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title: "Week 7: Disability & Neurological Emergencies"

Week 7: Disability & Neurological Emergencies

Week 7 revision focuses on assessing consciousness and altered mental state in critically ill patients. This integrates content from Week 1 (ABCDE approach, seizures) with focused revision on GCS scoring and systematic disability assessment.

1. Consciousness Assessment

Glasgow Coma Scale (GCS)

The GCS provides objective assessment of consciousness across three domains. Total score ranges from 3 (deep coma) to 15 (fully alert).

Clinical interpretation:

• GCS 13-15: Mild impairment
• GCS 9-12: Moderate impairment
• GCS ≤8: Severe impairment (typically requires intubation for airway protection)

Common pitfalls:

• Don't add fractional scores — if patient has different responses, take the best response
• Sedation affects scoring — document "GCS 3T" if intubated (T = tube)
• Localizing pain (M5) means purposeful movement toward stimulus, not just withdrawing

AVPU Scale

Simpler rapid assessment used in DETECT/ABCDE approach:

• Alert — spontaneously conscious, oriented
• Voice — responds to verbal stimuli
• Pain — responds only to painful stimuli
• Unresponsive — no response to any stimulus

When to use:

• AVPU: Quick triage, handovers, rapid deterioration screening
• GCS: Detailed assessment, trending consciousness, ICU monitoring

Pupil Examination

Part of neurological assessment in altered mental state:

2. Altered Mental State — AEIOU-TIPS

Systematic differential diagnosis framework for undifferentiated altered consciousness:

Clinical approach:

1. Rapid bedside glucose — treat hypoglycemia immediately (50mL D50% IV)
2. Vital signs — fever (infection), hypo/hypertension (shock, stroke)
3. Focused history — collateral from paramedics, family, medication bottles
4. Exam — pupils, focal neurology, signs of trauma, needle marks

Key investigations:

• VBG: Glucose, pH, lactate, CO2, Na+, hemoglobin
• Blood cultures if febrile
• CT brain if focal neurology, trauma, or no obvious metabolic cause
• LP if meningitis suspected (after imaging rules out mass effect)

3. ABCDE/DETECT Approach

Systematic framework for detecting and preventing deterioration in critically ill patients. Used extensively in simulation and bedside assessment.

ABCDE Assessment Structure

A — Airway

• Look: Obstructed? Foreign body? Vomitus?
• Listen: Stridor, snoring, gurgling
• Feel: Air movement
• Action: Open airway (jaw thrust, suction), consider intubation if GCS ≤8

B — Breathing

• Look: Respiratory rate, work of breathing, chest symmetry
• Listen: Breath sounds, wheeze, crackles
• Feel: Trachea, chest expansion
• Action: Oxygen to target SpO2 92-96%, treat reversible causes (bronchodilators for asthma, tension pneumothorax decompression)

C — Circulation

• Look: Skin color, cap refill, peripheries
• Listen: Heart sounds, murmurs
• Feel: Pulses (rate, rhythm, volume), BP
• Action: IV access, fluid bolus if hypovolemic, vasopressors if septic shock

D — Disability

• Look: GCS/AVPU, pupils (PEARL), posture
• Listen: Speech quality, orientation
• Feel: Focal weakness, tone
• Action: Treat hypoglycemia, reverse opioids (naloxone), seizure management (benzodiazepines)

E — Exposure

• Look: Full body examination, rashes, trauma
• Listen: Abdomen (bowel sounds), signs of bleeding
• Feel: Temperature, abdomen for rigidity/guarding
• Action: Warm/cool patient, treat specific findings

F — Fluids

• Check: Input/output balance, urine output
• Action: Adjust fluid therapy, consider catheterization

G — Glucose

• Check: Bedside glucose
• Action: Treat hypo/hyperglycemia

ISBAR Handover

Structured communication for escalation and handovers:

• Identification — Your name, role, location
• Situation — Patient name, age, presenting problem
• Background — PMHx, current medications, allergies
• Assessment — ABCDE findings, observations, your impression
• Recommendation — What you want them to do (review, escalate, transfer)

4. Severe Traumatic Brain Injury

Pathophysiology

Munroe-Kelly Doctrine: The skull is a fixed volume. Any increase in one compartment (brain, blood, CSF, mass) causes reciprocal decrease in others. Beyond compensatory capacity → rapid ICP rise → herniation.

ICU Management Goals

Avoid secondary brain injury:

1. Avoid hypoxia — PaO2 >60 mmHg, SpO2 >92%
2. Avoid hypotension — Systolic BP >100 mmHg, MAP >80 mmHg
3. Avoid hypovolemia — Adequate fluid resuscitation
4. Avoid hyperthermia — Target normothermia (fever increases metabolic demand)
5. Optimize CPP — Manipulate MAP and ICP

Tiered ICP Management

Tier 1 (First-line):

• Head up 30° — improves cerebral venous drainage
• Sedation + analgesia — midazolam or propofol, fentanyl (reduces metabolic demand)
• Maintain normocapnia — PaCO2 ~35 mmHg (avoid hypercapnia → vasodilation → increased ICP)
• EVD drainage — if external ventricular drain in place, drain CSF to reduce ICP

Tier 2 (Refractory ICP >20 despite Tier 1):

• Neuromuscular blockade — vecuronium or rocuronium (prevents bucking on ventilator, stops patient-ventilator asynchrony)
• Osmotherapy:
  • Mannitol 0.25-1 g/kg IV — osmotic diuretic, draws fluid from brain tissue
  • Hypertonic saline (3% or 23.4%) — raises serum sodium, reduces cerebral edema
  • Monitor serum osmolality (<320 mOsm/kg to avoid renal injury)

Tier 3 (Last resort for life-threatening ICP):

• Barbiturate coma — sodium thiopentone infusion titrated to burst suppression on EEG (reduces cerebral metabolic rate by up to 50%)
  • Side effects: Hypotension (may need vasopressors), long half-life, hyperkalemia
• Therapeutic hypothermia — cool to 33-35°C (no strong evidence, increases infection risk)
• Decompressive craniectomy — discussed below

Monitoring in Severe TBI

Bedside monitor interpretation:

• ICP waveform — normal shows pulsatile pattern; loss of pulsatility suggests poor compliance
• CPP calculation — continuously calculated from MAP and ICP
• EEG (if thiopentone used) — target burst suppression pattern
• End-tidal CO2 — proxy for PaCO2 (confirm with ABG)

When to escalate:

• ICP >20 mmHg sustained despite Tier 1/2 interventions
• CPP <50 mmHg
• Pupillary changes (blown pupil = herniation)
• Sudden neurological deterioration

DECRA Trial — Decompressive Craniectomy

Key findings (NEJM 2011):

Clinical implication:

• Decompressive craniectomy is not routinely recommended for diffuse TBI with refractory ICP
• May still be used for mass lesions (subdural, extradural) causing focal compression
• Focus on optimizing medical management (Tier 1/2/3) before considering surgery

5. Headache Differentials

Primary vs Secondary Headache

SNOOP Red Flags

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6. Subarachnoid Haemorrhage (SAH)

Clinical Features

• Thunderclap headache — "worst headache of my life," maximal at onset
• Neck stiffness (meningism — blood irritates meninges)
• Nausea, vomiting, photophobia
• Loss of consciousness at onset (~50%)
• Focal neurological signs (CN III palsy → posterior communicating artery aneurysm)
• Seizures (~10%)

Investigation Algorithm

Hunt and Hess Grading

SAH Complications

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7. Status Epilepticus

Timed Drug Algorithm

ESETT Trial

Refractory Status Epilepticus

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8. Seizure Classification

ILAE Classification

First Seizure Workup

Driving Restrictions (Australian — Austroads)

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9. Cross-References

For detailed management of specific causes of altered mental state, see:

• Stroke and SAH imaging → content/critical-care/emergency-medicine.mdx (Section 7)
• Opioid toxicity → content/wiki/opioid-toxicity.mdx
• Hypoglycemia → content/wiki/deteriorating-patient-abcde.mdx
• Anaesthetics and sedation → content/critical-care/anaesthetics.mdx
• Headache/seizure in trauma → content/critical-care/week5-trauma.mdx (TBI section)

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Practice Questions

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title: "Week 7: Fracture Management"

Week 7: Fracture Management

1. Describing Fractures Systematically

Why Two Views?

Always obtain orthogonal views (anteroposterior and lateral). A fracture may appear well-aligned on one view but have significant displacement on another. Include the joint above and below when possible.

Source: AO Foundation; local orthopaedic imaging protocols.

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2. Bone Anatomy

Parts of a Long Bone

Describing Location

• Proximal - closer to the trunk
• Distal - further from the trunk
• Mid-shaft - middle third of diaphysis
• Subcapital - just below the head (e.g., femoral neck)
• Intertrochanteric - between trochanters (femur)

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3. Fracture Types

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4. Paediatric Fractures

Children's bones are different - more porous, more flexible, have growth plates.

Special Paediatric Fracture Patterns

Salter-Harris Classification

Forearm Fractures in Children

• Very common injury
• Often treated with closed reduction and casting
• Mid-shaft fractures need above-elbow cast to control rotation
• Good remodelling potential in children

Source: Salter-Harris classification (original 1963 paper); local paediatric fracture pathways.

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5. Describing Displacement

Always describe the position of the DISTAL fragment relative to the PROXIMAL fragment.

Types of Displacement

Varus vs Valgus

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6. Dislocations

Terminology

Shoulder Dislocation

• Most common: anterior-inferior (humeral head goes forward and under glenoid)
• Requires urgent/semi-urgent reduction
• Axillary nerve at risk (winds around surgical neck of humerus)
• Risk of avascular necrosis if prolonged

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7. Neck of Femur Fractures

Classification

Displacement Patterns

• Valgus impacted - Common, may be subtle on X-ray, better prognosis
• Varus displaced - Worse prognosis, higher avascular necrosis risk

Complications

• Avascular necrosis - Blood supply comes UP the femoral neck to the head
• Non-union
• Collapse
• Mortality (related to immobility, comorbidities)

Treatment Options

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8. Ankle Fractures

Key Anatomy

• Medial malleolus - Distal tibia
• Lateral malleolus - Distal fibula
• Posterior malleolus - Posterior lip of tibia
• Syndesmosis - Tibiofibular ligament complex

Important Findings

• Talar shift - Lateral subluxation of talus under tibia (unstable)
• Syndesmotic diastasis - Widening of tibiofibular joint (>5mm)
• Medial clear space widening - >4mm suggests deltoid ligament injury

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9. Open (Compound) Fractures

Signs of Open Fracture

• Bone visible through wound
• Wound communicating with fracture
• Gas in soft tissues on X-ray (subtle sign)

Management Priorities

1. Assess neurovascular status - pulses, sensation, motor function
2. Photograph wound - avoid repeated exposure
3. Saline-soaked dressing
4. Intravenous antibiotics - within 1 hour
5. Tetanus prophylaxis
6. Theatre within 6 hours (ideally 4 hours) for washout and debridement
7. Temporary stabilisation - external fixator if definitive fixation not appropriate

Why External Fixator First?

• Allows wound access for dressings and soft tissue management
• Avoids putting implants in potentially contaminated wound
• Can convert to internal fixation once soft tissues healthy
• May require plastic surgery for flap coverage if wound can't be closed

Source: AO Foundation; local orthopaedic trauma protocols.

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10. Fixation Methods

Complications of Internal Fixation

• Stress concentration - At tip of plate/intramedullary nail, risk of fracture at this point
• Stress shielding - Bone weakens under plate (less load)
• Hardware prominence - Can irritate soft tissues
• Infection
• Re-fracture after removal - Screw holes weaken bone temporarily

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11. Neurovascular Assessment

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12. Practice Questions

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13. Wound Management

General Principles

Primary Closure Timing

Suturing

Local Anaesthetic

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14. Tetanus Prophylaxis

Tetanus-Prone Wounds

Prophylaxis Guide

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