SIMMAN - emergency conditions Flashcards
INR and Warfarin
- Normal INR value
- INR target when pt on Warfarin
- Reversal of Warfarin
- what to do pre-surgery + if pt has mechanical heart valves or recurrent VTE
Reversal agents for
- Rivaroxaban, apixaban, and edoxaban
- Dabigatran
- Warfarin
- Heparin (unfractionated/LMWH)
Treatment of an opioid overdose
IV naloxone
Scenario: What is the diagnosis?
- Presenting symptoms: high fever, headache, stiff neck, nausea/vomiting, and a non-blanching purpuric rash
- GCS is slightly decreased
- Pt also has photophobia/discomfort with bright lights
Meningococcal meningitis
Acute management of meningococcal meningitis
- IV ceftriaxone/cefotaxime (3rd gen cephalosporin)
(if penicillin allergic - IV chloramphenicol)
(if penicillin-resistant strain - IV vancomycin)
- IV dexamethasone - for cerebral oedema + reduces hearing loss complications
- Supportive - analgesics/antipyretics/antiemetics +/- fluids +/- oxygen (high flow)
(if fever - IV paracetamol)
- Close monitoring for complications - raised ICP, seizures, neuro deficits
(any acutely unwell pt - secure airway)
Simman (meningitis) - Pt has ache behind ear, what is the likely cause of the meningitis?
mastoiditis (ache behind ear)
- perform otoscopy
Simman (meningitis) - how many tubes/samples are used for lumbar puncture and why is blood measured in the first and last sample?
4 tubes used (glucose/protein/WCC/culture) - 1st and last samples both check for blood (if traumatic tap then blood in 1st but not last sample)
Simman (meningitis) - most common organism + other organisms
- Neisseria meningitidis
- Streptococcus pneumoniae, and Haemophilus influenza (neonates - E.coli, Listeria monocytogenes, group B Strep)
Simman (meningitis) - Bacterial CSF
low glucose, high protein, WCC (neutrophils), bacterial culture
Simman - what is the main LP (lumbar puncture) contraindication + what would you do instead?
raised ICP (CT head first)
Simman (meningitis) - what is the test for meningitis rash (non-blanching)?
tumbler test (glass test), press a clear glass against rash, if it doesn’t fade (non-blanching) then indicates meningitis rash
Simman (meningitis) - is meningococcal meningitis a notifiable disease?
Yes, notify public health
Simman (seizure post-meningitis) - Acute management of a tonic-clonic seizure
- Put out crash call (2222) / call senior
- Buccal Midazolam / IV Lorazepam 4mg (Benzodiazepine)
- if still fitting 5 mins after dose, contact anaesthetist —> then give another dose after 5 mins
- if still fitting then IV phenytoin
(Supportive - analgesics/antipyretics/antiemetics +/- fluids +/- oxygen (high flow))
(any acutely unwell pt - secure airway)
Simman (seizure post-meningitis) - What are some ways to tell if the pt is having a ‘real’ seizure or a psychogenic non-epileptic seizure?
- Eyes - open (’real’), closed/squinting (psychogenic)
- Saline drop on eye - if psychogenic then pt will blink
- Lactate - high in ‘real’ seizures (lactic acidosis due to muscles working hard due to spasms)
- Prolactin is another marker - raised in ‘real’ seizures
Simman (seizure post-meningitis) - Bradycardia + Hypertension, what is this called?
Cushing’s reflex (due to raised ICP)
Simman (seizure post-meningitis) - How will the pt feel after the seizure episode?
drowsy, disorientated etc. (post-ictal)
Simman (seizure) - What is the most common cause of a seizure?
hypoglycaemia
Simman (seizure) - If seizure is due to hypoglycaemia, what would you give the pt?
IV dextrose
Simman (seizure) - What is the management of psychogenic non-epileptic attacks (pseudoseizures)?
observe, monitor O2 sats/pulse/resp. rate, avoid parenteral drugs
Simman (seizure) - If you suspect the seizure is due to alcohol abuse or impaired nutrition, what would you give the pt?
- Glucose (50ml of 50% solution)
- and/or IV Pabrinex (thiamine 250mg)
Simman (seizure post-meningitis) - If lorazepam is unavailable, what would you give?
IV midazolam
Simman (seizure post-meningitis) - If phenytoin is contraindicated, what would you give?
sodium valproate
Simman (SAH) - Acute investigations + management
Acute management:
- CT head (can see bleed if < 6hr onset)
- LP (done after 12 hrs onset to allow for xanthochromia to form)
- (CT angiogram - look for aneurysms)
1. IV Nimodipine (prevents vasospasm + secondary ischaemia)
2. Refer to neurosurgery
3. Regular neurological observations
4. (If pt on anticoagulation/blood thinners - reverse)
5. Supportive - analgesics/antipyretics/antiemetics +/- fluids +/- oxygen (high flow)
(any acutely unwell pt - secure airway)
Simman (SAH) - What electrolyte should be monitored?
sodium (risk of hyponatraemia - SIADH)
- why? - can exacerbate cerebral oedema, increase ICP, and worsen outcome
- (hypopituitarism is another complication)
Simman (SAH) - Why is the pupil dilated?
brain injury/bleed has compressed the oculomotor nerve (loss of parasympathetic innervation to the pupil, causing it to dilate due to unopposed sympathetic activity)
Simman (SAH) - Why might the CT head appear ‘normal’?
if not < 6hrs onset then CT head can appear normal (due to blood being redistributed and broken down)
- need to perform LP (12 hrs after onset to allow for xanthochromia to form)
Simman (SAH) - complications of SAH
- Rebleed
- Cerebral vasospasms
- Hydrocephalus
- Cerebral oedema - causing raised ICP
Simman (spinal cord compression) - Acute management
- MRI spine
1. Refer to spinal surgeons
2. Give IV dexamethasone - to reduce inflammation and minimise neurological damage
3. Supportive - analgesics/antipyretics/antiemetics +/- fluids +/- oxygen (high flow)
(any acutely unwell pt - secure airway)
Simman (spinal cord compression) - What is the cause of this spinal cord compression?
Scenario:
- Brief: 70yo male presents with fall + incontinence (fall due to weakness of legs + no head injury + no LOC), PMH of prostate cancer
- Obs: A to E normal except for weakness and brisk reflexes in left leg from hip down
older male with prostate cancer —> have to think secondary metastases
Simman (spinal cord compression) - What is a key differential (life-threatening)?
Scenario:
- Brief: 70yo male presents with fall + incontinence (fall due to weakness of legs + no head injury + no LOC), PMH of prostate cancer
- Obs: A to E normal except for weakness and brisk reflexes in left leg from hip down
Cauda equina
- usually L4/L5 or L5/S1 level
Seizures in pts younger than 20yrs VS seizures in pts older than 20yrs - cause
- Under 20yrs - primary generalised
- Over 20yrs - structural problem
What seizure medications are contraindicated in women of childbearing age?
- Sodium valproate
- Topiramate
Syncope VS Seizures
How would you calculate a GCS score
- what score requires intubation?
(obeys commands - put arms up and make a fist/grip my finger)
(painful stimulus - supraorbital pressure or trapezius squeeze)
- Eye opening (1-4)
- Spontaneous: 4
- Verbal stimulus: 3
- Painful stimulus: 2
- No eye opening: 1 - Verbal (1-5)
- Orientated: 5
- Confused: 4
- Inappropriate words: 3
- Incomprehensible sound: 2
- No verbal response: 1 - Motor (1-6)
- Obeys commands: 6
- Localises painful stimulus: 5
- Withdraws from painful stimulus: 4
- Abnormal flexion to pain: 3
- Abnormal extension to pain: 2
- No response
Meningitis - Post-exposure prophylaxis
If close contact - give a single dose of ciprofloxacin as prophylaxis
What is the most common complication of bacterial meningitis?
Hearing loss
- Sensorineural hearing loss can occur due to cochlear damage
