Archive for May, 2012

An approach to an unconscious patient

Posted: May 23, 2012 by kiamseong in Medicine

State of awareness can be assessed by GCS score

  • 15 conscious
  • 14-8 impaired/delirious
  • 3-8 unarousable

According to severity of injury:
*Minor injury score 13-15
*Moderate score 9 -12
*Severe injury ≤ 8

E4- spontaneous opening
3 open on speech/call
2 open on pain
1 not open

V5- oriented speech
4 confused
3 inappropriate
2 incomprehensible
1 none

M6 – obey command
5 localised pain
4 withdrawal to pain
3 decorticate (abnormal flexion of limb)
2 decerebrate (abnormal extension of limb)
1 not responding

Causes

  1. Bilateral cortical diseases/processes
    1. Trauma – head injury
    2. Hypoxia – HIE, sinus thrombosis, CVA
    3. Infection – cerebral abscess, meningitis, encephalitis
    4. Haemorrhage – SAH, SDH
    5. Metabolic – DKA, HHS, hypo or hyper Na/K, hypoglycaemia
    6. Organ failure – liver or renal
    7. Postictal
    8. Endocrine – thyroid storm, myxoedema, Addison crisis
    9. Drugs – opiates, alcohol, opioid, alcohol, cocaine, benzodiazepine, antidepressant
  2. Brainstem disorder ~ Supratentoral/infratentoral lesions à SDH, EDH, ICB

Approach

Priority should be given to ABC resuscitation and perform examination simultaneously, then: –

  1. Obtain quick history from witness
    1. Onset – abrupt/gradual
      i.      Acute (sec/min)– CVA, cardiac arrest, SDH, head injury
      ii.      Subacute (min-hrs) – sepsis, infections, drug, hypo
      iii.      Protracted

2.      Recent complaints – headache, depress, weakness, vertigo
3.     Recent injury
4.     Previous medical illness

2. Examination

  1. Vitals – T, PR, BP, RR
  2. Skin petechial rashes, ecchymosis (meningoencephalitis)
  3. Neurological assessment
    i.      Posture
    * Lack of movement of one side
    * Intermittent twitching
    * Multifocal myoclonus
    * Decortication
    * decerebration

ii.      Level of consciousness
iii.      Neck rigidity
iv.      Pupil sizes – Horner Syndrome (ptosis, myosis, anhydrosis and enophthalmus), atropine overdose, opioid poisoning, ICB etc
v.      Funduscopy
vi.      Brainstem reflex – pupil reflexes
vii.      Corneal reflex
viii.      Doll’s eye reflex (eye move to opposite side of movement so it always goes to centre) – if negative à brainstem injured

4. Racoon eyes ~ basal skull #
5. Otorrhoea/rhinorrhoea
6. Nails, dxt marks
7. Breathing
i.      Cheyne-Stroke – rapid, shallow with periodic apnoeic episodes à heart failure, strokes, traumatic brain injuries, tumours, CO poisoning, morphine, toxic metabolic encephalopathy
ii.      Kussmaul – deep laboured breathing (usually met acidosis) e.g. DKA, renal failure
iii.      Biot breathing – cluster pattern ~ pontine malfunction
iv.      Gasping – severe hypoxia
3. Ix

ü  FBCü  RBS

ü  ESR/CRP

ü  LFT/RP

ü  Blood C+S

ü  ECG/CXR

ü  Urine toxicologyü  ABG/VBG/Lactate

ü  KIV LP

ü  Serum toxicology

ü  CT Brain

ü  Skull Xray etc

4. Immediate Mx

  • Maintain IV line, O2 therapy
  • Blood sample for RBS
  • Control seizures
  • Consider IV glucose, thiamine, naloxone, flumazenil

5. Further Mx

Depending on the Hx and examination findings, TFT, carboxyHb levels, BFMP and plasma osmolarity (increased in methanol, ethylene glycol and isopropyl alcohol) may be required.
6. Definitive Mx – depends on the cause.

However, while the patient is undergoing evaluation, it is essential to:

  • pressure area care
  • care of the mouth, eyes and skin
  • physiotherapy to protect muscles and joints
  • risks of deep vein thrombosis
  • risks of stress ulceration of the stomach
  • nutrition and fluid balance
  • urinary catheterization
  • monitoring of the CVS
  • infection control
  • maintenance of adequate oxygenation, with the assistance of artificial ventilation if necessary

Algorithm

ABC of life support

Oxygen and I.V access

Stabilize cervical spine

Blood glucose

Control seizures

Consider I.V glucose, thiamine, naloxone, flumazenil

Brief examination and obtain history

Investigate

Reassess the situation and plan further

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An approach to patient with hypoglycaemia

Posted: May 23, 2012 by kiamseong in Medicine

Whipple’s triad

  • SSx consistent with hypoglycaemia
  • Documented glucose level low
  • Treatment given causes SSx resolves

 

Definition of hypoglycaemia:

For healthy individual DXT < 3.0 mmol/L

For DM patient DXT < 3.8 mmol/L

 

SSx

Autonomic (peripheral NS)

Shaking, trembling, sweating, palpitation, hunger, pins and needles in lips and tongue etc.

Neuroglycopenic (CNS)

Confuse, anxiety, couldn’t concentrate, abnormal mental state, irritable, focal neurological signs, impaired vision etc.

 

Precipitating causes

  • Underlying liver or renal diseases (source of gluconeogenesis)
  • OHA
    § Glibenclamide à used more in KK, higher risk of hypoglycaemia than others because it has more prolonged action
    § Gliclazide
    § Metformin
  • Cortisol deficiency
  • Insulinoma etc

 

Management
1.Withhold all OHA or insulin.
2.If mental functions intact and tolerating orally, give 15g carbohydrates

  • 1-2 tablets of glucose/sweet
  • 3 teaspoon of sugar
  • 1-2 cups of milk, orange juice
  • Pieces of fruits
  • 3 pcs of crackers
  • 1-2 pcs of bread/sandwich

Repeat DXT after 15 min. If still <3.9, give another 15g carb.

  1. If minimal hypo, could not tolerate orally à give 30-50cc D50% then repeat DXT monitoring
  2. If persistently hypo (usually due to OHA) à give 50cc D50% + 25g Carb + IV 1 pint D10% /24hrs
  3. To consider IM glucagon if difficult IV access, once regain consciousness, to encourage orally
  4. For pt who remain unconscious due to prolonged hypoglycaemia, start IV Dexa 4mg QID or IV Mannitol to treat cerebral oedema, and find out other causes of coma (drug overdose or stroke)

An approach to patient with hyperglycaemia

Posted: May 22, 2012 by kiamseong in Medicine

Mortality caused by DKA and HHS = 30%

Precipitating factors

  • Noncompliance to medication
  • Infection
  • Pancreatitis
  • Myocardial infarction
  • Steroid
  • Thiazide
  • Stroke etc.


Difference between DKA and HHS

In DKA ~ absolute insulin deficiency –> induce lipolysis –> ketone formation

In HHS ~ relative insulin deficiency


Differential diagnosis

If presence of ketone can be also due to:

  • Starvation
  • Alcohol

 

DKA

To diagnose must fulfil these 3 criteria:

  • pH < 7.3
  • glucose > 14
  • blood ketone > 2

 

Severity:

Mild                        pH 7.25-7.30  HCO3 15-18 Alert

Moderate              pH 7.00-7.24  HCO3 10-14 Drowsy

Severe                    pH <7.00        HCO3 <10 Stupor/Coma

 

HHS

To diagnose must fulfil these 2 criteria:

  • glucose > 33
  • serum osmolarity > 320 mOsm/L
  • HCO3 > 18

 

Mental status drops if osmolarity ­increased

 

Ix

  • DXT
  • Ketone stick
  • ABG/VBG
  • RBS (esp DXT HI)
  • BUSE, Creatinine
  • Serum ketone
  • Serum osmolarity
  • UFEME
  • FBC
  • ECG
  • CXR
  • Blood C+S
  • HbA1c

 

Mx of Hyperglycaemia

  1. Fluid replacement
  2. Insulin
  3. Electrolyte correction
  4. Treat precipitating cause

 

Fluid replacement

Set 1 line in each arm

One for running bolus

One for maintenance

 

For deficit – DKA 6 litres, HHS 9 litres

Run in bolus

1 litre in 1 H

1 litre in 2 H

1 litre in 4 H

1 litre in 6 H

1 litre in 8 H

 

Maintenance calculated by Holliday Segar formula

 

Choice of fluid

If hyperNa or EuNa à use HS

If hypoNa à use NS

 

Always start from fluid replacement because:

  • To prevent hypotension
  • To obtain K+ result before insulin therapy
  • Insulin effectiveness decrease if hyperosmolar not corrected
  • Sufficient fluid therapy decrease counteracting hormones

 

Insulin therapy

Not to start if K < 3.3

IV regular insulin 0.1U/kg bolus then 0.1U/kg/H per sliding scale

Target to reduce glucose level 2.7-3.8 mmol/L/H

  • Not too fast à can cause cerebral oedema
  • If cannot reach target à double the dose

 

Target glucose level: (keep till DKA/HHS resolves)

DKA 8-11mmol/L

HHS 14-16 mmol/L

 

In DKA if patient in hypoglycaemia – cannot stop insulin therapy because it can cause ketoacidosis due to lipolysis

è  To give insulin but give patient on D10%

 

Electrolyte correction

Check BUSE and VBG QID

 

Criteria to start K replacement:

  • No ECG evidence of hyperkalemia
  • K < 5mmol/L
  • Good urine output 0.5cc/kg/H

 

To correct hypokalemia (as a result of insulin therapy), include in each/alternate pint fluid in maintenance drip 0.5-1g KCl

 

Hyperglycaemia resolution (at least 3 criteria)

DKA                                       HHS

Glucose < 11                         Serum osmolarity < 320

HCO3 > 18                            Gradual recovering mental alertness

pH > 7.3                                               

Anion gap < 12  

 

Formula: AG = Na + K – Cl – HCO3

 

After resolve, if patient tolerating orally

Change to basal bolus regime (0.5-0.8 U/kg/day) and titrate with overlapping 1-2hrs with sliding scale

 

Indication of bicarbonates

If pH 6.9-7, gives 50cc HCO3 in 200cc HS with 10ml KCl over 2hrs

If pH < 6.9 gives double dose

 

Be aware of fluid overload in elderly or when massive replacement is required. Consider CVP monitoring.