Evaluation and Management Flashcards

Question

First seizure evaluation and management

Answer 1

Initial response - Establish seizure has stopped - Vitals - >haemodynamic stability - Primary survey - >injuries - Safety - >sit/lie down Hx - Prior - >triggers - >aura - >headache - During - >duration - >awareness - >movements (focality) - >injuries - Post - >hemiparesis/aphasia - >post ictal confusion - Past hx - >previous episodes/medication compliance - >significant comorbidities (neuro/endocrine/metabolic) - Family hx - >seizures/epilepsy - Medications - >pro-seizure - Psychosocial - >work/ADLs - >driving - >drugs and alcohol Exam - alertness and orientation - speech - focal neurological signs - meningism - systems review for infective source - assess for injuries Investigations - Blood glucose - ECG - FBC - VBG - >electrolytes - >acid base - Urea and creatinine - Toxicology screen (if indicated) - bHCG if female (treatment) - MRI brain - >structural lesion - EEG - >relatively low sensitivity - >best within 48hrs - Lumbar puncture - >if infection suspected Management - Admit - >multiple seizures/status - >prolonged confusion/focal features - >positive investigations - Discharge - >normal evaluation - >returned to baseline - >organise follow up/EEG - Safety - >explain risk of recurrence - >teach first aid (provide written information) - >no driving/heavy machinery until cleared by neurologist - >certificate needed to drive - >avoid swimming/bathing alone (cold tap first) - >avoid stress/drugs and alcohol/sleep deprivation - Anticonvulsants - >not usually given if normal evaluation + first seizure

Answer 2

Initial management - Call for help - Attach vitals - ECG + ongoing monitoring - >confirms STEMI diagnosis - >move straight to management - 2x IV canula - O2 - >if <90 (liberal use = increased mortality) - Analgesia - >sublingual nitrates up to 3 sprays - >IV nitrates +/- morphine - Metoprolol oral (consider IV if severe pain) - >consider contraindications Primary survey - Evidence of hypoperfusion - >hypotension - >tachycardia - >altered mental status - >pale, cool, clammy skin - Evidence of heart failure - >JVP elevated - >crackles Hx - Typical pain (OPQRST) - >Onset is gradual - >Precipitated by exercise/Palliated by rest/NO - >Quality is discomfort/crushing/tightness etc - >Radiates to epigastrium/scapula/jaw/throat/arms - >Site is diffuse, should not be able to point with one finger - >Time longer than 20 minutes - Associated symptoms - >most commonly SOB - >palpitations - >nausea/vomiting - >diaphoresis/clamming - >syncope/presyncope - Consider risk factors - Bleeding risk - >past hx - >medications Investigations - High sensitivity troponin - >baseline with repeat within 3 hours - >confirms STEMI/non STEMI if symptomatic with rise/fall with one >99th centile - VBG - >signs of shock or pulmonary oedema - Glucose - >hyper/hypoglycaemia common - FBC - >anaemia (anti-platelet therapy) - Electrolytes and CMP - >arrhythmias - Creatinine/eGFR - >baseline for angiography contrast - >baseline for medications - CXR - >rule out ddx Tests once stable and diagnosis confirmed - Angiography - >everyone high/very high pre-test probability - >identifies culprit artery and % stenosis - Echo - >LV wall motion abnormalities - >decreased LV function - >MI complications - BNP - >contribute to severity score Tests once stable and UA suspected - Stress testing - >low/intermediate pre-test + normal ECG/trops - >post risk score = Duke's treadmill score - Stress echo - >limited availability - Coronary CT angio - >low to intermediate pre-test - >may reduce time to diagnose compared to stress test Further management - Dual anti platelet - >aspirin 300mg oral/dissolved - >clopidegrel 300-600mg - Anticoagulation - >enoxaparin 1mg/kg SC - >give initial 30mg IV bolus then SC if for fibrinolysis - >additional dosing not required for PCI - >use UFH if severe kidney disease (different pathway) - STEMI - >PCI/fibrinolysis - NSTEACs - >CAABG/PCI

Answer 3

Time is brain - Call for help - Concurrent - >Vitals - >Primary survey - >Targeted/collateral history - >Beside investigations - Empiric management Vitals - Cushings reflex - >HTN/tachycardia/cheynes stokes - Fever - Pulse ox Primary survey - A - >loss of protection - B - >loss of respiratory drive (brainstem involvement) - >hypoventilation/hypercapnoea = vasodilation + high ICP - >risk of aspiration (wheeze/crackles) - C - >AF - >palpate/auscultate carotid - D - >serial GCS - >NIHSS score - E - >signs of anticoagulation - >signs of peripheral vascular disease - >head trauma - F - >gain IV access - >insert catheter - G - >hypoglycaemia as ddx - >secondary hyperglycaemia worsens outcome Hx - PC - >details of presentation (before/during/after) - >determine time last seen well - >acute or gradual onset of symptoms - >nausea/vomiting/neck stiffness/LOC - Trigger - >preceding illness - >palpitations - >aura - >trauma - >seizure activity - Past - >strokes/MI - >CVD risk factors - Thrombolysis contraindications - >recent bleeds - >recent surgery - >active malignancy - >anticoagulation - >coagulopathy - Medications - Social - >level of functioning Investigations - ECG - >AF - >demand ischaemia - VBG - >glucose - >electrolytes - >lactate - FBC - >platelets - EUCs - Coags - CT non con - >haemorrhagic/ischaemia/intracerebral lesion - CT perfusion - >estimate penumbra - CT angio (intracranial + aortic arch) - >ischaemic = thrombus - >haemorrhagic = aneurysms/vascular malformations Management - Secure airway + support breathing - >supplement O2 if <94 (not higher) - Position - >avoid cervical collars - >flat for ischaemia/45 degrees if aspirating - Keep NBM until swallowing assessed - IV access - >fluid resuss and maintenance - >avoid hypotonic solutions - HTN - >management determined by aetiology - >haemorrhagic = labetolol - >ischaemic = avoid lowering - Fever - >1g paracetamol may improve outcome - Transfer to stroke unit - >improves outcome - VTE prophylaxis - >cause of 10% mortality - Haemorrhagic specific - >consider anti-coagulant reversal - >monitor ICP - >haematoma excavation/craniotomy for some - Ischaemic specific - >endovascular intervention if within 6hrs - >thrombolysis if within 4.5hrs (aim for <1hr) - >consent (5% haemorrhage -> 50% are fatal) - >consider severity/goal of treatment/likely improvement - >aspirin 300mg daily after thrombolysis

Answer 4

Issues - Cause or result of fall - Hypovolaemic - >dehydration - >haemorrhage - Orthostasis - >HAND Initial response - Vitals - >haemodynamically stable - >fever - Primary survey - >evidence of shock - >evidence of trauma or infection Hx - Details of fall - >force and mechanism - >injuries/LOC - >length of lie - Typical orthostasis symptoms - >dizziness - >weakness - >dimming of vision - Typical orthostasis timing - >early morning - >prolonged standing - >after exercise - >heat - >large meal - Atypical - >occurs while seated - >not relieved by sitting/lying down - Neuropathy - >pain/burning/tingling/loss of sensation - Exclude cardiac - >palpitations - >chest pain - Past - >falls - >neuro (parkinsons) - >dementia (lewy body) - >diabetes - Medication review - Social - >alcohol - >home setup - >carer/carers Exam - Postural BP - >SBP <20, DBP <10 - Autonomic failure - >HR increase <20 - Pulse - >absent sinus arrhythmia - Volume status - Gait - Peripheral neuro exam - >power/sensation/proprioception - Cardiac - >murmurs Investigations - ECG - Glucose - FBC - >anaemia - EUC - >electrolytes - >dehydration Management - Admit - >geriatrician/neurology consult - >work up for autonomic dysfunction - Review medications - >reduce dose/cease where possible - >consider alternative anti-HTN - Advise - >sit before standing - >no straining on toilet/valsava while exercising - >may need to treat constipation - >eat smaller, more frequent meals - >toe standing/crossing legs/muscle tensing - Non pharm - >stockings to increase venous return - >increase salt supplementation - >2L water per day - Pharm - >fludocortisone (mineralocorticoid) - >midodrine (alpha 1 agonist) - >pyridostigmine (AcH inhibitor) - >droxidopa (noadrenaline pro-drug for neurogenic)

Answer 5

Immediate response - Call for help - Remove allergen - Lay flat - Attach vitals - >haemodynamically stable - >febrile - Prepare IM adrenaline - Collapsed - >assess pulse and breathing - >ALS pathway Primary survey - A - >evidence of obstruction - >examine lips, tongue, pharynx - >angio-odema/stridor/change in voice - B - >wheeze in lower obstruction - >O2 sats - C - >evidence of shock - D - >serial GCS - E - >rashes - >stings - F - >gain 2x IV access - >insert catheter - G - >glucose Management - Airway - >support with adjuncts - >low threshold for intubation - Breathing - >high flow O2 on hudson/non-rebreather - >upper obstruction = nebulised adrenaline - >lower obstruction = nebulised salbutamol - Circulation - >IM adrenaline 10mcg/kg (up to 0.5mg) - >500mL fluid boluses as fast as possible - Resistant to treatment - >transfer to ICU - >adrenaline infusion - Post acute consider - >diphenhydramine IV/cetirizine oral (itch) - >methylprednisone IV/prednisone oral (biphasic) - Observation - >at least 4 hours - >longer if severe/hx of biphasic/risk factors of fatal - >consider remote or isolated - >biphasic reaction in 5% (higher in kids) up to 3 days later - Safety net - >recurrence in 20% - >patient education - >provide anaphylaxis action plan (ASCIA) - Allergen avoidance - Follow up with immunologist - Epinephrine - >prescribe 2x auto injectors - >urge patient to fill immediately - >education on proper use

Answer 6

Initial response - Sit/lie patient down - Attach vitals - >haemodynamically stable - >febrile - Primary survey - >signs of shock - >arrest - Initial investigations - >ECG - >VBG (electrolytes + glucose) Hx - PC - >abrupt or slow onset/offset - >palpitation/dyspnoea/dizziness/chest tightness - Red flags - >angina - >syncope - Associated symptoms - >fever/flu like = sinus tachy/atrial tachy/AF - >substance use = sinus tachy/atrial tachy/AF - >bounding in neck = AVNRT/AVRT - Past - >paroxysmal episodes = AVNRT/AVRT - >congenital heart/IHD/valvular disease - >stroke - >thyroid - Family - >cardiomyopathy - >long QT - Medications - >anti-arrhythmics - >anti-depressants - Social - >caffeine + energy drinks - >alcohol + drugs - >stress + anxiety Exam - Pulse - >regular - >irregular - Assess volume status - Thyroid - JVP - >raised - >cannon waves - Full cardiovascular exam - >usually unremarkable - >murmurs = valulvar disease - >HF = acute decompensation/cardiomyopathy Investigations - ECG - >AF = no p waves/irregular ventricular rate - >flutter = regular sawtooth waves in II,III,aVF/300:150 rate - >atrial tachy = abnormal P wave/inverted in II,III,aVF - >AVNRT = no P wave or inverted in II,III,aVF - >AVRT = delta wave/variable QRS/discordant T wave - >monomorphic VT = regular wide QRS - >polymorphic VT = QRS variable heigh +- long QT (torsades) - FBC - >anaemia - CMP - TSH - Consider - >trops - >tox screen - >drug levels Management - Unstable - >IV sedation - >synchronised DC cardioversion - >IV amiodarone - Stable narrow - >attempt carotid massage or valsalva - >resolves AVNRT/AVRT but not flutter/atrial tachy - Adenosine - >give to any regular SVT - >avoid in irregular (AF with aberrant tract = VF) - >resolution AVNRT/AVRT - >unmask atrial tachyarrhythmia - >requires saline flush (rapid half life) - Definitive - >AVNRT = catheter ablation of alpha pathway - >AVRT = catheter ablation of accessory pathway - Monitoring - >holter monitor for frequent - >wearable loop for infrequent - >inserted loop for infrequent + unstable - Consider - >Echo for structural lesion - >Exercise for provoked VT - >EPS for wide QRS - AF/Flutter - >beta blocker + flecanide - >amiodarone - Atrial tachycardia - >beta blocker or CCB - Monomorphic VT - >amiodarone - Polymorphic VT - >beta blocker - Torsades - >mag sulfate

Answer 7

Unstable - Red flags on vitals - >hypotension - >tachycardia - >low sats - A - >jaw thrust/chin lift - B - >respiratory distress - >ipsilateral reduced breath sounds/chest expansion - >hyper-resonance - >tracheal deviation to contralateral - C - >evidence of shock - D - >altered mental status - E - >evidence of trauma to ribs - Empirical management - >call for help - >high flow O2 - >needle aspirate second interspace mid clavicular - >ultrasound at bedside Stable - Targeted hx - Investigations - Management Hx - PC - >onset and evolution - >trauma - DDx - >angina - >cough/haemoptysis - >stings/bites/food - >foreign body - Past - >lung disease (COPD/asthma/cystic fibrosis) - >VTE and risk factors - >heart disease and risk factors Investigations - VBG - >hypoxia - >respiratory alkalosis - FBC - >platelets for drain - Coags - >for drain - CXR - >visceral pleural line - >large = visible rim >2cm - >small visible rim <2cm - Unstable - >US - CT - >still symptomatic with negative CXR Management - Analgesia - Give O2 if required - Primary with small visible rim - >consider discharge - >follow up in 2 weeks - Primary with large visible rim - >aspirate 2.5L using canula - >repeat CXR - >now small = consider discharge - >still large = insert chest drain + admit - Secondary with large visible rim - >insert chest drain + admit - Secondary with visible rim <1cm - >high flow O2 + admit/observe 24hrs - Secondary with visible rim 1-2cm - >aspirate 2.5L using canula - >repeat CXR - >now <1cm = high flow O2 + admit/observe 24hrs

Evaluation and Management Flashcards

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