Week 2 - Acute Medical Presentations 2 Flashcards
If a P has a reduced GCS - where is the likely problem?
In the brainstem
Which cranial nerves are found
- in the midbrain?
- in the pons?
- in the medulla?
Midbrain = III & IV
Pons = V, VI, VII, VIII
Medulla = IX, X, XI, XII
What does the reticular system do?
Is the essence of awareness and consciousness
What are the two types of cause of impaired consciousness?
Neurological
Metabolic
When looking at differentials for impaired consciousness - what should you consider?
Meningitis
Brain tumour
Acute Stroke
Toxic-metabolic derangement
Spinal cord compression
What are possible causes of a fluctuating GCS?
Vascular
Seizure
Drug use / withdrawal
Metabolic
Infectious
Neurogenerative
Migraine
What are the steps of an acute neurological evaluation?
What are the following types of posture called?
(1). Decorticate posturing
(2). Decerebrate posturing
What is myoclonus?
Brief involuntary twitching/jerking
What is asterixis?
Inability to maintain sustained posture - brief, shock like movement - e.g. flapping tremor
Give an example of the following:-
- Simple midline command
- Simple acral command
- Two-part command
- Three-part command
- Complex command
What is anisocoria?
One pupil is bigger than the other
Why is it important that the pupillary light reflex is resistant to metabolic derangement?
It means it will still be intact if the P has metabolic derangement. If not intact, is unlikely to be a metabolic derangement cause.
The midbrain has the vertical gaze centre - what is this responsible for?
Gives the P the ability to look up
The pons has the horizontal gaze centre - what is this responsible for?
Gives P the ability to look right and left
What is paradoxical breathing?
When the chest expands during inhalation and the abdomen is drawn inwards and then during exhalation the abdomen is pushed outwards
In which part of the brainstem are the breathing centres located?
Pons - Pneumotaxic & apneustic centres = automatic breathing
Medulla = inspiratory and expiratory centres - chemosensitive control
What two tests can be done for neck stiffness?
Kerning’s sign
Bradzinski’s sign
What is the oculocephalic reflex also known as?
Dolls head sign
If the GCS is less than 8, which reflexes should be assessed?
Pupillary light reflex
Swinging flashlight test
Oculocephalic reflex
Corneal reflex
Gag reflex
Ciliospinal reflex (response to pain)
What is the biochemical triad of DKA?
Hyperglycaemia (BG >11)
Hyperketonaemia (>3 or ketonuria >2+)
Metabolic acidosis (HCO3 <15 or venous pH <7.3)
What initial investigations should you do for DKA?
Capillary BG
Blood ketones
VBG
Glucose, U&Es, FBC
ECG
CXR
Blood culture
MSUH
How is DKA managed?
Fluids
Insulin
Correct electrolytes - esp K+ (replaced if below 5.5)
Treat precipitating factors
VTE Prophylaxis
How much fluid do Ps with DKA need to be given?
Typical deficit = 100ml / kg
1L over first hours
1L over next 2 hours x 2
1L over next 4 hours x 2
1L over next 6 hours
Reassess at the 12 hour status. Monitor electrolytes!
How much insulin is given in DKA?
1st hour - Fixed Rate IV Insulin Infusion (FRIII) - 50 units at 0.1 ml/kg/hour (7ml/hr for 70kg P)
AIM = reduce ketones by 0.5mmol/L/hr
Assess at 1hr - if not falling fast enough increase FRIII by 1ml/hr
Commence 10% dextrose when BG is <14.
Switch to VR III when ketones <0.6, pH >7,3 and HCO3 >18
What monitoring do DKA Ps need?
What is resolution of DKA defined as?
Ketones <0.3 and venous pH >7.3
What is euglycaemic DKA?
Acidosis
Ketonaemia
Normal or slightly raised BG
What can cause euglycaemic DKA?
SGLT2 Inhibitors
Pregnancy
Pancreatitis
Renal tubular acidosis
Starvation
Pre-hospital insulin (partially treated DKA)
A patient has
- Dehydration
- BG >30
- Blood ketones <3
Osmolality >320 (high)
What condition do they have?
Hyperosmolar Hyperglycaemic State (HHS)
High BG, normal ketones, high osmolality
How does HHS management differ from management for DKA?
Needs to be GRADUALLY normalised osmolality, fluid status and glucose.
HHS - often affects older Ps and can exacerbate CVS problems if you give them rapid fluid replacement
What is the management of HHS?
Fluid replacement
- 1L over 1 hour, then 3-6L over 12 hours - but not rapidly
Insulin - not usually required in first hour. Only needed if BG stops falling with IV fluids alone or if ketonaemia
Treat precipitating factors
VTE prophylaxis
How does HHS resolve?
What is Addison’s disease?
Primary hypoadenalism - caused by destruction of adrenal cortex = deficiency in glucocorticoid, mineralocorticoid and sex steroid deficiency
What are the causes of Addison’s disease?
What are the symptoms of Addisons?
What are the signs of Addisons?
Which tests can be done for Addisons?
Random cortisol
Short synacthen test
Plasma ACTH - v high = primary adrenal failure, less than 10 = secondary adrenal failure
U&Es
BG
Adrenal ABs
CXR and AXR
How is Addison’s managed?
IV Hydrocortisone
Fluid resus
Monitor BG
Fludrocortisone later
Steroid card and Medic alert bracelet
How is Addisons treated on a daily basis?
Hydrocortisone has both glucocorticoid and mineralocorticoid activities; whereas fludrocortisone, a synthetic corticosteroid, possesses very potent mineralocorticoid activity.
What are the clinical features of thyrotoxicosis?
How is acute thyrotoxicosis managed?
Establish cause
Commence antithyroid drugs - Carbimazole (Propylthiouracil instead if pregnant) and Propranolol
Treat complications - ECG, Digoxin, Diuretic, Anticoagulation
How is thyroid storm managed?
Propylthiouracil / Carbimazol - blocks T4 synthesis
Oral KI - blocks T4 release
Propanolol & IV HCS - block T4 effects
Paracetamol (anti pyretic) and IV fluids
What level is malignant hypertension diagnosed at?
> 180/120
What are the two types of malignant hypertension?
Hypertension Urgency - sudden inc in BP without acute end-organ damage
Hypertension Emergency - sudden inc in BP with acute end-organ damage
What are the physiological signs of malignant hypertension?
Hypertensive retinopathy - inc haemorrhages or exudate on retina
Papilloedema
Cardiac failure
Encephalopathy = seizures, cortical blindness, coma
How is malignant hypertension treated?
If BP >180/120 + organ damage - admit
Fluids
Adalat Retard = Ca Channel Blocker
What endocrine conditions can cause hypertension?
Conn’s Syndrome (aldosterone)
Cushing’s syndrome
Acromegaly
Phaechromocytoma
What are the clinical features of a phaeochromocytoma?
Hypertension
Headache
Cold Sweats
What clinical signs can be used as indicators of meningitis?
Elevated WCC and protein in the CSF
What is the mortality rate of bacterial meningitis?
20%, 30% if pneumococcal
Which bacterial meningitis are older adults or immunocompromised adults at risk of?
Listeria monocytogenes
What percentage of meningitis has a viral cause?
Probably 50-80%
What are the clinical S&S of meningitis?
Headache, neck stiffness, fever
Often + photophobia + vomiting
Which two signs are used to test for meningitis?
Kernig’s sign
Brudzinki sign
How is meningitis managed?
A-E
D = GCS, focal neurological signs and papilloedema
Blood cultures, LP
Ceftriaxone (or cefotaxime) immediately after LP/blood cultures of no LP
Dexamethasone 10mg IV
CT - not normally indicated if fully alert.
How is meningitis treated differently if there are signs suggested of brain shift & raised ICP?
How are Ps treated who have signs of severe sepsis or rapidly evolving rash?
Sepsis guidelines
If purpura and ecchymoses are seen in meningitis - what is this suggestive of?
That the clotting system is failing
What antibiotics are given in bacterial meningitis?
What alternative can be given if allergic to penicillin?
Ceftrixaone or Cefotaxime
Alternaive = chloramphenicol & co-trimoxazole
When should you delay a LP for meningitis?
Why do you sometimes do CT rather than MRI in meningitis?
Because Ps are often acutely unwell and cannot tolerate an MRI
Where is there a high incidence of tuberculosis meningitis?
African and Indian subcontinents
What is the mortality rate of tuberculosis meningitis
60% - even if treated
What are possible complications of meningitis?
Hydrocephalus
Abscess
Epilepsy
Cognitive impairment
Focal neurological signs
How does viral meningitis usually present?
Neck stiffness, photophobia & headache
Usually no reduced consciousness - if altered then consider encephalitis
How is viral meningitis treated?
Initially treat as bacterial until proven viral - then stop Abx.
Is no evidence for aciclovir or other anti-virals to be used.
Tx = supportive - fluids and analgesia
What is inflammation of the brain termed?
Encephalitis
What is it called when a patient has brain inflammation and inflammation of the meninges?
Meningoencephalitis
What can cause encephalitis?
Viruses
Small intracellular bacteria
Some parasites
Acute disseminated encephalitis myelitis (ADEM) - occurs when P has had recent vaccination / infection - antibodies are made which then damages the brain
Can also get AI Antibody-Associated Encephalitis
What is the most common cause of viral encephalitis?
Herpes simplex
Varicella zoster, Cytomegalovirus and Enterovirus also possible
How does viral encephalitis present?
Fever, altered, headache, N&V
How is encephalitis investigated?
LP asap (unless CI)
CT asap
MRI within 48hr max
EEG
PLEDS
What is the Tx for viral encephalitis?
IV Aciclovir
What is AI Encephalitis?
Caused by the immune system attacking the brain causing inflammation. Can be a paraneoplastic cause.
How is AI encephalitis treated?
Steroids - IV (methyl-prednisolone) then LT oral
Immunoglobulins
Plasma exchange
Rituximab
