Topic 2 - ALOC

Question 1

ALOC - 2 Categories

Answer 1

• Intracranial pathology (structual)
  
  • CVA, subarrachnoid hemorrhage, intracerebral hemorrhage, DAI, meningitis, ecephalitis, status epilepticus, space-occupying injury
• Extra-cranial pathology
  
  • Cardiovascular system - arrythmias
  • Metabolic
  • Endocrine
  • Toxins
  • Other - hyper/hypothermia, hypoxia/hypercarbia, infection, psychiatric

Question 2

Stroke versus TIA

Answer 2

A TIA is defined as a breif episode of neurological dysfunction (traditionally 24 hours) resulting from focal temporary cerebral ischemia.

Question 3

Stroke lysis time

Answer 3

• 4.5 hours from the onset of symptoms - time must be unambiguous
• Only to consider acute stroke referal if symptom onset was within 3.5 hours of presentation to paramedics

Question 4

Stroke/TIA management

Answer 4

• O2
• Antiemetic
• Analgesia
• IV fluid
• Consider stroke mimics
• 45 degree semi-recumbent positioning to balance perfusion with reducing oedema

Question 5

Stroke Mimics

Answer 5

• Hypoglycemia
• Intracerebral mass lesions
• Seizures and post-ictal states
• Hemiplegic migraine
• Electrolyte abnormalities
• Conversion disorder

Question 6

Focal seizures - definition and types

Answer 6

• A focal seizure is where abnormal neuronal activity originates and is limited to one hemisphere of the brain
• Focal dyscognitive seizures are another type of focal seizure where conciousness is affected however full conciousness is not completely lost

Question 7

Generalised seizures and types (Absence, Atonic, Tonic, Myoclonic)

Answer 7

A generalised seizure is one where the abormal neuronal activity rapidly engages both hemispheresof the cerebral cortex. Several types include:

• Abscence - breif loss of awarness and responsiveness (usually 10 seconds) with no post-ictal phase
• Atonic - sudden loss of muscle tone (<2 seconds) which results in a fall
• Tonic - sudden increased muscle tone that most often oxxure in clusters during sleep
• Myoclonic - a breif sudden jerking action of a muscle or group of muscles that may occur in a series leading to a tonic-clonic seizure
• Tonic clonic - abrupt LOC with involuntary muscle contractions (tonic phase) followed by symmetrical jerking movements (clonic phase)

Question 8

Phsycogenic non-epileptic seizures management

Answer 8

• Where doubt to cause exists, Midazolam is appropriate

Question 9

Provoked seizure definition

Answer 9

A seizure resulting from a recognised cause including hypoxia, hypotension, pregnancy eclampsia, drugs, cerebral pathology etc.

Question 10

Complications of prolonged seizure activity

Answer 10

• Hypoxia
• Hypercarbia
• Progressive lactic and respiratory acidosis
• Hyperthermia
• Hypertension
• Hypo/perglycemia
• Hyperkalemia
• Physical injury

Question 11

Focal dyscognitive seizure management

Answer 11

• Manage as per generalised seizure if GCS 12 or less

Question 12

Midazolam (Pharmacology)

Answer 12

• Enhances the action of inhibitory neurotrasmitter GABA. Binds to GABA-A receptors which potentiates the effects of GABA by increasing opening of chloride channels

Question 13

Midazolam (ACP Indications)

Answer 13

• Generalised seizure/focal seizure (GCS 12 or less)

Question 14

Midazolam (Contraindications)

Answer 14

KSAR or hypersensitivity to midazolam

Question 15

Midazolam (Precautions)

Answer 15

• Reduced dosages should be used in elderly, renal failure, CCF and shock
• Respiratory depression in COPD
• Myasthenia gravis
• MS

Question 16

Midazolam (Side Effects)

Answer 16

• Hypotension
• Repiratory depression when used with any other CNS depressants