Neurological Flashcards

1
Q

Which challenging behaviour patients may be given IM droperidol without consult?

A

Without consult: patients who are all of
* 16-64yrs
* Uncooperative with oral medication
* SAT score >=+2
* non-medical cause of challenging behaviour

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2
Q

In which challenging behaviour patients should EOC consult be sought?

A

Patients for who droperidol is contraindicated / ineffective, i.e.
* >=65yrs, or
* SAT>=+2 from likely medical cause.

EOC clinician may consult MO or advise
* IM/IV midazolam
* IM droperidol

IM droperidol not indicated for pts < 16yrs for paramedics; consult anyway.

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3
Q

What dose of droperidol may be given for acute behavioural emergencies?

A

5-10mg, repeat after 15min if SAT score still >=+2.
Max dose droperidol + olanzapine is 20mg in 24hrs.

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4
Q

What are the contraindications for droperidol?

A

Relative: age < 16 or > 64yrs (consult)
Absolute:
* Hx of neuroleptic malignant syndrome
* Parkinsons
* Pregnancy
* Phaeochromocytoma
* Long QT syndrome (challenging behaviour only; ok as an anti-emetic as lower dose unlikely to prolong QT interval)

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5
Q

What are the components of the Mental State Examination?

A
  • Appearance
  • Behaviour
  • Conversation
  • Mood / Affect
  • Perception
  • Cognition
  • Insight
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6
Q

What monitoring should be performed after procedural sedation?

A

Nasal capnography (for RR, not EtCO2)
Regular vital signs
Continuous ECG

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7
Q

What is the guideline for dealing with escalation of a mental health patient during inter-facility transport?

A

If SAT score increases to +2 during transport:
* De-escalate, if unsuccessful
* Consult EOC clinician for sedation consistent with previous management

If EOC clinician unavailable:
* IM droperidol 5-10mg (5 mg will be adequate in most patients)
* Repeat after 15 mins if SAT still ≥ +2
* Total max dose 20 mg in 24 hours

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8
Q

When should clinical support be considered in seizure patients?

A

Consider clinical support (e.g. ICP or MedSTAR) if:
* Specific cause of seizure e.g. TBI
* Prolonged transport time
* Generalized seizure if 2nd dose of midazolam administered

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9
Q

When is midazolam indicated in seizures; what is the dose, dose interval, and max dose?

A

Midazolam is first-line pharmacotherapy for generalised seizures when there is risk of physical injury, hypoxia or aspiration

Indicated for generalized seizure > 5min (continuous or repetitive seizures without regaining consciousness).
Dose = 100mcg/kg, repeat after 5min if ineffective, max dose 200mcg/kg.

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10
Q

When should clinical support / EOC clinician be called for seizure patients?

A

Clinical support if second dose of midazolam given (ICPs can give levetiracetam).
Consult EOC clinician if second dose of midazolam ineffective

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11
Q

Do seizure patients need to be transported if seizure resolves?

A

Not if their seizure management plan indicates otherwise

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12
Q

When should the Arm Chat Tap assessment be used?

A

Patients with a positive Rosier score

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13
Q

When should Code Stroke be activated in patients with positive Rosier and negative ACT?

A

Activate code stroke and transport to CSU/STS for thrombolysis consideration if
* independent premorbid functioning and
* < 4 hrs symptom onset to arrival at closest available CSU/STS and
* < 60 mins travel time

If > 60 mins travel time, consult EOC clinician who may advise:
* transport direct to CSU/STS (Code Stroke activation)
* RV enroute to CSU/STS
* transport to alternate destination e.g. country ED

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14
Q

When should Code Stroke be activated in patients with positive Rosier and positive ACT?

A

Activate Code Stroke if:
* independent premorbid functioning and
* < 24 hrs symptom onset to arrival at RAH and
* < 60 mins travel time to RAH

Transport aim is the Royal Adelaide Hospital (RAH) for eligible LVO stroke patients

If all criteria met but > 60 mins travel time to RAH, consult EOC clinician who may advise:
* transport direct to RAH (Code Stroke activation)
* transport and RV enroute to RAH
* alternate destination (CSU/STS preferred) and retrieval

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15
Q

What is the procedure for code stroke notification / transport?

A

Confirm:
* patient identification details
* telephone contact details of patient’s substitute decision maker or close relative or carer

Notify ‘Code Stroke’ to CSU/STS stroke coordinator via SAAS Code Notification Line using ISBAR including confirmation of:
* Code Stroke eligibility criteria
* ETA

If SAAS Code Notification Line unanswered or where local procedure directs, request SAGRN notification to receiving hospital ED

Treatment: provided no delay in transport time, consider:
* 18 g IV access each arm
* 12 lead ECG

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16
Q

What is the procedure for suspected stroke patients where Code Stroke criteria are not met?

A

If stroke is clinically suspected and:
* > 24 hrs symptom onset, and/or
* ROSIER positive and ACT negative > 4 hours and/or
* diminished pre-morbid independent living:

Transport to closest CSU/STS (preferred) or
ED (in country area)

17
Q

What are the components of the ROSIER assessment?

A

LOC or syncope (-1)
Any seizure activity (-1)

Is there new acute (< 24hrs) onset of
Asymmetric face weakness (+1)
Asymmetric arm weakness (+1)
Asymmetric leg weakness (+1)
Speech disturbance (+1)
Visual field deficit (+1)

Also assess for pre-morbid independence and BGL (if < 3.5 treat and re-assess)

18
Q

What are the components of the ACT assessment?

A

Arm - single arm drops within 10 sec

If right arm weakness -> Chat
* any language deficit (not just slurring, but mute, gibberish, incomprehensible)

If left arm weakness -> Tap
* Obvious gaze deviation of both eyes away from weak side or failure to turn to weak side when tapped

ACT positive if unilateral arm weakness and Tap/Chat +ve
ACT negative if no weakness both arms

19
Q

In the ACT assessment, what are we looking for when assessing Tap?

A

If left arm weakness -> Tap
* Obvious gaze deviation of both eyes away from weak side or failure to turn to weak side when tapped

20
Q

In the ACT assessment, how do we assess arm weakness?

A

Arms outstretched - positive if single arm drops within 10 sec

21
Q

In the ACT assessment, what are we looking for when assessing Chat?

A

If right arm weakness -> Chat
* any language deficit (not just slurring, but mute, gibberish, incomprehensible)

22
Q

What treatment should be provided to patients with suspected stroke?

A

ROSIER and ACT assessments
BGL
Code stroke notification

Consider (provided no transport delay)
* 2 x 18G access
* 12 lead ECG

23
Q

What screening tool do we use to assess delirium (i.e. acute confusion)?

A

The 4AT assessment

24
Q

What are the components of the 4AT screening tool?

A
  1. Alertness
  2. AMT (age, DOB, present address and year)
  3. Attention (recite months of year backwards)
  4. Acute change or fluctuating course (significant change in alertness/cognition over last 2 weeks and evident in last 24hrs)
25
Q

In which patients should we suspect a medical cause for acute behavoural disturbance?

A

If the symptoms are
* newly onset at age ≥ 45
* abnormal vital signs
* disorientation / LOC
then it is reasonable to suspect that the challenging behaviour is related to a medical disorder

26
Q

What are the contraindications for droperidol?

A

Contraindications
* Hx of neuroleptic malignant syndrome
* Parkinsons disease
* Pregnancy
* Phaeochromocytoma (hormone secreting tumour of adrenals)

Relative: pts with long QT syndrome (anti-emetic doses unlikely to affect QT)

27
Q

What are the adverse effects of droperidol?

A

Significant adverse effects include
* Hypotension
* Respiratory depression
* Extrapyramidal effects (dystonias including torticollis, trismus, and oculogyric crisis)

28
Q

What are the indications for midazolam?

A
  • Prolonged / repeated seizures (IM)
  • Mental health transfer with SAT>=2 (IM/IV) (Consult)
  • CPR induced consciousness (IV/IO)
29
Q

What is the midazolam dose for a patient with prolonged/repeated seizures?
What is the dosage interval?
How many doses may be given?

A

100microg/kg up to 10mg
Repeat once after 5min

If seizure not controlled following 2 doses of midazolam, levetiracetam (ICP only) is recommended

30
Q

What are the contraindications for olanzapine (x2)?

A

Parkinsons disease
Hx of Neuroleptic Malignant Syndrome

31
Q

What are the potential adverse effects of olanzapine (x4)?

A
  • Hypotension
  • Respiratory depression
  • ECG changes
  • Extrapyramidal events (dystonias including torticollis, trismus, and oculogyric crisis)
32
Q

What age patients can be given olanzapine without consult? With consult?

A

Without consult: 16-64yrs
With consult: 8-15yrs and >=65yrs