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There are several pupillary abnormalities that all clinicians should be aware of. We will review the basic physiology before outlining abnormal pupillary responses and how to identify them.
Pupillary constriction:
- controlled by the parasympathetic nervous system
- achieved by a circular muscle called the sphincter pupillae
- starts at the Edinger-Westphal nucleus near the occulomotor nerve nucleus
- nerve fibers enter the orbit along with CNIII and synapse at the cilliary ganglion
Pupillary dilation:
- controlled by the sympathetic nervous system
- achieved by dilator pupillae muscles in the peripheral 2/3 of the iris
- starts at the cortex then cilliospinal (Budge's) center then down the brain stem to the cervical sympathetic chain and superior cervical ganglion then through the carotid plexus into the orbit via the 1st division of the trigeminal nerve
Pupillary exam:
- check size and shape at rest
- check the direct light response: constriction of illuminated pupil
- check the consensual light response: constriction of opposite pupil
- check accommodation: pupillary constriction when viewing a close object
- repeat on opposite pupil
Anisocoria:
- 1 pupil larger than the other
- normal in about 20% of people if less than 1mm and both eyes reacting normally to light
- may be Horner's syndrome (e.g. carotid dissection) or CNIII damage (e.g. aneurysmal expansion)
Relative Afferent Pupillary Defect (RAPD, Marcus Gunn Pupil):
- abnormal direct light response due to severe retinal diseases or optic nerve damage
- Swinging flashlight test differentiates decreased vision due to ocular issues (eg cataracts) from optic nerve problems by checking the pupillary light reflex
- in optic nerve lesions, the affected pupil won't constrict to direct light but will do so if light is shone in the other eye (consensual response)
- RAPD differentials include optic neuritis, ischemic optic or retinal disease, severe glaucoma with optic nerve damage, direct optic nerve injury (trauma, radiation, tumors), retinal detachment, severe macular degeneration, retinal infection (CMV, herpes)
Adie's (Tonic) Pupil:
- benign and common in women in their 3rd/4th decade of life
- nil or sluggish direct and consensual response to light
- thought to be from denervation in the postganglionic parasympathetic nerve
Argyll Robertson Pupil
- hallmark of tertiary neurosyphillis
- small baseline pupils which constrict with accommodation but not light
Horner's Syndrome:
- loss of sympathetic innervation with the clinical triad of ptosis (drooping eyelid), miosis (pupillary constriction) and anhidrosis (decreased sweating)
- differentials include: tumors (panacoast, nasopharyngial), carotid artery dissection, brachial plexus injury, lymphoproliferative disorders, cavernous sinus thrombosis, fibromuscular dysplasia
This information is for academic purposes only and opinions may differ. Please always use and refer to your local guidelines and protocols.
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Adult BLS -> DRSABCD
Danger:
- check for environmental hazards
- Fire, wet floors, chemical spills, sharps, body fluids, unstable relatives etc
- continue only when dangers have been removed and environment is safe
Response:
- COWS -> Can you hear me, Open your eyes, What's your name, Squeeze my hand
- Gently squeeze shoulder/trapezius muscle if no response to voice
- Signs of life -> eye opening, verbal, movement
Send for help:
- shout for help in 4 directions
- call an ambulance
- press the emergency button if in hospital
- request BLS equipment and AED where available
Airway:
- open the airway
- tongue is the most common cause of obstruction in unconcious patients
- chin lift and head tilt
- jaw thrust if spine injury suspected
- remove obvious foreign material, vomit, blood etc
Breathing:
- 1 ear close to the patient's nose and mouth, and your eyes directed to their chest
- Look, listen and feel for at most 10 seconds
- Look at the chest for rising and falling
- Listen and feel with your ear for breathing
- if no response start CPR
Cardiopulmonary resuscitation:
- Alternate 30 compressions with 2 breaths
- interlock hands over centre lower half of chest
- shoulders above hands and elbows straight
- 100 -120 compressions/min
- compress to 1/3 depth of chest (about 5cm)
- let chest re-expand between compressions
- Bag valve mask (Ambu bag) -> open airway (chin lift, head tilt, jaw thrust); use mask to form tight seal over nose and mouth (1 hand C-E grip or double hand grip if extra help available); squeeze bag over 1 second and watch chest rise; let air escape and watch chest fall; repeat for second breath then restart compressions
Defibrillator (AED):
- attach pads below right clavicle and left lower lateral chest
- ensure dry skin, no hair, and away from pacemaker or ecg pads
- follow AED prompts
- stand clear of patient when AED is analysing the rhythm (every 2 minutes) and when it advises to deliver shock
- restart compressions if no shock required or soon after shock is delivered
When to stop CPR:
- experienced help arrives and takes over
- patient shows signs of life
- physically exhausted and unable to continue CPR
This information is for academic purposes only and opinions are likely to differ. Please always refer to your local guidelines and protocols for recommended clinical practices.
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Acute exacerbations of asthma and COPD are often initially managed with inhaled beta2-agonists (salbutamol), inhaled anticholinergics (ipratropium bromide), steroids and O2. In severe cases, treatment adjuncts such as MgSO4 IV, Salbutamol IV, Aminophylline IV and Adrenaline may be considered. Administration of salbutamol has traditionally been via nebulisation, but we will consider burst therapy as an alternative here as well.
Salbutamol nebulisation:
- nebulised in saline/sterile water (1 - 2ml)
- 2.5mg (<5yrs) or 5mg (>5yrs)
- repeat at 30min to 1hour interval, then 2 - 4hourly until recovered
Ipratropium nebulisation:
- may be combined in nebuliser with Salbutamol
- 250mcg (<5yrs) or 500mcg (>5yrs) every 20min for 3 doses
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Salbutamol burst therapy:
- Metered dose inhaler (MDI) 100mcg
- Spacer device recommended
- Bursts -> 6 puffs/dose (<5yrs) or 12 puffs/dose (>5yrs)
- about 4 breathes between each puff
- repeat every 20min for an hour (3 doses in total) & reassess after each dose
- then give burst doses prn
- if subsequent bursts are required at <2hourly intervals consider admission, adjunct treatments and alternative diagnoses
Ipratropium burst therapy:
- MDI 21mcg
- Spacer device recommended
- Bursts -> 4 puffs per dose (<5yrs) or 8 puffs per dose (>5yrs)
- repeat bursts every 20min for an hour (3 doses in total)
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Burst therapy vs nebuliser:
- Burst therapy is generally just as effective as nebulisation with the advantages of being faster, more targeted, cheaper and not requiring electricity or special equipment
- Nebulisation takes longer to deliver medication and patients may need to sit still for 10 or more minutes
- Nebulisation has more facial and oropharyngeal deposition of medication resulting in at best 10% reaching the lungs. This may result in side effects such as tachycardia and tremors.
- Nebulisation however is preferred where patients struggle to co-ordinate taking a deep breathes through a spacer.
- Burst therapy is therefore a useful initial approach before switching to nebulisation if it's ineffective
This information is for academic purposes only and opinions are likely to differ. Please always refer to your local guidelines and protocols for recommended clinical practices.
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The visual acuity test determines the smallest letters at 6 meters a patient
can read on a standardised eye chart such as the Snellen chart. Patients with
6/6 vision are considered to be normal because they can read at 6 meters what
most people can read at 6 meters. Those who can only read upto the 6/60 line have poor vision because they can only read at 6 meters what most people can
read at 60 meters. Reading below the 6/6 line is considered to be better than
normal vision.
Steps:
- stand the patient at the appropriate distance from the chart
- patients with glasses should be allowed to wear them during the test
- provide an occluder to cover the eye not being tested
- ask the patient to read the smallest line they can see on the chart
- if a patient can read the 6/6 line but gets 2 letters wrong, it would be recorded as 6/6 (-2) visual acuity
- if more than 2 letters are wrong, then the visual acuity is the previous best line
- repeat these steps on the opposite eye
This information is for academic purposes only and opinions are likely to differ.
Please refer to you local guidelines for clinical best practises.
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Maintaining serum urate levels within a recommended target ranges is associated with fewer gout flare ups and the resolution of tophi. With regular monitoring and optimization of urate levels (for example <0.3mmol/L), gout flare ups tend to be less severe and less frequent. This is good because the patient is less likely to require NSAIDs, colchicine or oral corticosteroids which are commonly used in flare up management. In addition to this, serum urate monitoring is essential in the dose titration of allopurinol which is used in the long-term treatment and prevention of gout. (This is not clinical advice. Please refer to your local guidelines or consult with the relevant specialists)
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Urine color and concentration can indicate your hydration status. Pale, straw-colored urine suggests adequate hydration, while darker yellow or strong-smelling urine may indicate dehydration.
Urine Specific Gravity (USG) is a quantitative measure of urine concentration. This test measures the density of urine compared to water. A USG of ≤1.020 is generally considered indicative of euhydration (adequate hydration). A higher specific gravity (e.g., above 1.020) suggests the kidneys are working to concentrate urine, possibly due to dehydration. Normal ranges are typically between 1.003 and 1.030.
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(HRE)
