Syncope and collapse

Question 1

What scoring system is used for assessing risk of adverse outcomes after syncope/stroke?

Answer 1

San Francisco Syncope Rule: CHESS
C - CHF Hx
H - haematocrit <30%
E - ECG abnormality
S - SOB
S - SBP <90

Question 2

What is the NIH stroke scale used for?

Answer 2

Assessing stroke severity. Looks at most possible symptoms, e.g. speech, movement, gaze, vision loss, following commands, facial palsy, sensory, language etc

Question 3

When is the Oxford/Bamford stroke classification used?

Answer 3

To determine the location of a stroke: total anterior circulation stroke, partial ACS, posterior circulation, lacunar circulation

Question 4

What are the criteria for performing a CT head within 1h in a stroke presentation?

Answer 4

• if within 4h window
• risk of bleeding (on A/Cs, bleeding disorder etc)
• GCS <13
• sudden headache at onset Sx
• Evidence increased ICP

Question 5

What are the 3 main symptom categories of strokes? How do the presence of these determine the location of the stroke?

Answer 5

Higher function - speech, apraxia, neglect
Hemianopia
Hemi-loss - motor/sensory

Question 6

What are the various stroke syndromes?

Answer 6

TACS = all 3 H Sx
PACS = 2/3 H Sx
Lacunar = 1/3 H Sx
POCS = variety of homonymous visual field defect, cerebellar signs, CN palsies, motor or sensory deficits, eye movement etc

Question 7

If a patient has an infarct of the L cerebellum, what might the deficits be?

Answer 7

L sided lack of coordination or balance. Cerebellar and brainstem infarcts –> defects on the ipsilateral side of the body.

Question 8

What part of the brain does the MCA supply?

Answer 8

Lateral aspects of temporal, parietal and frontal lobes.

Question 9

Patient presents with predominantly L sided leg weakness and parasthesia following a suspected stroke. Where might the infarct be?

Answer 9

Motor area for leg is supplied predominantly by the ACA. Therefore infarct of ACA causes weakness of leg > arm.

Question 10

What vessels supply the posterior aspects of the brain, e.g. cerebellum, brainstem.

Answer 10

Vertebrobasillar arteries

Question 11

What does the posterior cerebral A supply? What deficits might you see in an infarct here?

Answer 11

Occipital lobe, thalamus, inferior temporal lobe. Infarct –> homonymous hemianopia, involuntary movements, sensory impairment

Question 12

How might the face be affected in MCA stroke?

Answer 12

Contralateral paralysis of lower aspect of face. (whole side of face would indicate facial N deficit)

Question 13

What is the Mx of a seizing patient in the first 5 mins?

Answer 13

Start timing the seizure.
Put pt in recovery position
Check glucose - if <3.5 –> 100ml 20% glucose
After 3-4 mins try to get venous access –> bloods: FBC, U&E, glucose, CRP etc

Question 14

What would you do with a patient that had been seizing for 10 minutes?

Answer 14

Attach a cardiac monitor, consider an airway adjunct.

Give IV lorazepam (4mg) OR PR midazolam (10mg) –> repeat at 10 mins if still seizing

Question 15

Patient still seizing after 30 mins, has had 20mg of IV lorazepam to no effect. What is the next step?

Answer 15

IV phenytoin 20mg/kg (unless already taking it), or phenobarbital 10mg/kg

Question 16

what are the Sx of SAH?

Answer 16

Sudden onset severe headache radiating behind occiput. Assoc with N/V, altered consciousness, neck stiffness, focal neuro signs.
Patient may have experienced a Herald bleed int he preceding days-weeks.

Question 17

What is the Hunt & Hess scale?

Answer 17

Used to assess risk of mortality from SAH.
Grade 1 = <5% risk
Grade 5 = up to 70% risk

Question 18

What might you see on LP of SAH?

Answer 18

Xanthochromic CSF

Question 19

What investigations are performed in suspected SAH?

Answer 19

Initially –> CT, picks up 95% of cases.

If -ve but strong suspicion of SAH –> perform LP

Question 20

What is the Mx of SAH?

Answer 20

Urgent referral to neurosurgery!
Analgesia - codeine or morphine
Anti-emetics - metoclopramide
Avoid any activity that might aggravate the bleed - lie flat, avoid eating, straining to pass still, quiet room etc.

Question 21

What investigations are performed in patients with transient LoC?

Answer 21

All pts –> must have ECG.

Other Ix guided by description of event –> bloods (Hb, glucose), lying & standing BP, bHCG

Question 22

Red flags in an ECG for transient LoC? (3)

Answer 22

Any conduction abnormality (heart block, BBB etc)
Long or short QT
ST or T wave abnormalities

Question 23

What are the red flags for transient LoC?

Answer 23

PC: new/unexplained breathlessness, heart murmur, TLoC on exertion, any Hx or Sx of HF.
Ix: any of the ECG red flags
FH: of sudden cardiac death <40y