-risk case that does not need admission. (B) Classic vasovagal syncope, not a high-risk case. (D) Rapid recovery is typical of benign syncope, not a red flag.

Answer 22

Answer: ✅ B) IM naloxone – Correct. If the patient is breathing but altered, IM naloxone is the recommended treatment. ❌ A) IV naloxone – Incorrect. IV naloxone is reserved for ongoing respiratory depression, usually in a hospital setting. ❌ C) Activated charcoal – Incorrect. Activated charcoal is not useful for opioid overdose as opioids do not undergo enterohepatic circulation significantly. ❌ D) IV fluids – Incorrect. While IV fluids may help with circulation, they do not directly reverse opioid overdos

Answer 23

**Answer: ✅ B) Hypothermia – Correct. Serotonin syndrome is characterized by hyperthermia, not hypothermia.** ❌ A) Hyperreflexia – Incorrect. Increased neuromuscular excitability, such as hyperreflexia, is a key sign of serotonin syndrome. ❌ C) Clonus – Incorrect. Clonus is a hallmark feature used in the Hunter Criteria for diagnosis. ❌ D) Autonomic instability – Incorrect. Serotonin syndrome leads to autonomic dysfunction, including hypertension and tachycardia.

Answer 24

**Answer: ✅ C) Atropine – Correct. Atropine is the primary treatment for cholinergic toxicity as it blocks muscarinic receptor activation.** ❌ A) Physostigmine – Incorrect. Physostigmine is used for anticholinergic toxicity, not cholinergic toxicity. ❌ B) Naloxone – Incorrect. Naloxone is used for opioid overdose, not cholinergic toxicity. ❌ D) Cyproheptadine – Incorrect. Cyproheptadine is used to treat serotonin syndrome, not cholinergic toxicity. **CHOLINERGIC TOXICITY Diagnostic Criteria:** * Clinical features + history of exposure. * RBC cholinesterase levels (confirmatory but not required for acute treatment). Pre-Hospital Management: * Decontamination (remove contaminated clothing, wash skin). * Atropine 1-2mg IV every 5 minutes until secretions dry. * Pralidoxime (2-PAM) 600mg IV for organophosphate poisoning. CHOLINERGIC TOXICITY Etiology: * Caused by excess acetylcholine from organophosphate pesticides, carbamates, nerve agents. * Overactivation of muscarinic and nicotinic receptors leading to SLUDGE symptoms. Clinical Presentation: * SLUDGE Symptoms: Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis. * Killer B’s: Bradycardia, Bronchospasm, Bronchorrhea (life-threatening pulmonary effects). * Muscle fasciculations, weakness, respiratory failure.

Answer 25

**Answer: ✅ C) Mydriasis – Correct. Anticholinergic toxicity causes pupil dilation ("blind as a bat").** ❌ A) SLUDGE symptoms – Incorrect. SLUDGE (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis) is associated with cholinergic toxicity, not anticholinergic toxicity. ❌ B) Bradycardia – Incorrect. Anticholinergic toxicity typically causes tachycardia, not bradycardia. ❌ D) Hyperreflexia – Incorrect. Hyperreflexia is a feature of serotonin syndrome, not anticholinergic toxicity. **ANTICHOLINERGIC SYNDROM E Etiology:** * Caused by excess anticholinergic agents (TCAs, antihistamines, atropine, scopolamine, jimson weed). * Blocks muscarinic acetylcholine receptors leading to widespread autonomic dysfunction. Clinical Presentation: * Dry as a bone: Dry skin, mucous membranes. * Red as a beet: Flushed skin. * Hot as a hare: Hyperthermia. * Mad as a hatter: Delirium, hallucinations. * Blind as a bat: Mydriasis, blurry vision. * Tachycardia, urinary retention, absent bowel sounds.

Answer 26

Answer:** ✅ C) Blood glucose and ketones – Correct. DKA is diagnosed with high blood glucose (>13.9 mmol/L or 250 mg/dL) and ketonemia or ketonuria.** ❌ A) Serum osmolality – Incorrect. Serum osmolality is more useful in diagnosing hyperosmolar hyperglycemic state (HHS). ❌ B) RBC cholinesterase levels – Incorrect. This test is used to confirm organophosphate poisoning, not DKA. ❌ D) Toxicology screen – Incorrect. While useful in some cases, a toxicology screen is not essential for diagnosing DKA. **DIABETIC KETOACIDOSIS (DKA) Etiology:** * Insulin deficiency leading to ketone production & metabolic acidosis. * Often triggered by infection, missed insulin doses, or new-onset diabetes. Clinical Presentation: * Polyuria, polydipsia, dehydration * Kussmaul respirations (deep, labored breathing) * Fruity breath (ketones), nausea, vomiting * Altered LOC (progressive deterioration) Diagnostic Criteria: * Blood Glucose >13.9 mmol/L (250 mg/dL) * pH <7.3, Bicarbonate <18 mEq/L * Positive serum or urine ketones

Answer 27

**Answer: ✅ B) IV fluids and gradual glucose correction – Correct. HHS is treated with fluid resuscitation and slow glucose correction to prevent cerebral edema.** ❌ A) Rapid insulin administration – Incorrect. Rapid insulin correction can cause dangerous shifts in osmolality and worsen cerebral edema. ❌ C) Physostigmine administration – Incorrect. Physostigmine is used for anticholinergic toxicity, not HHS. ❌ D) Atropine administration – Incorrect. Atropine is used for cholinergic toxicity, not HHS **HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS) Etiology:** * Severe hyperglycemia without ketosis * Common in elderly, type 2 diabetics with dehydration Clinical Presentation: * Severe dehydration, altered mental status, coma * Very high glucose levels (>33 mmol/L or 600 mg/dL) * Neurologic deficits (mimics stroke at times) Diagnostic Criteria: * Serum Osmolality >320 mOsm/kg * Glucose >33 mmol/L (600 mg/dL) * Absence of significant ketonemia/acidosis Pre-Hospital Management: * IV Fluids (0.9% NaCl initially, then switch to 0.45% NaCl if needed) * Monitor for neurological symptoms (risk of cerebral edema with rapid correction) * Call EMS for transport to hospital Basic In-Hospital Care: * Gradual glucose correction (IV insulin at lower rates than DKA) * Careful fluid resuscitation to prevent cerebral edema * Electrolyte monitoring (especially K+ and Na+)

Answer 28

**Answer: ✅ B) Cyproheptadine – Correct. This is a serotonin antagonist used to treat serotonin syndrome.** ❌ A) Atropine – Incorrect. Atropine is used for cholinergic toxicity, not serotonin syndrome. ❌ C) Naloxone – Incorrect. Naloxone is used for opioid overdose, not serotonin syndrome. ❌ D) Pralidoxime – Incorrect. Pralidoxime is used to treat organophosphate poisoning, not serotonin syndrome. ***SEROTONIN SYNDROME Etiology:** * Caused by excess serotonergic activity from medications (SSRIs, MAOIs, MDMA, linezolid, tramadol, St. John’s Wort). * Results in autonomic dysfunction, neuromuscular excitability, and altered mental status. Clinical Presentation: * Neuromuscular: Hyperreflexia, myoclonus, clonus, rigidity. * Autonomic instability: Hypertension, tachycardia, hyperthermia (>38.5°C). * CNS effects: Agitation, delirium, seizure, coma. Diagnostic Criteria: * Hunter Criteria (clonus + autonomic/CNS dysfunction). * Clinical history of serotonergic agent exposure. Pre-Hospital Management: * Stop offending agent immediately. * Sedation with benzodiazepines (lorazepam 1-2mg IV/IM). * Cooling measures for hyperthermia (>38.5°C).

Answer 29

**Correct Answer: C– Syncope during exertion suggests cardiac or neurologic origin and is a red flag requiring EMS.** Explanation: A. Incorrect – Postictal confusion must persist for >5 minutes to be a red flag. B. Incorrect – Positional syncope is less concerning than exertional syncope. D. Incorrect – Mild headache alone isn’t a red flag unless it’s severe or associated with vomiting.

Answer 30

Correct Answer: C. Correct – Motor response is scored out of 6, the highest of the three components. Explanation: A. Incorrect – Eye opening has a max score of 4. B. Incorrect – Verbal response maxes at 5. D. Incorrect – Reflexes are not part of the GCS.

Answer 31

Correct Answer: D. Correct – Cellulitis is an infection, not typically a direct cause of TLOC unless associated with sepsis, which isn't implied here. Explanation: A. Incorrect – Electrolyte abnormalities fall under METABOLIC. B. Incorrect – CVA is a HEAD (neurologic) cause. C. Incorrect – Cardiac events like MI are HEART causes.

Answer 32

**Correct Answer: C. Admit to hospital for monitoring and treatment ✅ C. Admit to hospital for monitoring and treatment – ✔️ Correct. GCS ≤ 8 typically indicates a need for airway protection and close monitoring in a hospital setting. This is a medical emergency.** Explanation: A. Monitor in outpatient clinic – ❌ Incorrect. A GCS of 8 indicates moderate to severe impaired consciousness and is a red flag for hospitalization. B. Refer for psychiatric evaluation only – ❌ Incorrect. While psychiatric care may be needed later, the immediate concern is impaired consciousness, which needs medical stabilization first. D. Reassure and discharge – ❌ Dangerous. A GCS of 8 means the patient is at risk of losing airway reflexes or further deterioration. Never discharge in this condition.

Answer 33

**✅ Correct Answer: B. Continue monitoring in clinic and arrange outpatient follow-up ✅ B. Monitor + outpatient follow-up – ✔️ Appropriate for moderate impairment (GCS 9–12) if the patient is stable, improving, and there are no red flags. Explanation:** A. Immediate neurosurgical evaluation – ❌ Too aggressive unless signs of trauma or neurological deficits are present. C. Activate EMS – ❌ Not necessary unless GCS is declining or other red flags present (e.g., vomiting, focal deficits). D. Discharge without follow-up – ❌ Even with moderate symptoms, follow-up is crucial to rule out deterioration.

Answer 34

**✅ Correct Answer: C. Arrange urgent CT head and consider observation ✅ C. CT + observation – ✔️ This is the safest next step. GCS 13, especially with amnesia or confusion, requires imaging to rule out bleed, and monitoring in case of deterioration.** Explanation: A. Discharge home with instructions – ❌ Not ideal for GCS 13, even though it’s technically mild TBI. Confusion and lower end of mild scale warrant further assessment. B. Routine outpatient follow-up – ❌ Delay in evaluation could miss an evolving intracranial issue. Not safe for someone acutely altered. D. ICU referral – ❌ Too aggressive at this point unless CT reveals significant findings.