Neurology and Pharmacology Quiz

Lumbar Puncture (LP)

• Contraindications: Bleeding disorders, compromised breathing/cardiovascular function, infection at the needle insertion site, and increased intracranial pressure (suspected if severe headache, altered consciousness, falling pulse, rising blood pressure, vomiting, neurological symptoms, or papilloedema). A CT scan is recommended prior to LP in these situations, as a lumbar puncture can cause severe complications if ICP is elevated.

• Method: Explain the procedure to the patient, outlining the purpose, necessity of cooperation, and opportunity to communicate. Position patient on their left side, fully flexed. Mark the L3/4 intervertebral space (or one below, L4/5) using aseptic technique and 2% chlorhexidine in 70% alcohol. Assemble sterile tubes. Insert a spinal needle perpendicularly, feeling for resistance of spinal ligaments, dura, and then the subarachnoid space. Measure opening pressure. Collect CSF into tubes. Apply dressing. Record CSF appearance and opening pressure. Send samples to the lab for tests such as microscopy, culture, protein, lactate, glucose, cytology, fungal studies, TB culture, virology (including herpes and other PCR), and syphilis serology.

• CSF Composition (Normal Values): <5 lymphocytes/mm³, no polymorphs, protein <0.4g/L, glucose >2.2 mmol/L (or ≥50% plasma level, and pressure <200 mm CSF.

• Bloody Tap: An artefact from piercing a blood vessel, indicated by decreasing red blood cells in successive CSF samples and no yellowing (xanthochromia). To estimate the true wcc in the CSF, subtract a white cell for every 1000 red cells. To estimate true protein levels, subtract 10mg/L for every 1000 red cells/mm³.

• Subarachnoid Hemorrhage: Xanthochromia (yellow supernatant on spun CSF). Red cells in equal amounts in all samples are not reliable for identification. Elevated protein levels may also appear yellow.

Complications of Lumbar Puncture

• Post-dural puncture headache: Risk of 10-30% incidence, typically within 24h, resolving in hours to 2 weeks. Characterized by positional worsening of headache, often frontal. Minor/transient neurological (i.e., numbness, weakness, or sensory problems) can also occur.

• Serious Neurological symptoms: Any change in lower-body neurology (pain, weakness, sensory changes, bladder or bowel disturbance) after an LP should be treated as a potential cauda equina compression (either hematoma or abscess) until otherwise proven. Urgent spinal MRI is needed.

Cardioversion/Defibrillation

• Indications: Restore sinus rhythm in cases of ventricular fibrillation/tachycardia, atrial fibrillation, flutter, or supraventricular tachycardias, if other methods (e.g., medication) have failed or there's haemodynamic compromise. Procedure can be emergency or elective.

• Procedure: Patient likely needs anesthesia except for critically ill patients. If elective cardioversion for cases such as Atrial fibrillation adequate anticoagulation beforehand is necessary. Place electrodes on the chest (apex and below right clavicle). If Ventricular Fibrillation/Pulseless VT follow the Advanced Life Support Algorithm. Synchronized shock with rhythm via "SYNC" button on device. Set appropriate energy levels (monophasic/biphasic) for different rhythms. After a shock, resume CPR if needed or monitor ECG for potential further shocks.

Taking Arterial Blood Gas (ABG) Samples

• Procedure: Explain procedure to patient. Use sterile technique and local anesthesia using a 25G needle; then use a 23G needle. Hold the syringe with the bevel facing upwards and insert the needle at a 45-degree angle beneath your palpated pulse. Allow 1-2mL blood to fill the syringe. Apply firm pressure for 5-10 minutes once removed, depending on if the sample was anticoagulated.

• Other Sites: Additional sampling locations include the femoral artery (less apprehensive) and the brachial artery, although the median nerve is nearby.

Emergency Airway Management - Cricothyroidotomy

• Indications: For airway obstruction above the larynx where intubation is impossible, like foreign bodies, facial edema (burns or angioedema), maxillofacial trauma, or infection (epiglottitis).

• Procedure: Position the patient supine, with the neck extended. Locate the cricothyroid membrane. Use a cricothyroidotomy kit; if not available use a large-bore cannula for a needle cricothyroidotomy. Establish an oxygen supply. A more definitive airway using a tracheostomy may be necessary.

Emergency Needle Pericardiocentesis

• Procedure: Position the patient supine with the head slightly lower. Clean the site with chlorhexidine in 70% alcohol and wear sterile gloves. If possible, perform under ultrasound guidance. Insert an 18G cannula just below and to the left of the xiphisternum, aiming towards the left scapula. Carefully collect fluid and monitor the ECG. Monitor patient's vital signs & correct, as indicated.

• Complications: Laceration of the ventricle or coronary artery (consequence: hemopericardium); aspiration of ventricular blood; arrhythmias (ventricular fibrillation); pneumothorax; or puncture of the aorta, esophagus, or peritoneum

Central Venous Cannulation

• Indications: Measuring central venous pressure (CVP), administering drugs, and providing intravenous access.

• Sites: The common sites used are the internal jugular, subclavian, and femoral veins.

• Complications: Bleeding, arterial cannulation, access fistulas, air embolism, pneumothorax, and/or hemothorax. Phlebitis, thrombus formation, bacterial colonization, cellulitis, and/or sepsis at the insertion site.

Temporary Cardiac Pacemaker Insertion

• Indications: AV block, inferior MI, anterior MI, second degree block (Wenckebach/Mobitz II), first degree block, bundle branch block, sino-atrial disease with serious symptoms.

• Technique: Prepare patient (ECG monitoring, defibrillator; peripheral access; radiologist and protective lead apron). Insert introducer into the internal jugular (ideally right side) or subclavian. Pass wire through introducer into the right atrium. Locate the pacing threshold (lowest effective voltage at which stimulation is observed). Set pace maker rate, suture wire to skin. Ensure adequate radiological safety and monitoring.

Non-invasive Transcutaneous Cardiac Pacing

• Indications: Alternative to transvenous pacing in emergencies.

• Procedure: Administer sedation and analgesia. Ensure a dry area for electrical pad placement. Connect devices to appropriate pads. Adjust the pacemaker according to the ECG and patient status.

Emergency Presentations

• Chest Pain: Assess for potentially life-threatening causes (ACS). Also, consider other potential causes, including cardiac, respiratory, gastrointestinal, and musculoskeletal issues. Troponin, ECG, and CXR are helpful in the initial assessment and diagnosis.

• Breathlessness: Note severity. Atypical history of respiratory disease, anaphylaxis, and examination findings are helpful in determining the cause. ABG, ECG, and CXR are indicated.

• Coma: Determine a Glasgow Coma Scale or AVPU score to assess the conscious state. Look for signs of trauma, such as hematomas/lacerations, bruising, or presence of CSF/blood in nose/ears. Check for decorticate or decerebrate posturing, and pupil size/response. Address treatable causes such as hypoglycaemia or sepsis. Also consider a head CT.

• Shock: Characterized by inadequate organ perfusion. Address etiology (i.e., hypovolemia, cardiac pump failure, and distributive shock, a loss of peripheral vascular resistance, sepsis). Check for cold & clammy or warm skin, HR, BP, and urine output. Immediately administer fluids and expert care

• Sepsis: Life-threatening organ dysfunction related to infection. Assess risk factors, including immunosuppression, surgery/trauma. Prompt antibiotics, O2, fluids are critical.

• Major Haemorrhage: Significant blood loss (150mL/min). Control bleeding. Replace blood volume, using blood components whenever possible (RBCs + plasma + platelets). Use crystalloid-restorative fluids only if/until blood products are available to avoid dilution & coagulopathy.

• Anaphylactic Shock: Severe allergic reaction to an allergen. Suspect in any acute ABC (DE) problem. Give IM adrenaline (epinephrine) and other appropriate care. Steroids are not used in the emergency treatment of anaphylactic shock.

• Hypertensive Emergencies: BP ≥200/120mmHg associated with organ damage. Treat slowly to avoid sudden drops in blood pressure.

• Acute Coronary Syndrome (ACS): Includes unstable angina, STEMI (ST-elevation myocardial infarction), and NSTEMI (non-ST-elevation myocardial infarction). Manage with antiplatelets, morphine, nitrates, oxygen. Evaluate eligibility for reperfusion therapy such as percutaneous coronary intervention (PCI) or immediate fibrinolysis.

• Pulmonary Oedema: Excess fluid in the alveoli, can be cardiogenic (↑pulmonary venous pressure) and non-cardiogenic (altered permeability/reduced oncotic pressure). Urgent treatment is essential.

• Cardiogenic Shock: Inadequate tissue perfusion due to cardiac dysfunction. Monitor BP and respiratory rate, administer fluids, & optimize fluid status.

• Broad Complex Tachycardia: Rapid heart rate (>100bpm) with wide QRS complexes. Manage according to suspected rhythm (Ventricular tachycardia). Assess pulse and BP. Address acute electrolyte abnormalities, including K+ and Mg+.

• Narrow Complex Tachycardia (often SVT): Rapid heart rate (>100 bpm) with narrow QRS complexes. Consider vagal maneuvers, adenosine, or calcium channel blockers.

• Bradycardia: Heart rate <60bpm. Identify the underlying cause and treat appropriately (often with atropine and expert help).

• Acute Severe Asthma: Life-threatening. Reassess every 15 minutes, deliver oxygen, nebulized beta2 agonists, oral steroids, and ipratropium bromide as needed.

• Acute Exacerbation of COPD: Use oxygen, bronchodilators, and steroids.

• Pneumothorax: Trapped air in the pleural space. Treat with aspiration or chest tube insertion, as indicated, and seek expert help.

• Pneumonia: Lung inflammation from various agents. Identify and treat promptly.

• Pulmonary Embolism (PE): Blood clot in the lung vasculature. Rapid treatment is critical, using thrombolysis when indicated by risk assessment, oxygen, anticoagulation.

• Acute Upper Gastrointestinal Bleeding: Assess for shock, determine risk with Glasgow-Blatchford score. Rapid/urgent endoscopy.

• Meningitis: Identify by symptoms (headache, fever, neck stiffness, abnormal skin color), physical examination (meningism; non-blanching rash), and investigations (CSF analysis). Prompt treatment with antibiotics (and expert help) is essential.

• Encephalitis: Brain inflammation with possible fever, neurological symptoms, and altered consciousness. Treatment includes aciclovir.

• Cerebral Abscess: Pus collection in the brain. Urgent neurosurgical intervention for evacuation is necessary.

• Status Epilepticus: Prolonged seizure activity. Treat immediately with benzodiazepines (lorazepam or midazolam), and consider second-line anticonvulsants. Seek help for intensive care if treatment not successful immediately.

• Head Injury: Secure airway and stabilize the patient's neck and circulatory system. Assess for risk factors. Consult Neurosurgery for urgent CT scans/treatments

• Raised Intracranial Pressure (ICP): Treat with oxygen, supportive therapy, and treatment of the underlying cause (trauma, infection, hemorrhage).

• Diabetic Ketoacidosis (DKA): Insulin deficiency, marked hyperglycemia and acidosis. Immediate treatment with insulin and fluids, and attention to correction of electrolyte abnormalities. 

• Hyperglycemic Hyperosmolar State (HHS): Similar to DKA, but without the ketosis. Treat with immediate fluids and correction of electrolytes.

• Acute Adrenal Insufficiency: Treat with hydrocortisone; monitor potassium; correct electrolyte abnormalities

• Pituitary Apoplexy: Rapid glucocorticoid replacement is essential

• Phaeochromocytoma: Seek urgent expert help. Use α-blockade to regulate blood pressure

• Thyroid Emergencies: Treat with appropriate thyroidectomy

• Burns: Initial management includes cooling, cover with saline gauze. Administer IV fluids according to the Parkland formula and monitor urine output, while also evaluating for inhalation injury, circumferential burns, or other significant injuries.

• Hypothermia: Treat with slow, gradual rewarming using blankets & warming fluids, avoid rapid changes in temperature. Monitor for arrhythmias and other complications during rewarming.

• Major Incidents: Address injuries based on triage to minimize serious complications, and provide critical care where needed..