Neurological Flashcards
Which challenging behaviour patients may be given IM droperidol without consult?
Without consult: patients who are all of
* 16-64yrs
* Uncooperative with oral medication
* SAT score >=+2
* non-medical cause of challenging behaviour
In which challenging behaviour patients should EOC consult be sought?
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.
What dose of droperidol may be given for acute behavioural emergencies?
5-10mg, repeat after 15min if SAT score still >=+2.
Max dose droperidol + olanzapine is 20mg in 24hrs.
What are the contraindications for droperidol?
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)
What are the components of the Mental State Examination?
- Appearance
- Behaviour
- Conversation
- Mood / Affect
- Perception
- Cognition
- Insight
What monitoring should be performed after procedural sedation?
Nasal capnography (for RR, not EtCO2)
Regular vital signs
Continuous ECG
What is the guideline for dealing with escalation of a mental health patient during inter-facility transport?
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
When should clinical support be considered in seizure patients?
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
When is midazolam indicated in seizures; what is the dose, dose interval, and max dose?
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.
When should clinical support / EOC clinician be called for seizure patients?
Clinical support if second dose of midazolam given (ICPs can give levetiracetam).
Consult EOC clinician if second dose of midazolam ineffective
Do seizure patients need to be transported if seizure resolves?
Not if their seizure management plan indicates otherwise
When should the Arm Chat Tap assessment be used?
Patients with a positive Rosier score
When should Code Stroke be activated in patients with positive Rosier and negative ACT?
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
When should Code Stroke be activated in patients with positive Rosier and positive ACT?
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
What is the procedure for code stroke notification / transport?
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
What is the procedure for suspected stroke patients where Code Stroke criteria are not met?
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)
What are the components of the ROSIER assessment?
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)
What are the components of the ACT assessment?
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
In the ACT assessment, what are we looking for when assessing Tap?
If left arm weakness -> Tap
* Obvious gaze deviation of both eyes away from weak side or failure to turn to weak side when tapped
In the ACT assessment, how do we assess arm weakness?
Arms outstretched - positive if single arm drops within 10 sec
In the ACT assessment, what are we looking for when assessing Chat?
If right arm weakness -> Chat
* any language deficit (not just slurring, but mute, gibberish, incomprehensible)
What treatment should be provided to patients with suspected stroke?
ROSIER and ACT assessments
BGL
Code stroke notification
Consider (provided no transport delay)
* 2 x 18G access
* 12 lead ECG
What screening tool do we use to assess delirium (i.e. acute confusion)?
The 4AT assessment
What are the components of the 4AT screening tool?
- Alertness
- AMT (age, DOB, present address and year)
- Attention (recite months of year backwards)
- Acute change or fluctuating course (significant change in alertness/cognition over last 2 weeks and evident in last 24hrs)
