Disability Flashcards
what is AVPU?
alert
voice - responds to voice
pain - responds to pain e.g. sternal rub/ trapezius squeeze
Unresponsive
what is the GCS scoring system?
Eyes response
- eyes open spontaneously (4 points)
- eyes open to verbal command
- eyes open to pain
- no eyes opening (1 point)
Voice response
- orientated - 5 points
- confused conversation but able to answer Qs
- inappropriate responses
- incomprehensible sounds/ speech
- no verbal response - 1 point
Motor response:
- obeys commands for movement - 6 points
- purposeful movement to painful stimulus
- withdraws from pain
- abnormal flexion (decorticate)
- abnormal extension (decerebrate)
- no motor response - 1 point
score from 3- 15
describe the causes of reduced GCS
head injury - basal skull fracture, epidural haemorrhage, subarachnoid haemorrhage, subdural haemorrhage, concussion and contusion
neoplasm - e.g. glioblastoma or mets
infection - meningitis, encephalitis
seizures
metabolic - electrolytes, cerebral oedema, hepatic encephalopathy, wernickes , hypoglycaemia, hypoxia, uraemia, acidosis
drugs - opioids, intoxication.
describe overall presentation of a head injury?
laceration
obvious skull deformity
C spine tenderness deformity
signs of basal skull fracture
- racoon eyes, battle sign, rhinorrhoea/ottorrhoea, haemotypanum (blood on tympanic membrane)
signs of raised ICP - headache, papilloedema, vomiting, focal neurological signs (cranial nerves, weakness in certain area)
hearing and visual problems
confusion/ drowsiness/ low GCS , amnesia
seizures
decorticate/ decerebrate positioning
cushings triad - high BP, low HR, irregular breathing (late sign)
unequal pupils
what is coup and contra coup injury?
coup injury is bruising at the site of head trauma
contra coup is injury on the opposite site due to transmission of forces.
what is an epidural haemorrhage ?
between skull and dura
often caused by blow to side of head (at pterion) where the skull fracture can rupture middle meningeal artery.
presents with immediate unconsciousness, lucid interval and then slow loss of consciousness. features of raised ICP too.
what is a subdural haemorrhage ?
between dura and arachnoid
caused by lacerations of bridging veins.
most commonly at frontal and parietal lobes.
risk factors include old age, alcoholism, anticoagulation
what is a subarachnoid haemorrhage?
between pia and arachnoid
sudden occipital headache (thunderclap), worst headache ever, neck pain, photophobia, vomiting
can be caused by ruptured cerebral aneurysm
what is monro kellie Doctrine hypothesis?
volume in the brain is fixed and made up of 3 components: brain, blood and CSF. so if any of these increases the others will reduce to compensate until the displacement has reached its maximum and there will be a sharp rise in ICP and brain can herniate.
for example increased brain tissue will result in raise in ICP which will reduce cerebral perfusion to lower ICP. however this can cause brain ischaemia.
what is the cerebral perfusion pressure ? and what happens to MAP if ICP rises?
Mean arterial pressure - ICP
if ICP rises, then MAP needs to increase to maintain cerebral perfusion pressure otherwise brain ischaemia.
When ICP is high enough, MAP cant compensate and cerebral perfusion pressure drops and results in brain ischaemia. what is the physiological response after this?
sympathetic NS stimulation - vasoconstriction to increase resistance and thus HTN. also by increased HR and CO initially.
parasympathetic stimulation: baroreceptors in aortic arch detect the rise in BP and trigger parasympathetic response via the vagus nerve. this leads to bradycardia
raised ICP also puts pressure on brainstem and respiratory centre in medulla oblongata. this results in an irregular respiratory pattern.
overall = cushings reflex = hypertension, bradycardia, irregular respiration .
what causes raised ICP (categorise into blood, brain , CSF)?
blood - haematoma
CSF - hydrocephalus, cerebral oedema, infection
brain - tumour, abscess, infarct and resulting oedema.
what are the NICE indications for a CT head scan within 1 hour ? (adults)
GCS <13 initially after injury GCS <15 - 2 hours after injury post traumatic seizure >1 episode of vomiting neurological deficit suspected open skull fracture or depression signs of basal skull fracture
although not indicated by NICE, may emergency departments consider anticoagulation as an absolute indication for CT scan in context of head trauma.
what are the NICE indications for CT head scan within 8 hours?
loss of conscious/ amnesia + one of following:
- age >65
- dangerous mechanism of injury e.g. motorcyclist
- amnesia retrograde >30 mins
what are the indication for CT scanning of head in under 16s?
known loss of consciousness >5 mins amnesia >5 mins GCS <14 in >1yrs GCS <15 in <1yrs drowsiness
suspected open fracture
signs of basal skull fracture
<1yrs and laceration of >5cm on head or bruising/ swelling
seizure (in non epileptics)
3 or more episodes of vomiting
focal neurological deficit
dangerous mechanism of injury
suspicion of non accidental injury
how is a head injury managed?
A to E
- C spine immobilisation if head injury and GCS <15, neck pain/ tenderness or focal neurology
- intubate if GCS = 8
- avoid hypoxia, low BP (can maintain cerebral perfusion pressure), hypothermia/hyperthermia and hypoglycaemia
treat seizure
treat raised ICP
analgesia (to avoid rise in ICP)
contact neurosurgery if required
wound management
may need Abx and tetanus
frequent neurological observations
discharge advice for patient.
how is raised ICP treated?
elevate head of bed to 30 degrees to promote venous drainage
hyperventilate to keep CO2 low and promote vasoconstriction of cerebral vessels. (not used anymore)
mannitol - 0.5-1mg/kg over 10-15mins
fluid resus - maintain systemic pressure to help MAP and cerebral perfusion.
treat the cause
last resort - Burr holes to relieve pressure.
how often should GCS be recorded post head trauma?
half hourly GCS until GCS is 15, then half hourly for 2 hours, then hourly for 4 hours and then 2 hourly.
what discharge advice would you give someone post head injury?
advised to return if any of the following develop:
- unconsciousness, confusion, drowsiness
- problems with understanding, speaking, balance, weakness
- blurred vision, headache, vomiting
- seizures
- clear straw coloured fluid from nose/ ears
- bleeding from ears.
written and verbal advice should be given
what is the outcome after a head trauma?
death
complete heal after 2 years
ataxia
seizures
speech disorder
tinnitus
CN palsies
personality change - emotional disturbance, irritable
headaches
dizziness, fatigue, depression
poor memory/ concentration
what are the causes of seizures?
genetic - abnormalities in ion channels metabolic space occupying lesion - tumour drugs/ ilicit substance use withdrawal from: Alcohol, benzodiazepine, barbiturates, anti epileptics (ABBA) trauma stroke
what is meant by focal neurological deficit?
signs of impaired neurology that affect one region of the body and thus relate to a specific brain location.
what causes focal neurological deficit?
trauma, tumour, strokes, infections/ abscess, haemorrhage
what focal neurological signs would you see in damage to the:
a) temporal lobe
b) frontal lobe
c) parietal lobe
d) occipital lobe
e) cerebellum
a) emotional and behavioural change, dysphasia
b) personality change (disinhibition), dysphasia (brocas area), anosmia, hemiparesis
c) hemisensory loss, decreased 2 point discrimination, inability to recognise familiar objects, sensory inattention (ignore one side of world)
d) visual loss of one side of vision e.g. left eye temporal loss and right eye nasal loss.
e) DANISH - dysdiadokinesia, ataxia, nystagmus, intention tremor, slurred speech and hypotonia.
what are the characteristics of migraines?
recurrent severe headaches: unilateral and throbbing
associated with: aura, nausea and photosensitivity
aggravated by routine activities of daily living. in women it may be aggravated by menstruation
what are the characteristics of a tension headache?
recurrent, non disabling, bilateral headache, described as a tight band
not aggravated by routine activities of daily living.
what are the characteristics of cluster headaches?
pain typically occurs once - twice a day:
- each episode lasts 15mins to 2 hours
- clusters typically last 4-12 weeks
intense pain around one eye and patient is restless during attack (always affects same eye)
accompanied by: redness, lacrimation, lid swelling
more common in men and smokers.
what are the causes of headaches?
primary - tension, migraine, cluster
secondary - medication overuse, meningitis, encephalitis, subarachnoid haemorrhage, head injury, sinusitis, glaucoma, psychological / anxiety. substance missuse/ withdrawal , metabolic (hypoglycaemia, hypoxia, hypercapnia, CO poisoning)
how would you investigate someone who presents to A+E with a headache?
detailed history - how did it start? worst headache ever? associated symptoms?
examination - rashes? Kernigs sign? papilloedema, neurological examination. palpate sinuses for tenderness.
full set of obs
bloods - rule out metabolic cause (electrolytes, LFTs, glucose), FBC and CRP (infection), if pyrexic (blood cultures)
imaging: CT/ MRI brain - once stable CSF analysis (lumbar puncture)
how do you treat someone who presents with headache
after serious causes are ruled out
analgesia, fluids, IV metoclopramide with IV fluids.
what is the emergency management for meningitis?
cefotaxime 2g IV
if >55yrs add ampicillin to cover listeria
IV dexamethasone
fluids and analgesia
what is the management of a subarachnoid haemorrhage?
A to E
Ix: clotting, FBC, U+Es, CT head, ECG, admit for lumbar puncture (carried out >12 hours after headache onset
use hunt and less scale to grade
analgesia and antiemetic
contact neurosurgery
may require mannitol IV if evidence of raised IC
what is the hunt and hess scale?
scale used for subarachnoid haemorrhage
grade 1 - asymptomatic, mild headache, slight nuchal (neck) rigidity
grade 2 - moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy
grade 3 - drowsiness/confusion, mild focal neurology
grade 4 - stupor, moderate - severe hemiparesis
grade 5 - coma, decerebrate posturing
how is an acute migraine attack managed?
analgesia and antiemetic
may give sumatriptan (contraindicated in ischaemic heart disease)
what does CSF show in:
a) viral meningitis,
b) bacterial meningitis
c) fungal meningitis
d) TB meningitis
a) clear , slightly raised WCC, mainly lymphocytes, pressure slightly raised
b) cloudy/turbid, very high WCC, neutrophils, raised protein, low glucose, high pressure
c) fibrin webs seen, slightly high white cell, mainly lymphocytes , very high pressure.
d) cloudy/viscous, slightly raised WCC, mainly lymphocytes, raised protein, very low glucose, high
note: mumps is unusually associated with low glucose (also herpes too sometimes)
what tests can be done to analyse CSF fluid?
colour, WCC, Red cells, protein, glucose culture and sensitivity PCR for virology acid fast/ zeihl nelson stain xanthochromia - subarachnoid haemorrhage electrophoresis - oligoclonal bands in MS cytology - tumour
what are the clinical features of poisoning?
fast irregular pulse - salbutamol, antimuscarinics, tricyclics, quinine
respiratory depression - opiate, benzos
hypothermia - barbiturates
hyperthermia - amphetamines, MAOIs, cocaine, ecstasy
seizures - recreational drugs, hypoglycaemic agents, tricyclics, theophylline
constricted pupils - opiates, insecticide
dilated pupils - amphetamines, cocaine, quinine, tricyclics
hyperglycaemia - MAOIs, theophylline
hypoglycaemia - insulin, oral hypoglycaemics, alcohol, salicyclates
metabolic acidosis - alcohol, methanol, paracetamol, CO poisoning
renal impairment - salicyclates, paracetamol
high osmolality - alcohol
coma - benzos, alcohol, opiates, tricyclics, barbiturates
how do we manage acute poisoning?
A to E
- consider ventilation if resp rate <8 or GCS <8
- resuscitate any shock / fluids/ catheterise
- if unconscious nurse in semi prone position to protect against aspiration
assess patient to find cause of poisoning:
- history, speak to family
- plasma toxology screen - all unconscious patients should have paracetamol, salicylates and glucose levels checked.
- urine toxology - good for recreational drugs
- glucose, FBC, INR, UEs, LFTs, ABG
- ECG
- monitor vitals
definitive treatment for toxin e.g. activated charcoal, gastric lavage, haemodialysis, antidote
psychiatric assessment
