Emergency

Question 1

Causes of delayed awakening after intracranial surgery

Answer 1

Brain injury
* Intracranial haemorrhage
* Stroke
* Cerebral oedema
* Hydrocephalus
* Pneumocephalus
* Seizures
Medication
* Sedatives, analgesics, NM blockers
* Anticonvulsants
Systemic
* Hypothermia
* Respiratory (hypoxia, hypercapnia)
* CV (hypotension, shock)
* Metabolic/endocrine (hypo/hyperNa+, glucose, panhypopituitarism, adrenal insufficiency, hypothyroid)
* Renal/hepatic failure
* Sepsis

Question 2

Focused examination in a patient with delayed awakening after intracranial surgery

Answer 2

Lvl. consciousness
* Arousability
* Motor responses
* Verbal output
Eyes
* Movements
* Pupillary light reflexes
Respiratory
* ABC
* Breathing patterns

Question 3

Levels of consciousness

Answer 3

Awake/alert
Lethargic (easily aroused to wakefulness)
Obtunded (aroused with stim, likely lapse back wo/ verbal/light tactile stim)
Stuporous (aroused by vigorous and repeated stim, lapse as soon as stim withdrawn)
Comatose (total absence of awareness)

Question 4

Pupils in comatose patients

Answer 4

Small reactive - metabolic, diencephalic
Large fixed, hippus - tectal
Pinpoint - pons
Midposition, fixed - midbrain

Question 5

Risk factors for spinal epidural hematoma

Answer 5

Multilevel laminectomies
Preop coagulopathies and vascular anomalies
Preop NSAID use
Intraop blood loss >1L
Age >60
Rh+
Intraop Hb < 10g/dL
INR>2 within the first 48hrs postop