Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?
Category: Neurology
Giant Cell Arteritis – GCA
GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA is far from a benign condition that can be passed back to the GP’s, it can lead to some significant problems
- Sudden irreversible visual loss
- Development of thoracic aortic aneurysm
Retrobulbar haemorrhage
What is retrobulbar haemorrhage?
- Rapidly progressing haemorrhage into the retrobulbar space which is rare but potentially sight threatening.
- Retrobulbar haemorrhage causes a rapid rise in intraorbital volume and pressure.
- If not treated it can quickly lead to retinal ischaemia and infarction resulting in permanent visual impairment or complete visual loss.
Meningitis – Adults
- Keep your suspicions high – early signs it may not be clear
- Sepsis Kills – give antibiotics & fluid early
- Consider Acyclovir
- Give Dexamethasone with Antibiotics – it can reduce neurological sequelae
- Consider indications for CT before LP
- Get SENIOR support early
Primary Intracerebral Haemorrhage
In anybody who there is suspicion of a non-traumatic haemorrhage arrange an urgent CT Head.
All patients need IV access and U&E, FBC, Coag
If CT confirms PICH (not traumatic, not SAH): –
Anticoagulation
If anticoagulated with warfarin or NOAC discuss with stroke consultant and Haematologist regarding reversal
If not anticoagulated give Tranexamic acid – 1g in 100mls Saline/Glucose over 10 mins followed by 1g in 250mls Saline over 6 hours.
Blood Pressure
BP needs to be <150/80 – use labetalol (max 400mg – until BP <160 or HR <50) and GTN infusion
Neurosurgical Referral
Not all patients with intracerebral bleeds need referral to neurosurgery – you could save yourself and your patient a lot of time and effort!
Those to refer:
- GCS 9-12/15 with lobar haemorrhage
- Isolated intraventricual haemorrhage
- Hydrocephalus on presentation
- Rapid deterioration following arrival (gcs drop by 2 points or more in the motor component)
- Cerebellar bleed
Admit those not going to Neurosurgery to HASU at CRH after discussion with Stroke team
Headache
There are numerous causes of headache, however, the pressing question in the ED is,
Is this a primary or SECONDARY headache?
- Primary headaches [e.g. tension & migraine}, maybe painful and need analgesia but don’t require emergency investigation.
- Secondary headaches, often but not always have serious underlying causes [e.g. SAH, central venous thrombosis] requiring emergent investigation and treatment
Delirium in the ED
Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.
3 subtypes of delirium
- Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
- Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
- Mixed
Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!! Read more
Assessing Functional Leg Weakness
When patients present with functional symptoms. It can be difficult to discern whether if it is an actual or functional weakness. And it can be even more difficult to convince the patient. However these tests can not only help you workout what is happening, but also demonstrate function to the patient. Read more
Are You CO Aware?
With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)
Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:
- Gas
- Coal
- Wood/Paper/Card
- Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)
CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.
Bell’s Palsy
Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.
However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more
