ACC – D week
Aaqid Akram MBChB (2013)
Clinical Education Fellow
Objectives
• Be able to calculate GCS in adults/children
• Be able to assess and manage a patient with
head/neck injury
• Be able to recognise and manage problems with
alcohol use
• Be able to recognise and manage drug overdoses
• Be able to recognise and manage meningitis
• Be able to recognise and manage seizures
Case 1
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50 year old male
Intoxicated with alcohol
Brought in by ambulance 2 hours ago
Tripped over and fell 8 steps on the way back home
haematoma noticed on the left temporal area of head
Disorientated in time an place
Unaware of the falling episode or why he is here, but
aware he was going home
• Following the nurses around the department, but sits
down in cubicle when you call him over.
• Making inappropriate sexual remarks
Glasgow Coma Score
Score
Response
4
Spontaneous
3
Sound
2
Pain
1
Unresponsive
5
Orientated
4
Confused
3
Words
2
Sounds
1
Unresponsive
6
Obeys commands
5
Localising pain
4
Normal flexion
3
Abnormal flexion
2
Extension
1
Unresponsive
Eyes (E)
Verbal (V)
Motor (M)
Case 2
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11 month old infant
Brought in by mother
Slipped out of arms and into the bath half an hour ago
Hit occiput on bath floor
Has since been crying intermittently
There was immediate crying
On examination there is a 4cm swelling
Not other abnormalities on inspection
Fontanelle still palpable and soft
Infant is looking for mother and reaching out to her
Case 2 continued
• The infant was taken to the paediatric ward
for observation
• Two hours later
• Supraorbital pressure induced flexion,
moaning and opening of eyes
Child’s Glasgow Coma Score
Score
>5 years old
<5 years old
4
Spontaneous
3
Sound
2
Pain
1
Unresponsive
Eyes (E)
Verbal (V)
5
Orientated
Alert, babbling, coos, words for normal ability
4
Confused
Less than usual ability, irritable cry
3
Words
Cries to pain
2
Sounds
Moans to pain
1
6
Unresponsive
Obeys commands
Normal spontaneous movements
5
Localising to supraorbital pain (>9 months) / (<9 months) withdraws to touch
4
Withdraws form nail bed pain
3
Flexion to supraorbital pain (decorticate)
2
Extension to supraorbital pain (decerebrate)
1
Unresponsive (flaccid)
Motor (M)
Case 3
• 45 year old female
• Had recently decided she was going to turn a new
leaf
• Tachycardia
• Anxiety / Sweating
• No chest pain
• Tremulous
• Disorientated in time an place
• No injuries on inspection
• No enlarged organs on examination
Alcohol withdrawal
Alcohol
GABAa receptor
stimulation
Sudden alcohol
withdrawal
Uncontrolled synapse
firing
CNS depression
Unopposed sympathetic
stimulation
Continued alcohol
Down-regulation (No +
Sensitivity) of GABAa
Autonomic hyperactivity
Agitation
Confusion
Anxiety
N +V
Hallucinations
Impaired GCS
Acute Alcohol Withdrawal
Delerium Tremens
Disorientation
Seizures
Tremor
Tachycardia
Delerium
Sweating
Scoring Systems
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CAGE Questionnaire:
– Have you thought about cutting down ?
– Are you annoyed by others criticism of your drinking?
– Do you feel guilty about your drinking?
– Do you need an eye opener
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AUDIT Questionnaire:
– Alcohol Use Disorders Identification Test
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CIWA Ar Scoring:
– (Alcohol withdrawal assessment scoring guidelines)
– Ten item scale for assessment and management of alcohol withdrawal
– Helps to prevent over sedation /under-treatment of in-patients
– Mild <16, Severe >20, Max = 67
CIWA Ar
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Chlordiazepoxide
(Librium)
40-50mg po
Repeat every 2 hours prn
Score>35 or unrelenting
symptoms – ICU input
• Day 1 total usage
– Baseline
• Day 2-6 reducing doses
Further Management
• Pabrinex
– 2 pairs (I+II + I+II) TDS for 2 days
– 1 pair (I+II) OD for the next 3 days
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Vitamin B1 – Thiamine
Vitamin B2 – Riboflavin
Vitamin B3 – Nicotinamide
Vitmain B6 – Pyridoxine
Vitamin C – Ascorbic Acid
Anhydrous Glucose
• Oral Thiamine + Vit B Co-Strong
Case 3 continued
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Same female comes in 3 months later
Back on alcohol
80 units a day
No appetite
Does not take prescribed supplements
Very unsteady on feet with wide gait
Confused
On examination, nystagmus seen and unable to
look laterally
Wernicke’s Encephalopathy
• Triad
– Opthalmoplegia
– Ataxia
– Confusion
• Low levels of thiamine
– GI malabsorption / diet
– Impaired utilisation by cells
• Oxidative damage
– Pro-apoptotic mechanism
– Mitochondrial damage
– Neurons/astrocytes
• Korsakoff’s Syndrome
Effects of alcohol
Neuro:
CVS:
Hypertension / AF / Cardiomyopathies /
Heart Failure
Wernike’s / Korsakoff’s / Psychosis /
Confusion / panic disorder / depression /
seizures / neuropathies
Pancreas:
Alcohol Ketoacidosis
Acute / Chronic Pancreatitis
Gastrointestinal:
Liver:
Bleeds / Cancers
Fatty / hepatitis / cirrhosis
Endocrine/Hormone:
Bone:
Osteoporosis
Gonadal Atrophy
Case 4
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20 year old male
Brought into emergency department by Ambulance
Generalised tonic-clonic seizure in Tesco car park
Appx 3 mins
No head injury noted
Now in post ictal state – drowsy but interacting
No temperature
No previous history of seizures
Not aware of seizure – remembers walking out of Tesco
and then in the ambulance
Case 4 continued
• On seeing your next patient the wall alarm has
been pulled by the mother of the patient
• He is having a tonic clonic seizure
Case5
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26 month old child
Unwell for 3 days
Grunting last night
Not feeding today
Very sleepy – opening eyes to voice
Pyrexial
Irritable crying
Floppy hands and feet, but moves hand if
attempting nailbed pain
• Notice a non blanching rash behind right knee
Moved to Resus
A. No additional Airway noises
B. RR 50 / SpO2 unrecordable
C. CRT 5 seconds / HR 180 / Nappy dry since last
night
D. GCS: 11
IV Access
Fluid
Resuscitation
Raised ICP
• X2 large bore
• Use one to immediately commence Ceftriaxone 80mg/kg
• FBC / U+E / CRP / Blood gas / blood cultures / Bone profile / Mg / lactate
/ clotting / cross match
• Bolus 20ml/kg 0.9% NaCl + Reassess
• Second bolus 20ml/kg 0.9% NaCl + Reassess
• If still signs of shock  urgent elective intubation and ventilation
• Once no signs of shock only – DO NOT PERFORM LP
• GCS < 9 / fluctuating GCS
• Bradycardia + hypertension
• abnormal posture / seizures / unequal pupils / papilloedema / dolls eyes
Meningitis
• Contact public health / ID consultant on call
• Kissing contacts / household / room mates
– Prophylaxis/immunisation
– Ciprofloxacin / ceftriaxone
• Causes
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Viral (enterovirus / mumps / measles / influenza)
Bacterial
Fungal (cryptococcus / blastomyces / histoplasma)
TB
Parasitic
Other (iatrogenic / cancer / drugs / head injury)
Bacterial Meningitis
Age Group
Pathogens
Newborn
Group B strep / E Coli / Listeria
Infants / Children
S Pneumoniae / N Meningitidis / HIb
Young Adults
S Pneumonaie / N Meningitidis
Older Adults
S Pneumonaie / N Meningitidis / Listeria
CSF
Pathogen
Glucose
Protein
WCC
Appearance
Normal
60-80% plasma
0.2-0.4 g/L
<5/mm3
Clear / no
colour
Bacterial
Low (<50%)
High (>1.5)
Neutrophils
>1000/mm3
Cloudy / turbid
Viral
Normal
Normal / High
lymphocytes
Clear
TB
Low (<50%)
Very High (>
bacterial)
Mix
Clear / slightly
cloudy
Case 6
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Variable
Value
O
RA
24 year old female
SpO
94%
Deliberate overdose
RR
9
HR
75
Co-codamol + Aspirin
Temp
37.1
Staggered
BP
110/60
Orientated in time, place and person
Wants to be left asleep and only opens eyes
and tries to move hand away, when applying
supraorbital pressure
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Further History
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Quantity and strength of each
Time take if possible
Anything else taken?
Alcohol
Any other regular medication
Previous attempts at self harm/suicide
Current reasons/motives
Mental health contact
Patient’s weight
Paracetamol
OD
Codeine
(opiate) OD
• Asymptomatic
• Nausea / vomiting
• RUQ tenderness
• Jaundice (Late)
• Hepatic Encephalopathy
• Reduced GCS
• Pinpoint pupils
• Reduced RR
• Bradycardia
• Coma
NSAID OD
• Asymptomatic
• Epigastric pain
• Nausea / Vomiting
• GI bleeding
• Renal failure
Salicylate OD
• Mild Pyrexia
• Tinnitus
• Nausea / Vomiting
• Hypotension
• Tachycardia
Parvolex (N-Acetylcysteine)
• Total dose given in 3 consecutive IV infusions over 21
hours.
1. 150mg/kg in 200ml of 5% glucose over 1 hour
2. 50mg/kg in 500ml of 5% glucose over 4 hours
3. 100mg/kg in 1000ml of 5% glucose over 16 hrs
• In very obese patients (>110kg) the dose should be
calculated using a body weight of 110kg rather than
their actual weight.
Objectives were:
• Be able to calculate GCS in adults/children
• Be able to assess and manage a patient with
head/neck injury
• Be able to identify and manage problems with
alcohol use
• Be able to identify and manage drug overdoses
• Be able to identify and manage meningitis
• Be able to identify and manage seizures