Pt w/ Collapse (including WARFARIN reversal)

Question 1

List some important question to ask in the history of a patient presenting with collapse

Answer 1

BEFORE
How did they feel
- Palpitations, dizzy, chest pain, breathlessness, headache, nausea, pale and clammy, weakness
Any triggers 
-last time they ate or drank?
-any illegal drugs or alcohol
DURING THE COLLAPSE
- do they remember falling or did they black out before 
- did they hit their head 
- did anyone else see (collateral hx)
- did they seize/shake/twitch 
- how long were they unconscious for?
- did they bite their tongue?
- were they incontinent or urine or faeces
AFTER
- How did they feel after (sleepy, sick)
- How do they feel now?
- Any ongoing chest pain or breathlessness

Question 2

When do symptoms of alcohol withdrawal commonly occur?

When will they peak?

Answer 2

Start around 6-8 hours

Peak around 10-30 hours and then will start to subside

Question 3

What are some features of alcohol withdrawal? (signs and symptoms)

Answer 3

Symptoms of alcohol withdrawal

• anxiety
• headache
• sweating
• fever
• restlessness/tremor
• nausea and vomiting
• seizures (within 24-48 hours)
• visual and auditory hallucinations
• problems sleeping

Signs

• tachycardia
• hypertension
• hypereflexia
• fever

Question 4

What is delirium tremens?
When does it occur?
Why is it important?

Answer 4

DELIRIUM TREMENS

• most severe form of alcohol withdrawal
• usually occur 2-3 days after alcohol withdrawal. Will also last 2-3 days
• important as can lead to death

PHYSICAL SIGNS:

• GLOBAL CONFUSION
• agitation
• fever
• seizures
• hallucinations
• sweating
• AUTONOMIC HYPERACTIVITY (increased BP and HR)

Question 5

What investigations are important in someone with alcohol withdrawal?

Answer 5

Investigationsalcohol withdrawal
Bloods: FBC, U&E, glucose, THIAMINE
ECG
ABG - for metabolic acidosis (can cause alcoholic ketosis)

Question 6

Initial management for alcohol withdrawal

Treatment for delirium tremens?

Answer 6

• the benzodiazepine CHLORDIAZEPOXIDE (10-30mg) is very useful in the treatment of alcohol withdrawal
• PABRINEX Is a thiamine-corrective solution that should also be given
• Atenolol or propanol for hypertension
• Carbamazepine for seizures

-ORAL LORAZAPAM if DELERIUM TREMENS (agitation, confusion, paranoia, and visual and auditory hallucinations)

Question 7

What is a common cardiac causes of collapse?

Explain what it is

Answer 7

COMPLETE HEART BLOCK

• incomplete/ lack of conduction between the SAN and the AVN
• heart cant beat properly>cardiac output drops
• complete (or third degree is the most likely to cause collapse)

Question 8

Why might there still be heart beat in someone with complete heart block? How will this appear on ECG

Answer 8

Sometimes there is some accessory pacemaker tissue that generates and conducts a signal - known as an ESCAPE RHYTHM

• will cause NARROW QRS COMPLEXES

Question 9

What are some others signs of complete heart block?

Answer 9

Complete heart block

• COLLAPSE
• Haemodynamic instability (hypotension and bradycardia)

Question 10

Whats the most common cause of complete heart block?

Answer 10

CORONARY ISCHAEMIA

INFERIOR WALL MI are the ones that are most likely to disturb the AVN and therefore ruin conduction and lead to heart block

Question 11

What are some relevant investigations for patients with heart block and what might you find?

Answer 11

Investigations heart block
Bloods: FBC, U&E (hypotension), Troponin

ECG:
-strange relationship between p waves +QRS complexes
1st degree: prolonged PR int. -bigger than 3-5 s. squares (0.12-0.20)
2nd degree type 1/wenkeback: increasing then drop QRS
2nd degree type 2: fine, then drop QRS (ratio 2:1 or 3:1)
3rd degree: atria + ventricles indépendant

Also look for LBBB as evidence of old MI

Question 12

Management of complete heart block?

Answer 12

Management

• Identify causes where possible
• Refer for pacemaker if idiopathic CHB

Question 13

How does DKA typically present?

Answer 13

ALWAYS CONSIDER THIS IS THE COLLAPSED YOUNG PERSON
Can present in a large variety of ways that can be quite non specific (think about that boy in Bradford)

GI: nausea and vomiting, abdominal pain
Resp: Kussmauls breathing to blow off CO2 from met acid
-thirst (polydipsia) 
-going toilet more (polyuria) 
-sweet smelling breath 
-confusion 
-recent weight loss and fatigue 
-dehydration (decreased skin turgor, dry membranes increased CRT)
-shock: hypotension and tachycardia

Question 14

Causes of DKA (explanation of symptoms)

Mechanism of DKA?

Answer 14

Causes

• undiagnosed diabetes in young person
• insufficient insulin (not enough/not taking)
• infection or illness

Mechanism

• Without insulin glucose is not drawn into cells
• glucagon is produced
• a) glycogenolysis b)gluconeogenesis (fatty acids>ketones)
• very high levels of plasma glucose leads to diuretic osmosis and water and sodium are drawn OUT OF CELLS leading to the polyuria and polydipsia

Question 15

Initial management of DKA

Answer 15

If the patient has altered mental state consider airway preservation and breathing support etc.

1. FLUIDS IMPORTANT - 0.9% NaCl IV infusion over 1 Hr (next over 2 hrs, next over 2 hours, next over 4 hours)
2. INSULIN INFUSION pump at 0.1 units/kg/hr
3. POTASSIUM CORRECTION (insulin drives K into cells)
   - Consider monitoring urine output (?catheter)
4. DEXTROSE

Question 16

What condition occurs when blood glucose is high but there isn’t a considerable ketoacidosis?

Answer 16

HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)

Question 17

What are some clinical features of HHS?

Answer 17

HHS

• Blood glucose >11.1mmol/L
• LACK of urinary ketones
• Increased blood osmolality leading to sx of polydipsia and polyuria
• Weight loss and fatigue
• Dehydration
• Weakness
• Leg cramps
• Vision problems
• Itchy skin
• Poor kidney function
• Altered consciousness

Question 18

What causes HHS?

Answer 18

• Can just happen with inter-current illness
• Can happen in someone who had diabetes that is poorly controlled
• Can occur in dehydration

Question 19

What investigations are relevant in HHS?

Answer 19

HHS investigations

• Blood glucose
• FBC, U+Es (can effect renal function), CRP (to look for infection)
• ECG
• CXR (to look for infection)

Question 20

What is the management of HHS?

Answer 20

VERY SIMILAR TO DKA

• Insulin infusion 0.1U/kg/hr
• Monitor potassium
• Keep hydrated with salt boosts - NaCl 0.9%

Question 21

What is classed as high blood glucose and what are some general symptoms?

Answer 21

BM >11.1mmmol
Classic triad of sx: polyphagia, polyuria and polydipsia

Sx of CHRONIC POOR GLUCOSE CONTROL:
- ED, blurred vision, poor kidney function, weight loss, restlessness, fatigue, poor wound healing, dry mouth, itchy skin

Question 22

What factors in the history are important to ascertain in someone presenting with seizures?

Answer 22

BEFORE
- any aura (visual, auditory, gustatory, olfactory, tactile), -headaches, feeling unwell - familiar to pt?
DURING
- were the jerking/twitching (tonic clonic)
-were they unconscious/how long for,?
-did they bite their tongue
-were they incontinent?
AFTER
- are they sleep/confused/drowsy and how long for
- Do they have headache

Question 23

Explain partial seizures

Answer 23

PARTIAL

• SIMPLE PARTIAL - they are aware. focal motor and sensory /autonomic symptoms
• COMPLEX PARTIAL
• awareness is impaired. Usually temporal lobe. Post-ictal confusion is common but fast to resolve
• parietal=strange feelings
• PARTIAL WITH 2RY GENERALISATION - seizure starts with focal motor or sensory deficits and then will become convulsions (2/3 of pt with partial seizures)

Question 24

Explain generalised seizures

Answer 24

GENERALISED

• ABSENCE SEIZURES: more common in children - unresponsive for several seconds
• TONIC-CLONIC SEIZURES: classical jerking seizures, pt will collapse. Post ictal period is considerable with dizziness and confusion
• MYOCLONIC - sudden jerking of a limb or trunk may cause patient to fall to ground
• ATONIC SEIZURES - pt goes completely floppy

Question 25

What is status epileptics? Management of status epileptics?

Answer 25

Status epileptics >5 mins OR 3+ seizures in 1 hour Management status epileptics - ABCDEG approach and call senior (maintain airway-nasopharyngeal airway) - Recovery position  - Start timing - Oxygen 15L/non-rebreathe mask - Check GLUCOSE – if <3.5 → 100ml of 20% glucose STAT    CALL FOR HELP!!! STEP 1 AT 5 MINS -IV lorazepam 0.1mg/kg (max 4mg) STEP 2 REPEAT AFTER 10 MINS STEP 3 AT 20 MINS - IV Phenytoin loading dose (20mg/kg max dose 2g) - If they already take phenytoin give IV phenobarbital infusion - use separate IV line STEP 4 INTUBATE (ICU and rapid sequence induction) - Thiopentone or propofol on ICU/HDU - Transfer to ICU

Question 26

Status Epilipticus What do you do if you cannot get IV ? What should you give if alcoholism suspected?

Answer 26

NO IV ACCESS IN STATUS EPILIPTICUS -buccal midazolam or rectal diazepam   *In an alcohol related seizure, give 200mg IV pabrinex(thiamine) 2 PAIRS IV

Question 27

What are the brain 2 initial blood supplies and what do these feed into? - Where are strokes more common?

Answer 27

``` Internal carotids (supply the anterior and middle cerebral arteries) Basilar arteries (supply the posterior cerebral arteries) ``` - Strokes more common in the anterior circulation

Question 28

What are the two main types of stroke and what are the proportions of their occurrence?

Answer 28

Ischaemia (80-85%) and haemorrhage (15-20%)

Question 29

What are the symptoms of anterior circulation stroke?

Answer 29

- Unilateral weakness (limb and facial droop) - Difficult speaking - Numbness and loss of sensation - Cognitive impairment

Question 30

What are some symptoms of posterior circulation strokes?

Answer 30

Posterior stroke symptoms Same plus: -vertigo/dizzyness -nausea CEREBELLAR SYMPTOMS (DANISH) - Dysdiadokinesia - Ataxia (Rombergs sign-close eyes lose balance) - Nystagmus (H test) - Intention tremor (nose to finger) - Slurred staccato speech - Hypotonia

Question 31

Causes of stroke / TIA

Answer 31

- Most common is atherosclerotic plaque aetiology - Haemorrhage: aneurysm rupture, SAH,HTN - Carotid artery dissection (most common cause of ischimic stroke in young people) - Cerebral embolism (from AF, endocarditis, MI)

Question 32

Investigations for stroke/TIA

Answer 32

ABCDEG assessment (CHECK GLUCOSE) FAST screen ROSIER to confirm stroke diagnosis URGENT CT WITHIN 1 HOUR

Question 33

Initial management of ischemic stroke

Answer 33

IF WITHIN 4.5 HOURS - Give ALTEPLASE thrombolysis once haemorrhage is excluded by CT (ischemia will look dark on CT). (0.9mg/kg max 90mg, 10% as a bolus) - Control BP (<180/110) - do CT 24 hours after to look for bleeds - Then give 300mg aspirin within 24 hours IF AFTER 4.5 HOURS - Give aspirin 300mg for 2 weeks - May need thrombectomy if within 6 hours - FIND CAUSE: carotid USS, echo and angiogram (might need thrombectomy if PCA and within 24 hours) - TREAT COMPLICATIONS (aspiration pneumonia-chest X ray) - ADMIT to stroke ward- NBM

Question 34

What are some symptoms of SAH? What is a really important thing to examine for in SAH presentation

Answer 34

THUNDERCLAP HEADACHE - collapse LOC - vomiting - neck stiffness (kernings sign) - photophobia - dizzyness and confusion - fits - EXAMINE FOR THIRD NERVE PALSY (down and out) posterior communicating artery aneurysm

Question 35

What is the cause of SAH?

Answer 35

Most commonly is ruptured berry aneurysm on the circle of willis - ask about FH because these are familial (also polycystic kidney disease)

Question 36

What investigations are important in SAH

Answer 36

Investigations SAH - ABCDEG assessment - OBSERVATIONS (raised ICP can cause Cushings triad (hypertension, bradycardia and irregular breathing) - CRANIAL NERVE EXAM (CN3 palsy) - URGENT CT head within 6 hours - starfish shaped hyperdensity  - ECG - LP - if CT head NEGETIVE but history is suggestive, yellow CSF due to bilirubin xanthochromia (wait 12 hours) - ANGIOGRAPHY - to identify aneurysms   - Do HUNT AND HESS score to asses severity

Question 37

Specific management of SAH

Answer 37

1. Analgesia and anti-emetic (codeine) 2. If there are evidence of ICP increase can give MANNITOL 200mL 10% 3. Prevent vasospasm - calcium channel blockers - NIMODIPINE 4. Prevent rebleeding - REFER to NEUROSURGERY (clipping and coiling (form clot to stop)

Question 38

What is mannitol?

Answer 38

-osmotic diuretic that forces protein out of the blood causes a drop in pressure - it temporarily decreases ICP until more definitive measures can be found

Question 39

What is the typical history of a VASOVAGAL SYNCOPE?

Answer 39

- Sudden, transient loss of consciousness/collapse <2 mins with a quick recovery - Other vasovagal symptoms such as sweating, flushing, paler, dizziness, feeling sick and visual/ hearing changes

Question 40

Causes of vasovagal syncope? | Whats a syndrome that can cause transient arrythmias and syncope?

Answer 40

- Due to neurological increase in vagal tone which causes a drop in BP (bradiacardia and vasodilation) and hence collapse - Provoked by emotion, pain, standing for too long, overwarm environment - Can often happen in a situation - situation syncope, cough, exercise or urination   - Stokes Adams syndrome - transient arrhythmias lead to decreased CO and LOC 

Question 41

Important investigations in someone with vasovagal syncope

Answer 41

Lying and standing BP (low BP can be a cause) - Rule out other causes: ECG and Bloods: - Blood glucose - FBC, U+Es

Question 42

Contraindications for Alteplase?

Answer 42

Contraindications for Alteplase ABSOLUTE •Current or previous haemorrhage  •Neurosurgery/head trauma/stroke last 3 months • Systolic BP >185 (treat with labetalol) • Aneurysm or intracranial cancer • Known clotting disorder (inc anticoagulants or INR>1.7 • Hypo or hyperglycaemic (<3 or >22)  ``` RELATIVE •Rapidly improving/minor symptoms •Recent surgery or non head trauma (2 weeks) • Seizure at onset of stroke  •Post MI pericarditis •Pregnancy • Recent LP ```

Question 43

What are your differentials for collapse?

Answer 43

REFLEX SYNCOPE - Vasovagal - Situational (cough) - Carotid sinus syncope ORTHOSTATIC HYPOTENSION - Primary autonomic failure - Secondary autonomic failure (diabetes, uraemia) - Drug induced (inc alcohol) - Volume depletion (haemorrhage/vomiting) CARDIAC SYNCOPE (worse prognosis) - Arrythmias - Structural heart disease ``` other causes Vascular: Stroke/AAA/vasovagal/ ACS/aortic dissection Resp: PE Neuro: Epilepsy/brain injury Cardiac: Heart block Metabolic: DKA, ectopic pregnancy Neoplasm: Trauma: ``` Rule of 15%: PE/aortic dissection/ACS/ectopic pregnany/ruptured AAA/SAH

Question 44

How will CT heads appear for patients with ischaemic and haemorrhagic strokes?

Answer 44

Ischaemic - large darkened patch | Haemorrhagic - large bright, white patch with possible midline shift and compression/disappearance of ventricles.

Question 45

What is the NIHSS score

Answer 45

severity of stroke

Question 46

Secondary prevention of ischemic stroke? What happens if caused by AF?

Answer 46

ISCHEMIC STROKE- PREVENT FURTHER DISEASE 1. 300mg Aspirin for 2 weeks/until discharge (or 600mg rectal if no swallow) 2. Aspirin and clopidogrol 75mg (1-3 months) 3. Lifelong clopidogrel 75mg IF CAUSED BY AF: give anticoagulation DOAC/warfarin if AF (start 2 weeks post stroke to prevent secondary haemorrhage)

Question 47

What do you do if someone is on warfarin with an MAJOR BLEED?

Answer 47

Warfarin and ACTIVE MAJOR BLEEDS (inc subdura,ocular) - STOP warfarin - IV Vitamin K 5mg - Prothrombin complex e.g. Beriplex, Octiplex - Re-check INR 24hrs

Question 48

What do you do about warfarin if MINOR bleed? (INR 5-8 vs INR >8)

Answer 48

Warfarin in minor bleeds - stop warfarin - IV vitamine K 1-3mg (if IRN>8 you can give another dose in 24 hours if not helped) - Continue when INR <5

Question 49

What do you do about raised INR for someone who is NOT bleeding? (INR 5-8 vs INR >8)

Answer 49

Warfarin for non bleeds INR 5-8 -hold warfarin 2 days -reduce next maintenance dose INR >8 -stop warfarin PO vitamin K 1-5mg Restart when INR < 5.0

Question 50

Name some important causes of seizures?

Answer 50

EPILEPSY (do EEG, nerve exams, prolactin) Vascular-Strokes/TIAs/SAH, Arrhythmias (check ECG) Infection- FBC, lumbar puncture and cultures Trauma-head injury (do MRI if focal) Autoimmune Metabolic- hypoglycaemia (check glucose). Electrolytes (UsEs) Idiopathic-drugs/alcohol (toxicology screen) Neoplastic (MRI if focal) Pregnancy (pregnancy test)