Brain

Question 1

what are the principles of management in increasesed ICP?

Answer 1

reverse ICP to normal level

maintain cerebral perfusion pressures (70-80 mmHg)

monitoring both BP and ICP to calculate CPP (CPP = MAP - ICP)

Question 2

what is the brief history that should be taken for any head injury?

Answer 2

when? how? where?

Did you fit? Are you epileptic? Lucid interval?

alcohol or drugs?

Question 3

what is the doses of BZDs for termination of seizures?

Answer 3

IV lorazepam 0.1 mg/kg as a slow bolus, repeat after 15 mins

iv diazepam / buccal midazolam

midazolam - 10 mg if >10 years old, 7.5 mg if 5-10 years old, 5 mg if <5 years old
squirt half dose into the mouth between lower gum and cheek

Question 4

what are the common causes for seizures?

Answer 4

epilepsy (unknown, known and undertreated)

hypoglycaemia

pregnancy - pre-eclampsia

alcohol and drugs (withdrawal or intoxication)

CNS space-occupying lesion or infection (encephalitis)

hypertensinve encephalopathy (& 2ary causes)

Question 5

what is the definition of status epilepticus?

Answer 5

seizures lasting >30 minutes, or multiple seizure activity lasting >30 minutes without a lucid interval between

Question 6

what is the diagnostic investigation for a cerebral abscess?

Answer 6

contrast-enhanced CT head/MR head

‘ring-enhancing’ lesion

Question 7

foundation management of cerebral abscess

Answer 7

escalate to neurosurgery and ID

full examination looking for sources of infection - teeth, ears, nose, skull #, endocarditis

check the patient for immunosuppression/immunocompromise and seek advice for stopping these medication. consider how this will affect antibiotic treatment.

Question 8

what diseases also present with symptoms similar to meningitis?

fever, altered consciousness, shock

Answer 8

encephalitis, septicaemia

malaria, dengue

subarachnoid bleed

Question 9

what is the rule for deciding on LP in a case of suspected meningitis?

Answer 9

if LP can be done in the first hour and there are no signs of shock, peitichial rash or raised ICP then do it

otherwise, give antibiotics immediately

Question 10

what bugs cause meningitis?

Answer 10

• neisseria meningitidis*
• streptococcus pneumoniae*
• haemophilus influenzae*
• listeria monocytogenes*

HSV, VZV, CMV, enteroviruses

toxoplasma gondii, mycobacterium tuberculosis

Question 11

what are the principle points of management for meningitis?

Answer 11

ICP vs diagnostic LP - check with a CT head, fundoscopy etc for raised ICP before trying to do an LP

antibiotics - minutes save lives, get them on board early

steroids are helpful if there are signs of meningism

contact tracing - ask a senior for help about contacting uni dorms or schools. more serious for people who have kissed the patient’s mouth

managemnet of sepsis

swabs - throat swabs for both bacteria and viruses

Question 12

what GCS do people need to have ICU involvement ?

Answer 12

GCS <= 8

Question 13

what are the signs of basal skull fracture?

what specific treatment should be given in this case?

Answer 13

battle sign, panda eyes

haemotympanum

CSF leak from nose or ear

tetanus immunoglobulin 250 U initially

Question 14

what are the early and late complications of head trauma?

Answer 14

early - extradural/subdural haemorrhage, seizures

late - chronic subdural haemorrhage, seizures, diabetes insipidus, SIADH, parkinsonism, dementia

Question 15

what are the indications for emergency (<1 hour) CT head in any head injury?

Answer 15

• GCS - less than 13 on initial assessment, less than 15 2 hours following injury
• focal neurology
• fractures - signs of basal skull #, depressed or open skull #
• post-traumatic seizure
• >1 episode of vomiting

Question 16

what is the dose for suspected viral encephalitis?

Answer 16

aim to start aciclovir iv 10 mg/kg/8 hours over 1 hour for 14 days within 30 minutes of presentation, empirical treatment for HSV-2

specific treatments also exist for CMV and toxoplasmosis if they are suspected

• CMV = ganciclovir and foscarnet
• toxoplasmosis = pyrimethamine, sulfadiazine, calcium folinate

Question 17

what are the considerations for phenytoin when used for termination of seizures?

Answer 17

should be done under serior guidance/ITU monitoring available

phenytoin = slows heart and drops BP.
do not give in the setting of heart block or bradycardia

requires BP and cardiac monitoring

don’t mix phenytoin and diazepam in the same IV cannula

Question 18

what are the antibiotics empirically for meningitis?

Answer 18

ceftriaxone 2g/12 hours iv

add amoxicillin 2 g/4 hours if patient in at the extremes of age or immunocompromised

if suspect viral meningitis or encephalitis, treat with aciclovir 10mg/kg q8 hours

Question 19

indications to perform an urgent (<8 hours) CT head in any head injury?

ACHA

Answer 19

• age > 65 years old
• coagulopathy
• high-impact injury
• retrograde amnesia >30 mins before accident

Question 20

what is the normal values of CSF fluid?

Answer 20

<5 lymphocytes/mm^3, no neutrophils

protein 0.15-0.45 g/L

glucose 2.8-4.2 mmol/L

Question 21

what are the investigations for encephalitis?

Answer 21

what bug?

blood cultures and serum for viral PCR

LP

throat swab for bactiera and viruses

toxoplasma IgM titre, thick and thin blood film

images

contrast-enhanced CT head

extra - EEG with diffuse abnormalities supports an urgent diagnosis

Question 22

what is the steroid that you could give in meningitis? what is the indication?

Answer 22

meningism - give steroids

dexamethasone 8.3 mg every 6 hours for 4 days

Question 23

what are the principles of management of head trauma?

Answer 23

ABC and resus, treat any shock accordingly
immobilize the C spine if # cannot be excluded

achieve haemostasis

monitor for and treat any seizure activity

assess neurology - GCS until 15, focal neurology, pupils, amnesia (antero-/retro-)

evaluate skull for fractures

evaluate for emergency/urgent CT head
polytrauma radiological survery (CT abdo, chest, neck and pelvis)

escalation to ITU/anaesthetics for airway and neurosurgery for fractures/ICP

Question 24

what investigations should be ordered for continuous seizure activity?

what is done before/after the initiation of treatment?

Answer 24

• *before treatment** - capilary blood glucose
• *after treatment** - everything else

standard: serum glucose, ABG, U&E, Ca²⁺, FBC. ECG.

monitoring: SpO2 and cardiac monitor

drugs: consider anticonvulsant levels if known epileptic to monitor for compliance.
toxicology screen for recriational drugs.

extra: LP, culture blood and urine, EEG, CT head, CO levels.

Question 25

some specifics of managing ICP that can be done by FY1

Answer 25

elevate head of bed to 30-40 deg

therapeutic hyperventilation aim PaCO2 3.5-4 kPa.

osmotic diuresis using mannitol, aiming for serum 300 Osm

fluid restriction to <1.5 L per day

escalation to ITU. neurosurgery for focal causes