Neurology - Level 2 Flashcards
Investigations to perform in first fit?
o Consider alcohol/drugs, withdrawal states, hypoglycaemia, arrhythmias, head injury, SAH, TIA/stroke, infection, metabolic
o Investigations
BMG
Bloods – glucose, FBC, U&Es, cultures if pyrexial
ECG
CXR if signs
Urine pregnancy test
CT scan if:
• Focal signs, head injury, known HIV, suspected intracranial infection, bleeding disorder or conscious level does not improve
Discharge advice to patient with first fit?
Accompanied by adult if normal neurological and CV examination, ECG and electrolytes are normal
Make appointment with epilepsy specialist in coming week
Do not drive or use heavy machinery
Supervision when performing swimming/bathing
Admit patient with first fit if?
More than one seizure in day
Definition of status epilepticus?
- Continuous generalised seizure for 5 minutes or longer, or recurrent seizures one after the other without recovery in between
- Mortality and risk of permanent brain damage increase with length of attack
Risk factors of status epilepticus?
o Under 5 or elderly age
Precipitants of status epilepticus?
Cerebral infarction, trauma, CVA, metabolic disturbances, febrile seizures
Symptoms of status epilepticus?
- Tonic-clonic easy to distinguish, non-convulsive states harder to spot
Community management of status epilepticus? Drugs if over 5 minutes long
o Buccal midazolam 10mg 1st line
o Alternative: rectal diazepam 10-20mg, IV lorazepam (if IV access)
o Call ambulance if still fitting 5 minutes after medications, concerns about ABC
Initial management of status epilepticus?
o Time the seizure
o Position patient to avoid injury
o Open and maintain airway, lay in recovery position - Remove false teeth, insert Guedel/Nasopharyngeal airway
o High flow oxygen 15L/min via NRB mask + suction
o IV access and take blood (FBC, U&Es, LFTs, glucose, Ca, Mg, VBG, toxicology screen)
o Blood cultures if septic
o Check BM glucose
o Assess cardiac and respiratory function
Drug management (after 5 minutes) in status epilepticus?
o IV lorazepam 4mg slowly
o Repeat IV lorazepam after 10 minutes if seizures fail to respond or recur
Alternative: IV diazepam
If no IV access, buccal midazolam or rectal diazepam
Drug management in status epilepticus if alcohol abuse suspected?
o If alcohol abuse – IV thiamine 250mg over 30 mins
Drug management in status epilepticus if hypoglycaemic?
o Treat hypoglycaemia with 50ml of 20% dextrose (10g)
Further drug management (if fails to respond after 25 minutes)?
o Phenytoin 15-20mg/kg IVI at rate of 50mg/minute – if fails to respond after 25 minutes
Alternative diazepam infusion until seizures respond
Monitoring of status epilepticus?
- Monitor ECG and BP
- Anaesthetic help
o May need ICU and ventilation
o RSI – propofol, thiopental, miadazolam and tracheal intubation
Olfactory nerve lesion - anatomy?
olfactory cells are bipolar neurones passing through cribiform plate to olfactory bulb
Olfactory nerve lesion - symptoms?
reduced taste and smell but not to ammonia which stimulates the pain fibres carried in trigeminal nerve
Olfactory nerve lesion - causes?
Trauma, frontal lobe tumour, meningitis
Optic nerve lesion - symptoms - visual field defects?
Scotomas
Monocular blindness – MS, GCA
Bilateral blindness – methyl alcohol, tobacco, neurosyphilis
Bitemporal hemianopia – optic chiasm compression (internal carotid artery aneurysm, pituitary adenoma, craniopharyngioma)
Homonymous hemianopia (loss of same half of visual field in both eyes on opposite side of lesions e.g. right sided lesion causes loss of left side of visual field) - lesions behind optic chiasm in optic tract/lateral geniculate nucleus/optic radiations including tumour, stroke, abscess
Optic nerve lesion - symptoms - optic neuronitis?
Pain on moving eye, loss of central vision, afferent pupillary defect, papilloedema
MS, syphilis, sinusitis
Optic nerve lesion - symptoms - optic atrophy?
Pale optic discs and reduced acuity
MS, frontal tumours, Friedreich’s ataxia, syphilia, glaucoma, optic nerve compression
Optic nerve lesion - symptoms - papilloedema?
Raised ICP (tumour, abscess, encephalitis, hydrocephalus, benign intracranial hypertension)
Inflammation (optic neuritis)
Ischaemia (accelerated hypertension)
Symptoms of oculomotor nerve lesion?
- Fixed dilated pupil
- Ptosis
- Down and outward deviation of eye
Causes of oculomotor nerve lesion?
- DM
- GCA
- Syphilis
- PCA aneurysm
- Raised ICP
Symptoms of trochlear nerve lesion?
- Diplopia due to weak down and in eye movements
- Eye up and outwards
- Patient tilts head away from affected side