The patient with collapse

Question 1

What is the definition of syncope?

Answer 1

Transient loss of consciousness due to transient cerebral hypoperfusion. Rapid onset, short duration and spontaneous, complete recovery.

Question 2

How do syncope and collapse differ?

Answer 2

Don’t always lose consciousness in a ‘collapse’, whereas there must have been some loss of consciousness in a syncopal episode.

Question 3

What are some reasons that a patient should be seen by a specialist within 24 hours for a CV assessment following a syncopal episode?

Answer 3

ECG abnormality, Transient Loss of Consciousness during exertion, new or unexplained breathlessness, heart murmur, FHx of SCD in someone < 40 or inherited CV condition, consider referral for those >65 if no prodromal symptoms.

Question 4

What features would suggest a simple vasovagal faint?

Answer 4

No features of an alternative diagnosis and features suggestive of the 3 Ps:
Posture - tLoC after prolonged standing
Provoking factors - Pain, medical procedure
Prodromal Sx - e.g. sweating/feeling hot before tLoC

Question 5

What features would suggest a diagnosis of situational syncope?

Answer 5

No features suggestive of an alternative diagnosis and syncope is clearly and consistently provoked by straining during micturition/coughing/swallowing.

Question 6

What are the seven features of alcohol dependence?

Answer 6

Increased tolerance
Prioritising drinking over other activities
Narrowing of drinking repetoire
Persistent dresire or unsuccessful efforts to cut down
Withdrawal symptoms
Relief from withdrawal Sx by further drinking
Use is continued despite knowledge of alcohol related harm

Question 7

When do alcohol withdrawal symptoms tend to peak?

Answer 7

Day 2, usually improved by day 4/5

Question 8

How many hours after stopping alcohol would you expect to see alcohol hallucinosis, withdrawal seizures and delirium tremens, respectively, in an alcohol dependent person?

Answer 8

Alcohol hallucinosis: 12-24 hours
Withdrawal seizures: 24-48 hours
Delirium tremens: 48-72 hours

Question 9

What are the symptoms of delirium tremens?

Answer 9

Hallucinations, delusions, severe tremor, agitation, clouding of consciousness, confusion, disorientation, fever.

Question 10

What is Wernicke’s encephalopathy and what are the 3 main signs of it?

Answer 10

Wernicke’s encephalopathy is a neurological emergency resulting from thiamine deficiency.

1. Ophthalmoplegia
2. Ataxia
3. Confusion

Question 11

What medication is given in the management of alcohol withdrawal?

Answer 11

Chlordiazepoxide - a benzodiazepine - on a reducing dose regimen.
Thiamine

Question 12

What drugs may be given to previously alcohol dependent patients to prevent relapse?

Answer 12

Acamprosate - reduces alcohol cravings

Disulfiram - acts as a deterrent by causing flushing, vomiting, palpitations, headaches when alcohol is consumed.

Question 13

What constitutes the diagnostic triad in diabetic ketoacidosis?

Answer 13

Hyperglycaemia (CBG > 11mmol/L or known diabetic)
Ketonaemia (> 3mmol/L) or ketonuria (++ on urinalysis)
Acidaemia (pH < 7.3 +/- HCO3- < 15mmol/L)

Question 14

What are risk factors for DKA?

Answer 14

4 Is
Infection
Infarction
Insufficient insulin
Intercurrent illness

Question 15

What clinical signs may be seen in DKA?

Answer 15

Dehydration
Kussmaul breathing (resp. compensation for metabolic acidosis)
Pear drop fetor (sweet smelling breath)

Question 16

What is the fluid regimen for management of DKA?

Answer 16

0.9% saline –> 1L over 1 hour. 1L over 2 hours. 1L over 2 hours. 1L over 4 hours.

Question 17

How is the hyperglycaemia of DKA managed?

Answer 17

iv insulin - fixed rate infusion of 0.1 units/kg/hour. Blood glucose should be regularly monitored and 10% glucose administered when the BM falls below 14mmol/L

Question 18

When is DKA said to have resolved?

Answer 18

When ketones < 0.3mmol/L and pH > 7.3. At this point, once biochemically stable and euglycaemic, discontinue iv treatment and switch to sc insulin

Question 19

How does iv insulin affect intracellular K+ levels and how do K+ levels affect management?

Answer 19

Increases K+ influx into cells.
K+ < 3.5: HDU
K+ 3.5-4.5: Add 40mmols K+
K+ 4.5-5: Add 20mmols K+
K+ >5.5: No replacement required

Question 20

What are the criteria for performing a CT head within 1 hour following a head injury?

Answer 20

GCS < 13 on initial assessment, GCS < 15 at 2 hours after injury on ED assessment, suspected open or depressed skull fracture, signs of basal skull fracture, post-traumatic seizure, focal neuro deficit, > 1 episode of vomiting.

Question 21

What are the criteria for performing a CT head within 8 hours following a head injury?

Answer 21

LoC or amnesia since the injury, > 65 years old, Hx of bleeding/clotting disorder, dangerous mechanism, > 30 mins retrograde amnesia of events before the injury.

Question 22

What are the criteria for performing a spine X-ray following a head injury?

Answer 22

Cannot actively rotate neck 45o Left or Right (or not safe to assess R.o.M of neck), neck pain or midline tenderness plus age > 65 or dangerous mechanism of injury, definitive diagnosis of C-spine injury urgently required.

Question 23

What are the criteria for performing a spinal CT following a head injury?

Answer 23

GCS < 13 on initial assessment, patient intubated, plain film inadequate or continued suspicion despite normal X-ray, multi-region trauma.

Question 24

What key investigations should be carried out for suspected subarachnoid haemorrhage?

Answer 24

CT scan within 1 hour (90% detection rate in acute setting)
Lumbar puncture > 12 hours after onset of headache (even if CT normal) - some contraindications: GCS < 15, focal neurology, age > 55, immunocompromised, seizure, vomits >= 3, papilloedema.

Question 25

How is subarachnoid haemorrhage managed?

Answer 25

ICU admission, intubate/ventilate if needed.
Surgical clipping or endovascular coiling.
Start on nimodipine (a CCB) to reduce vasospasm), phenytoin (seizure prophylaxis to prevent rebleeding) and a stool softener e.g. docusate (to prevent straining and rebleeding)