Neurology/ MFE Flashcards
Meningitis should be suspected in any patient presenting with …?
headache, fever, neck pain and rash
Some may present with seizures and focal neurological signs
Suspected meningitis
- examination
- Ix
- when might an additional Ix be needed before the LP?
- who is LP contraindicated in?
- Look for signs of meningism and perform a neurological exam to look for focal deficits especially cranial nerve lesions. Examine the fundus to look for papilloedema.
- Bloods: FBC,U&E,LFT,CRP, blood glucose, lactate, clotting profiles. Blood gases, Blood cultures. Throat swab. EDTA sample for PCR. Lumbar Punture
- CT brain required prior to LP if there are features of raised ICP (papilloedema, reducing LOC, focal neurological signs, seizures. This is to exclude any intracerebral lesions e.g. bleed, cerebral abscess that could cause similar symptoms.
- LP is contraindicated in patients with coagulopathy.
management of meningitis?
- ABCDE
- IV Ceftriaxone immediately, do not wait to perform LP.
- IV Ampicillin added for patients > 55y to cover listeria.
- Dexamethasone for 4 days started with or just before the first dose of antibiotics, particularly where pneumococcal meningitis suspected. Stop if non-bacterial cause identified
Any patient having acute onset unilateral neurological deficit should be considered as having a stroke.
Use the ___ Scale to differentiate from stroke mimics.
Rosier
Timeframe for thrombolysis in acute stroke?
can be contemplated if the patient has an onset of symptoms within 4.5 hours.
Ix in Acute Stroke
- Haematology
- Biochemistry
- ECG: if AF (and cerebral infarction) consider ____. Consider 24 hour ECG.
- Radiology
- Special tests
- FBC, Plasma Viscosity, INR if on warfarin, Clotting studies if cerebral haemorrhage
- U&E, Calcium, Glucose, Lipid profile (cholesterol, HDL, triglycerides), urate, CRP, (consider cardiac enzymes and creatine kinase)
- anticoagulation
- CXR; CT scan done within 12 hours of admission will exclude haemorrhage – “normal” early CT is compatible with infarction
- Carotid doppler (if cerebral infarction and patient fit for operation). Echo: consider where ECG is abnormal. Thrombophilia screen (if <50y/o)
Acute stroke management?
- ABCDE
- Urgent swallow assessment
- IV fluids – avoid dextrose in first 24 hr.
- Aspirin 300mg oral or per rectal if no contraindications
- Arrange for CT brain
- Call stroke team (9am – 5pm)
Patients on anticoagulation and presenting with new focal neurological deficit should have urgent CT brain immediately or within how long?
1 hour
T/F: aspirin should be given as a once off intervention prior to brain imaging in suspected stroke
false - should be given only after brain imaging has excluded an intracerebral bleed
For all patients with a TIA or confirmed cerebral infarction immediately start ____ 300mg daily and give a once off dose.
This should be given orally if the swallow screen is passed, or ____ if the swallow screen is failed.
aspirin
rectally
secondary prevention of ischaemic stroke?
aspirin once daily for 14 days followed by life-long clopidogrel
T/F: antiplatelets can be recommended 12 hours post thrombolysis
false - avoid all antiplatelets and anticoagulants for 24 hours post-thrombolysis.
first line maintenance therapy for confirmed cardioembolic ischaemic stroke?
First Line: warfarin
Second Line: rivaroxaban
seizure initial mangement?
- Secure airway and resuscitate (2222 if unable).
- ABC
- Establish IV access, prepare lorazepam 4mg (titrate to effect by giving 1mg each time, not as a bolus).
- Hx from patient + eye witness
- Use a stopwatch to note how long seizure lasts.
- Detailed neuro examination to look for any focal deficits.
Ix for a patient with a seizure?
- FBC, U& E, Calcium, Magnesium, Phosphate, LFT’s, Glucose
- Toxicology screen if indicated (benzos and opiates)
- ECG in all patients
- Some may need brain imaging
- Do not routinely organise for an EEG unless requested by a Neurologist
- If this is the first seizure which has resolved the patient should be referred to where?
- T/F: do not start patients on antiepileptic medications unless suggested by a neurologist
- the First Fit Clinic
- true
commonest cause for acute spinal cord compression?
metastatic disease (primary Lung, Breast, GI tract, Prostate and Kidney cancers)
other causes of acute spinal cord compression?
- Epidural haematoma: epidural / spinal anaesthesia
- Trauma: Vertebral body fracture or facet joint dislocation
- Neoplasia: Benign or malignant neoplasia of the spinal cord
- Degenerative: Prolapsed intervertebral disc, osteophyte formation
- Vascular: Epidural or subdural haematoma
- Infection: TB or pyogenic infections
- Inflammatory: RA
spinal cord compression - history?
- spinal pain, limb weakness, bowel and bladder disturbance.
- important to obtain history of cancer, recent trauma or spinal procedures like lumbar puncture/epidural anaesthesia.
examination in spinal cord compression?
- Motor symptoms: muscle weakness, gait disturbance
- Cervical spine disease > quadriplegia
- Thoracic spine disease > paraplegia
- Sensory symptoms: sensory loss and paraesthesia
- Tendon reflexes are often: increase below level of compression, absent at level of compression, normal above level of compression
investigation of choice for suspected spinal cord compression?
MRI
- If spinal cord compression is confirmed on MRI Spine treatment options include ___ or ____.
- Patients should be started on ____ IV/oral twice daily after discussion with the oncology reg
- Patients will need appropriate analgesia for pain relief (see pain ladder)
- surgery, radiotherapy
- Dexamethasone
describe the headache ass with SAH
severe, sudden onset headache
Classically maximal at onset (not gradual elevation of severity)
examination of pt with suspected SAH?
Full neurological examination including
- recording of GCS
- cranial nerve examination
- pupillary assessment
what urgent Ix is required for suspected SAH?
Urgent CT brain
what is status epilepticus?
a convulsive seizure lasting >5 minutes, or convulsive seizures that occur one after the other without full recovery between.
Management of status epilepticus?
- bloods
- Bedside blood glucose.
- If hypoglycaemic: 50ml 50% dextrose IV. Pabrinex if history of alcohol excess.
- Lorazepam 4mg IV. Repeat dose in 10 minutes if no repsonse (per rectal diazepam 10mg if no IV route)
- If status persists, IV phenytoin or phenobarbitone both with ECG monitoring
- If status persists inform ITU Registrar on call and seek neurology advice
what is delirium
acute onset of disturbed consciousness, cognitive function or perception that has a fluctuating course
what are the 3 clinical subtypes of delirium?
- Hyperactive (~30%): Restlessness, agitation/ Aggression, sleep Disturbance
- Hypoactive (~50%): Drowsiness, reduced Mobility, withdrawal
- Mixed
most common perceptual disturbance in delirium?
visual hallucinations
risk Fx for delirium?
- Age ≥75
- Pre-existing cognitive impairment/ dementia
- Hearing/Visual Impairment
- Polypharmacy (>4 drugs- especially anticholinergic, opiates, benzos & steroids)
- Physical Restraint e.g. IV access or catheterisation
- Multiple Chronic Illnesses
What are common precipitating causes of delirium?
- Infection
- Recent medication change
- Metabolic disturbance e.g. Hyper/hypoglycaemia
- Electrolyte imbalance
- Hypoxia
- Constipation
- Malnutrition
- Dehydration
- Change in environment e.g. ward transfers
- Anaesthesia/Major Surgery
- Alcohol/Drug withdrawal
If you suspect delirium, formally assess the patient using what tool?
the 4AT (≥4 indicates delirium is likely):
state the components of the 4AT scoring system
what score indicates delirium is likely?
- alterness
- AMT4 (age, DOB, current year, location)
- attention (months of the year backwards in order)
- acute change/ fluctuating course
(≥4 indicates delirium is likely)
T/F: sedation should routinely be used for patients with delirium
Low dose sedation can be used for unmanageable agitation/ distress, however, avoid sedation when possible as this can extend the duration of delirium
