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ODESSA NATIONAL MEDICAL UNIVERSITY
FAMILY MEDICINE AND GENERAL PRACTICE DEPARTMENT
Subject Title: “General Practice - Family Medicine”
Independent Study Guidelines for practical sessions for 6th year Medical Faculty
students
MODULE 1: «ORGANIZATIONAL ASPECTS OF PRIMARY HEALTHCARE
IN UKRAINE, ITS PRIORITY ROLE IN THE DEVELOPMENT AND
REFORM OF HEALTHCARE. FEATURES OF OUTPATIENT CARE»
CONTEXT MODULE 5: “Emergency Medical Aid in an Outpatient Setting”
Lesson 12: «EMERGENCY CARE IN FAMILY PRACTICE.SEIZURES
AND LOSS OF CONSCIOUSNESS»
Year: 6 th
Faculty: Medical
Approved
By the department methodical board
“____”_____________20__
Protocol № ______
Department Head
___________Velichko V.I., M.D., PhD.
Odessa
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Session Topic: «EMERGENCY CARE IN FAMILY PRACTICE. SEIZURES
AND LOSS OF CONSCIOUSNESS» - 4 hours.
І. CURRENT APLICATIONS:
Seizers are one of universal response of organism on different impacts, which reflects
expressed disorders of cerebral homeostasis. This is private reason of development of critical
conditions especially in children of early age which requires emergency care. The main
unfavorable risk factors for seizure syndrome are intensive muscular work, disruption of
respiratory muscles, variance of general and cerebral resources, development of respiratory and
metabolic acidosis, neurohumoral hyperfunction. Despite of emergency situation which is posed
by the development of seizures, treatment of seizures must be etiopathogenetic because the
efficiency depends on it.
ІІ. GOALS AND OBJECTIVES: To expand student’s knowledge of one of the most
common emergency conditions, which there are in children and adults. To systematize the
knowledge of early diagnosis and timely emergency assistance in seizures and loss of
consciousness.
Know:
-
features organization of prehospital emergency care
a set of medications for emergency assistance at home
Able to:
1. to syndrome diagnosis of threatened conditions
2. to administer adequate treatment in developing of main syndromes, which threatened
the patient’s life
3. correctly deal with question of patient transport and emergency hospitalization in an
intensive departments and profile centers
ІІІ. INTERDISCIPLINARY INTEGRATION:
№
Name of section
Diagnosis and treatment of seizures, which
1. threatened adult and children lives .
Department
Department of propaedeutics of internal
diseases
Department of internal diseases
Department of childhood illness
Department of surgery with course
anesthesiology and resuscitation
2. Medications, which is using for treatment of urgent Department of Pharmacology
status
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Content of the topic
Seizures are the pathological condition where body muscles contract suddenly,
frequently, involuntary and not infrequently followed by loss of consciousness. Seizures are the
urgent state which require from physician precise and consistent actions. The main attention
should be devote to keep an adequate oxygenation and circulation, and then to began
anticonvulsant therapy.
Symptoms
Manifestations of convulsive syndrome are varied and differ in duration, time of beginning,
state of consciousness, frequency, prevalence, form of manifestation. Character and type of
seizure depend from the type of pathological process which can be direct cause of their beginning
or play provocative role.
Depending on character of muscles contractions there are clonic and tonic seizures.
Clonic seizures are rapidly muscles contractions which follow each other in a short period of
time. They are rhythmic and arrhythmic and characterized by excitation of cerebral cortex.
Tonic seizures are long muscles contraction which arise slowly and continue a long time. They
can be primary or rise immediately after clonic seizures. They are generalized or localized.
When the seizures are a child suddenly lose contact with environment, his eyes are wandering,
then eyeballs are fixed up and away. Head is thrown back, hands are flexed at the wrists and
elbows, legs are extended, jaws are compressed. Possibly tongue is bite. Breathing and heart rate
slow down, perhaps sleep apnea. This is a tonic phase of clonic-tonic seizures that is continue less
than one minute. Second phase is clonic, that begins with twitching of face muscles, then
seizures go on limb and become generalized; noisy breathing , wheezing, foam appears on lips;
skin is pale, there is tachycardia. These seizures are more prolonged and can lead to death.
Seizures in children occur 4-5 times more frequently than in adults, predominately in early
age. The increased susceptibility of children to convulsive reaction associated with immature
brain, incomplete mielynation of nerve fibers, high blood-brain permeability, increased
hydrophilic properties of brain tissue, metabolic lability, weakness of inhibitory mechanisms,an
expressed tendency to generalization of excitation.
Disease in children has a significant impact on character of seizures. For example, during
neonatal asphyxia, seizures are tonic or clonic-tonic and in deriving children from asphyxia and
disappearance of edema of brain, they usually stop.
When intracranial (generic) injury is the seizures are often generalized in form of tonic or
clonic-tonic muscles contractions, accompanied by cyanosis, breath disorder. May be there is an
significant hyperthermia. There are tension of large fontanel, vomiting, regurgitation.
Hemolytic disease of newborns characterizes by tonic spasms with the transition to opisthotonus.
Seizures after injury are clonic-tonic. There are often loss of consciousness, vomiting,
hemiplegia, cranial nerve damage. There could be nystagmus, anisocoria, significant respiratory
disorders.
When thee is septic process in connection with acute cerebral ischemic, the symptoms of
stroke develop. There is loss of consciousness, clonic or tonic-clonic local seizures.
Hemiplegia occurs on the opposite side of the defeat. In acute infectious diseases seizures occur
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at the height of the disease and are a tonic or clonic-tonic in nature. Seizures are associated with
cerebral disorders and reflect encephalitic response to microbial invasion. Seizures usually
disappear simultaneously with the fall in temperature. In purulent meningitis the seizures
characterize by tonic muscle tension in the limbs and clonic muscle twitching of face and body.
There are tremor, trismus, and clonic convulsions in the beginning of disease when encephalitis
is.
Diagnosis
Diagnosis of convulsive syndrome in clinical manifestations is not difficult. History of life,
process of childbirth, history of disease, are important for diagnosisе
Among the additional methods there are used electroencephalography, echoencephalograph,
the study of ocular fundus and, according to indications, CT of skull. Lumbar puncture is the
great importance in the diagnosis of convulsive syndrome, which allow to establish the presence
of intracranial hypertension serous or purulent meningitis, subarachnoid hemorrhage or other
diseases of the CNS.
Electroencephalography (EEG) has crucial importance among the special methods of
investigation.
EEG is characterized by reduced basic rhythm gipersinhronnoy activity potentials, peaked
oscillations (spikes). Paroxysmal, especially such manifestations on the EEG, especially the
emergence of sharp wave complexes and peaks with a slow wave, indicative of epileptiform
process.
Increased cerebrospinal fluid pressure and the appearance of bloody CSF with the presence of
fresh or leached red blood cells indicates the presence of subarachnoid hemorrhage. Increasing
the number of cells in the cerebrospinal fluid (normal for young children from 5 to 20 cells per 1
mm3, 0,2-0,3% protein, 50-60 mg% glucose), lymphocytic pleotsitoz suggest aseptic meningitis.
Turbid fluid, neutrophilic or mixed neutrophil-lymphocyte pleotsitoz while increasing the protein
indicate purulent meningitis. Increase of protein in the cerebrospinal fluid to changes, but
relatively stable pleotsitoza indicates blockade of cerebrospinal fluid pathways. There is presence
of proteins of cell dissociation, increase the protein in the normal cytosine, can indicate the
presence of bulk process.
Always look for the link between convulsive syndrome in infectious and inflammatory diseases,
disorders of water and electrolyte balance, intoxication. This allows for pathogenetic treatment
simultaneously with symptomatic therapy.
Classification:
I. 1. Infections:
- Febrile convulsions.
- Meningitis and meningoencephalitis;
- Neurotoxicosis as an outcome of SARS;
2. Hypoxic:
- Affective respiratory spasms;
- With hypoxic-ischemic encephalopathy;
- In marked respiratory distress;
- With pronounced circulatory insufficiency;
- In a coma III of any etiology, etc.
4. Epileptic:
- Idiopathic epilepsy.
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5. Structural:
- Against the background of various organic changes in the central nervous system (tumors,
trauma, developmental anomalies, etc.).
II. 1. Connected with metabolic disorders:
- Gipokaltsiemicheskie (spazmofiliya, gipoparaterioz).
- Hypoglycemic.
- hypomagnesic.
- Piridoxine dependent.
2. Non-exchange
Epileptic reaction:
- Febrile convulsions;
- Affective respiratory spasms.
Epileptic syndrome:
- Organic brain damage;
- Traumatic brain injury;
- Neuroinfections;
- Poisoning;
- Cerebrovascular;
- Brain tumor
Causes of seizures:
Allergic • factors (vaccination convulsions);
• infectious and toxic factors (in infectious toxicosis, tetanus, meningitis, encephalitis, poisoning);
• metabolic disturbances (hypoglycemia, hypocalcaemia, hypokalemia, hypomagnemia,
pyridoxine deficiency );
• structure as a result of organic changes in the CNS;
• epileptic - idiopathic epilepsy;
• hypoxic (for diseases of the cardiovascular system, coma).
Anamnesis:
• the nature and duration of convulsions;
• presence of fever, headache, irritability, malnutrition;
• availability of trauma;
• possibility of acute poisoning;
• presence of nervous disorders and cramps in relatives.
The physical examination should begin with an assessment of breathing and circulation,
successively passing to elucidation of the causes of seizure activity
• the nature of breath, chest excursion;
• skin color (cyanosis, marbling, pallor, hyperpigmentation areas);
• signs of trauma (bruises, swelling, maceration);
• manifestations of septicemia (petechiae, haemorrhagic rash);
• pupils: size and their reaction to light;
• The status of springs and muscle tone.
Before proceeding to the anticonvulsant therapy should establish adequate oxygenation and
ventilation.
1. Maintenance of oxygenation and ventilation:
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• Ensure adequate airway;
• whenever possible, to give 100% O2;
• suck mucus from the oropharynx;
• when there is no effect to begin mask ventilation.
2. Ensure intravenous access:
• cannulation of peripheral vein;
• in order to maintain intravenous access permanent introduction of 0,9% solution of sodium
chloride or any other standard intravenous solution (5% glucose solution, Ringer's solution lactate);
• for suspected hypoglycemia - intravenous 40% or 25% glucose solution - 0, 5 g / kg;
• in cases of suspected acute intracranial hypertension to limit the intravenous infusion, but not
terminate - possible thrombosis cannula!
3. Anticonvulsant therapy.
Drug of choice in the treatment of cramps - benzodiazepines (diazepam, midazolam).
• diazepam (seduksen, relanium) – anticonvulsive drug immediately release with
moderately inhibits on the respiratory center. Initial dose - 0,2-0,3
mg / kg, given within 1-4 min. Repeated dose - 0,3-0,5 mg / kg;
• midazolam (versed) - anticonvulsant shorter action than diazepam, but to a lesser extent,
depress respiration. Initial dose - 0,15-0,2 mg / kg, is introduced for 1-4 min. Repeated dose (0,2 0,25 mg / kg) is introduced, if there is no effect of the original;
• oxybutyrate sodium (GHB) has a longer than benzodiazepines, anticonvulsant effect, but
oppresses the breathing. Dose - 50-70 mg / kg body weight (except for anticonvulsant, is a good
gipoksant).
Warning GHB is introduced very slowly (4-6 min.), As it increases blood pressure, which can
fatally exacerbate intracranial hypertension;
• Phenobarbital (Luminal) is used if a prior therapy to no avail. Dose - 10 mg / kg injected slowly
for 10-15 minutes. In the absence of relaxation for 20 minutes you can repeat the introduction in
the same dose.
Note! Benzodiazepines and phenobarbital significantly potentiate each other in the inhibition of
the respiratory center. When anticonvulsants are not effective, hexenal and / or miorelaxation and
artificial ventilation should be used.
Seizures in various states.
Febrile convulsions are noted in 2-5% of children from 3 month to 6 years. Often the first
symptoms are fever, convulsions. Febrile convulsions usually occur on the background of fever
lasts more than 15 minutes, has a generalized nature and usually passes spontaneously before the
arrival of the ambulance.
Features of treatment:
• well-docked antipyretic;
Therapeutic strategy:
1. The main task of a doctor who found a child's fever, is two questions:
• Do I lower the body temperature of the child and by what method?
• What should be the correct tactical decision?
2. Reduce body temperature of a sick child should be in the following cases:
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• baby first 3 months of life;
• when unfavorable premorbid background (presence of perinatal encephalopathy, seizures,
congenital heart disease);
• an increase in body temperature above 38,5 ° C.
In this case you should use antipyretics:
• children of the first two months of life - at a temperature above 38 ° C;
• Children older than 3 months and their temperature is above 39 ° C;
• at a temperature of 37 ° C to 38 ° C, if it is accompanied by complaints of poor health, muscle
pain or headache;
• at a temperature above 38 ° C in children with febrile convulsions in history;
• in a malignant hyperthermia with microcirculatory disorders.
3. First aid for hyperthermia depends:
• the magnitude of fever;
• the presence or absence of symptoms of peripheral circulation
The following drugs should not be recommended for children as antipyretics:
- Metamizole (analgine) causes inhibition of hematopoiesis.
-Ibuprofen is often a cause of adverse events (dyspepsia, intestinal bleeding).
Currently, pediatric practice excluded drugs such as amidopyrine, antipyrine, phenacetin.
Lytic cocktail:
I. Metamizole 50% - 5 mg / kg (0.1 ml / year) in / muscular, diphenhydramine, 1% or pipolfen
2,5% - 0,2 mg / kg (0.15 ml / year)
II. Metamizole 50% - 5 mg / kg / muscle, droperidol 0.25% - 0,05-0,25 mg / kg
III. pipolfen 2,5% - 0,2 mg / kg papaverine 2% - 0,2 mg / kg / muscle, analgine 50% - 5 mg / kg /
IV. chlorpromazine 2.5% - 1 ml, pipolfen 2,5% - 1 ml procaine 0.5% - 8 ml 0,1-0,15 ml of a
mixture of 1 kg of weight / muscle
To treat hyperthermic syndrome can also be used baralgin or voltaren 0.1 ml / kg
Desensitization drugs - reduce the level of pyrogens in the blood, reduce heat production by
acting on the center of thermoregulation.
Water - Acetic Wrap: vodka, 9% of household vinegar and water mixed in equal proportions
(1:1:1). Wet swab dipped this solution, wipe the baby's body, then let him dry off. The procedure
is repeated 2-3 times. Children with hyperthermia can not be limited drinking. The child should
try to give to drink in small portions is the amount of water, which he usually drinks.
4. Children are hospitalized with fever in the following cases:
• violations of the peripheral circulation;
• presence of neurological signs of toxicity (behavioral disorders, convulsive readiness);
• in such a presumptive diagnosis of meningococcal infection, meningitis, diphtheria, malaria,
surgical disease, septic state, etc.
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Hypoglycemic seizures:
• require urgent action to ensure oxygenation and intravenous access;
• intravenous 20% glucose solution 4.2 ml / kg body under the control of blood glucose every 4
hours may be combined with subcutaneous injection of 0.1% solution of adrenaline in the age
dosageThen an intravenous infusion of 10-20% solution - 6.4 mg / kg / min;
• prednisolone - 2-4 mg / kg intravenously;
• Hospitalization in endocrinology department of the hospital.
Lack of pyridoxine (pyridoxine depend convulsions) - pyridoxine 50-100 mg / kg body weight
intravenously, slowly, oral dose of 3.10 mmol / kg body weight per day.
Hypocalcaemia seizures:
• 10% solution of calcium gluconate - 1,0 ml / kg, dissolved in 2-fold glucose - by slow
intravenous injection;
• Hospitalization in general department.
Hypomagnesium seizures -25% Magnesium sulfate solution for 0.2 ml / kg body weight
intravenously slowly.
Hypertension - often accompanied by convulsive syndrome. Along with general activities, it
should establish an active antihypertensive therapy.
Neyrotoxicosis, meningitis, encephalitis:
• anticonvulsants (seduksen i / m or i / v and magnesium sulphate in / m);
• immediately after the cessation of seizures clean VAR to ensure their patency;
• oxygen therapy;
• with repeated seizures - GHB / m or i / v or hexenal 5% / m 0,5 ml / kg rectally 10% solution of
0,5 ml / kg intravenously 1% solution to obtain the effect, But not more than 15 mg / kg (atropine
to prevent vagotonicheskogo effect)
• Timely treatment with antibiotics;
• There are signs of shock, intravenous 0.9% sodium chloride - 20 ml / kg / h;
• Timely diagnosis and early treatment of brain edema;
• hospitalization in depattment of intensive theraphy of infectious hospital.
After stabilization of arterial pressure the total amount of input and drink the liquid should not
exceed 75% of the age of physiological needs.
Epileptic seizures:
• to prevent biting tongue and aspiration of vomit and blood;
• keep the patient during convulsions has not received a head injury and extremities;
•if seizures continue for more than 3-5 minutes, enter seduksen 0,3-0,5 ppm body weight by slow
intravenous, Magnesium sulphate intramuscular;
• in the absence of seduxen effect, administer hexenal;
• admission to hospital, having a neurological department.
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The sequence of treatment - tactical activities in convulsions in children:
1.
When respiratory disorders are:
- Insert gag (trowel)
- Clear the oral cavity and pharynx 100% O2 through a mask.
- The repeated attacks enter into the muscles floor of the mouth seduksen.
- With persisting symptoms of hypoxia enter there as atropine.
- Tracheal intubation.
- In the absence of effect and convulsions recur again seduksen and begin artificial ventilation.
- Provide access to the vein and enter the sodium oxybutyrate.
- Transportation to the intensive care unit on the background of continuing care interventions.
2. Etiology of seizures.
unclear
clear
Seduxen. Glucose 20% - 2 ml / kg and calcium gluconate 10% - 0,5 ml
/ kg - intravenously.
Treatment
of
respectively.
Oxygen therapy.
seizures,
If you still have cramps -access to the vein, the introduction of sodium
oxibutirate.
3.Consciousness after the attack.
Saved
The child is not hospitalized.
Lost
The depth of impaired consciousness.
Go to your doctor emergency In a coma I - II degree hospitalization in intensive care unit.
after 6 hours.
In a coma III - tracheal intubation after intravenous injection of
atropine. Mechanical ventilation, in / in dopamine.
Transportation to the continuation of resuscitation, hospitalization in
the intensive care unit.
VI. CONTROL QUESTIONS, TESTS, PROBLEM SOLVING
The sequence of treatment - tactical activities in convulsions in children, algorythms:
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1. When respiratory disorders are:
- Insert gag (trowel)
- Clear the oral cavity and pharynx 100% O2 through a mask.
- The repeated attacks enter into the muscles floor of the mouth seduksen.
- With persisting symptoms of hypoxia enter there as atropine.
- Tracheal intubation.
- In the absence of effect and convulsions recur again seduksen and begin artificial ventilation.
- Provide access to the vein and enter the sodium oxybutyrate.
- Transportation to the intensive care unit on the background of continuing care interventions.
2.Etiology of seizures.
unclear
clear
Seduksen. Glucose 20% - 2 ml / kg and calcium gluconate 10% - 0,5 ml
/ kg - intravenously.
Treatment
of
respectively.
Oxygen therapy.
seizures,
If you still have cramps -access to the vein, the introduction of sodium
oxibutirate.
3.Soznanie after the attack.
Saved
The child is not hospitalized.
Lost
The depth of impaired consciousness.
Go to your doctor emergency In a coma I - II degree hospitalization in intensive care unit.
after 6 hours.
In a coma III - tracheal intubation after intravenous injection of
atropine. Mechanical ventilation, in / in dopamine.
Transportation to the continuation of resuscitation, hospitalization in
the intensive care unit.
4. Neurotoxicosis, meningitis, encephalitis:
• anticonvulsants (seduksen in / m or I / O and magnesium sulphate in / m);
• immediately after the cessation of seizures clean VAR to ensure their patency;
• oxygen therapy;
• with repeated seizures - GHB intramiscular or intravenously or hexenal 5% / m 0,5 ml / kg
rectally 10% solution of 0,5 ml / kg intravenously 1% solution to obtain the effect, But not more
than 15 mg / kg (atropine to prevent vagotonic effect)
• Timely treatment with antibiotics;
• There are signs of shock, intravenous 0.9% sodium chloride - 20 ml / kg / h;
• Timely diagnosis and early treatment of brain edema;
• hospitalization in intensive department of infectious hospital.
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After stabilization of arterial pressure the total amount of input and drink the liquid should not
exceed 75% of the age of physiological needs.
5. Convulsive seizure in epilepsy:
• to prevent biting tongue and aspiration of vomit and blood;
• Keep the patient during convulsions has not received a head injury and extremities;
• If seizures continue for more than 3-5 minutes, enter seduksen 0,3-0,5 mg/kg body weight by
slow intravenous, magnesium sulphate intramuscular;
• in the absence of seduxen effect, administer hexenal;
• admission to hospital, having a neurological department.
1. Self Test Questions Quality of training:
1. Define cramps. The concept of tonic, clonic, localized, generalized convulsions. Diagnosis and
characteristics of emergency care.
2. Classification of seizures.
3. Preparing the patient for the provision of anticonvulsant therapy.
4. Describe the major anticonvulsants and justify their use.
5. Febrile convulsions. Diagnosis. Therapeutic strategy.
6. When should be used antipyretics for cramps?
7. Hypoglycemic, hypocaliemic, hypomagnesic cramps. Emergency.
8. Neurotoxicosis. Physician tactics on prehospital phase.
9. Convulsive seizure in epilepsy. Emergency.
Standards of answers in text topics.
2. Case problem:
Task 1. Patient was 28 years old, long ailing epilepsy. After violations of the treatment he
appeared frequent, large seizures, between which the patient remains unconscious. On pain
stimuli did not react. The pupils narrow, reaction to light was weak. Reduced muscle tone.
Determine the psychopathological state? (Status epilepticus). Emergency?
The standard answer:
• preventing the biting tongue and aspiration of blood and vomit,
• To monitor the patient during a seizure is not an injury of the head and limbs,
• If seizures last more than 3-5 minutes. To introduce seduksen 0,3-0,5 mg / kg body weight / in
fast and 25% solution of magnesium sulfate at the rate of 0.2 mg / kg intramuscular;
• in the absence of the effect of seduksena enter hexenal;
• hospitalization in the neurology department of the hospital.
Task 2. A sick noticed at the site of the bite ferret redness and swelling. The day before, a feeling
of concern inexplicable fear, is anxiety. On the third day of fever to 38 ° C, appeared spastic
convulsions, especially when trying to swallow the water became agitated, anxiety attack causes
convulsions.
Enter the likely diagnoses. (Rabies)
Emergency?
• anticonvulsants (seduksen intramuscular or intravenously, magnesium sulphate intramuscular);
• immediately after the convulsions clean VAR to ensure their patency;
• oxygen therapy;
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• when re-convulsive syndrome - GHB intramuscular or intravenously or hexenal 5% / m 0,5 ml /
kg rectally 10% solution 0, 5 ml / kg intravenously 1% p-p to get the effect, but not more than 15
mg / kg (atropine to prevent vagotonic effect);
• admission to the ICU of an infectious hospital.
V. MARERIALS FOR SELFCONTROL
1. Problem solving:
1. Olga M. 6 months - child of first birth, which took place without pathology. Feeding was
carried out with whole milk with 2 months. The diet is dominated by cereals. Vegetables girl
eats poorly. Independently not sitting. Seen from the observed marked frontal and parietal
tuber; palpable edge "rosary". Muscle tone decreased. Liver by 3,5 cm acts out of the costal
arch. From the lungs and heart abnormalities were detected.
1. Put the diagnosis.
2. Assign vitamin D2.
3. Specify the duration of the course.
The standard answer: Rickets II, height, subacute course. The dose of vitamin D2 - 4,000 IU.
The course is 30-45 days.
2. Child of 3 months, was admitted to hospital complaining of vomiting, restlessness, diarrhea,
refusal to eat. A child from the first pregnancy complicated by preeclampsia second half, was
born at gestational age 36 weeks in a state of mild asphyxia. Birth weight 2 100 g. Located on
the artificial feeding with 1 month (adapted mix "Baby", "Babe"). In one month, his mother
was giving the child to prevent rickets vitamin D and 1 drop of oil solution daily, and with a 2month switched to an alcohol solution, because Oil ended. Within a month child received 10
ml of alcoholic solution of ergocalciferol (a single drop of alcohol solution containing vit.D
4000 IU).
When you receive the child's condition serious: Sopore, skin pale with a pronounced "marble",
the skin and mucous membranes are dry, the subcutaneous fat layer thinned, turgor tissues is
flabby, muscular hypotonia. Heart sounds are muffled, tachycardia. Blood pressure - 100/70
mm.Hg. Breathing in a harsh islight shade. The abdomen was soft, the liver appears from
under the costal arch to 3 cm. Chair liquid. Body weight child is 3500g.
1. Your tentative diagnosis?
2. What diagnostic tests are needed?
3. Is it possible treatment of the child in the outpatient setting?
4. How often should monitor the level of calcium in the blood after discharge from hospital "
The standard answer:
1. Acute D hypervitaminosis, the crisis period.
2. Urinalysis, determination of calcium, phosphorus, and alkaline phosphatase activity in the
blood (normal calcium, 2,25 - 2,5 mmol / l, P 1,45 - 2,1 mmol / l), the determination of the
concentration and renal excretory function ( sample of Zemnitsky), total blood.
3. No.
4. 1 time in 3 weeks.
2.The list of practical skills needed to consolidate the material:
-Assess the state of respiration and circulation;
To provide a patent airway;
A-oxygenation;
-To suck the mucus from the fauces;
Plug-dropper;
-i/v;
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-A resuscitation in cardiac arrest and not breathing
3. Tests:
I. A sick noticed at the site of the bite ferret that occurred three days earlier, redness and
swelling. A day before she feeled anxiety, depression. On the third day temperature of 38 ° C
(spastic convulsions, especially when trying to swallow the water became agitated, anxiety
attack causes seizures. Specify the probable diagnosis
A Frenzy
B Atropism
C Hysteria
D Encephalitis
E Tetanus
II. At the examination of physician pregnant female in 30 weeks of pregnancy are having
convulsions with transient loss of consciousness. BP is 170/100 mm Hg, generalized edema. In
the analysis of urine a week ago, was determined by protein - 3 g / l, hyaline cylinders. What is
the most likely diagnosis?
A Epilepsy
B Eclampsia
C Hypertension pregnant
D Seizures
E Eclampsism
III. Emergency doctor pregnant Z. 29 years in term of 33 weeks which complains of pain in
the epigastric region, nausea, vomiting, flashing of "fly" in front of the eyes, twitching of
facial muscles and found BP on both arms 170/110 mm Hg , generalized edema. Enter any
anesthetic and resuscitation should be patient in the first place.
A Assign disaggregants
B Ensure effective ventilation (ALV)
C Assign resources that prevent cramps
D Assign antihypertensives
E Carry out correction of metabolic and water-electrolyte disorders
IV. The patient's 3-week-old admitted to the clinic in the state late phase of hypovolemic
shock and oligoanuric stage of acute renal failure was diagnosed. The child is withdrawn,
depressed reflexes, periodically - generalized convulsions, prefontanel pulsing. At the fundus
of the eye there is stagnant optic disk. What kind of complications should think?
A Uremic coma
B Arterial hypertension
C Meningoencephalitis
D Hypertensive encephalopathy
E Hemolytic uremic syndrome
V. Mother 3-month-old girl drew attention to the appearance of convulsions in a child for any
illness, which occurs with high fever. A child was born in asphyxiated. Convulsions are a
tonic-clonic in nature, they are generalized. What a survey should be a doctor in the first
place?
A Echoentsefaloskopiyu
B Rheotachygraphy
C Electroencephalography
D Skull radiography
E Lumbar puncture
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VI. Ambulance was called for boy 10 years old. Upon examination there are dry and pale skin
and mucous membranes. Breathing is frequent, noisy. Pulse is threaded. Last 3 months
complaining of thirst, lethargy, frequent urination. He lost weight. The most probably
comatose child is due to:
A Hypoglycemia
B hyperglycemia
C Acetonemia
D Uremia
E Encephalopathy
VII.U 10-month-old baby, whose birth was easy asphyxia, the first day of acute respiratory
viral infection accompanied by increased body temperature to 39 ° C appeared seizure tonicclonic seizures. The introduction of the drug will be most effective in this case?
A Difenina
B Seduksena
C Nifedipin
D Droperidol
E Chlorpromazine
VIII. A child 5 years old enrolled in the reception department at 8th day of wind wheels pox.
Upon examination there are headache, vomiting, unsteadiness of gait, drowsiness,
discoordination movements, tremor of limbs. There was a temporary disturbance of
consciousness and convulsions. What determines the severity of the disease syndrome?
A Neurotoxycosis
B Encephalitis
C Infectious-toxic shock
D Meningitis
E Encephalic reaction
IX. Large seizures are developed in child 6 years old, who from 3 years old are receiving
treatment for epilepsy at a reception at the district pediatrician. Priority actions doctor:
A Enter sibazon intramuscularly
B Ensure airway
C Carry oxygen
D Artificial ventilation of lungs
E Enter diuretics
X. There were a sharp cry, seizures, cyanosis, tonic-clonic seizures in a newborn boy after the
operation replacement blood citrate blood turned into anxiety, The content of sodium in the
blood serum 142 mEq / l, magnesium 0.9 mEq / l, calcium - 1.6 mmol / L, potassium - 4.8
mEq / l,. What electrolyte disturbances arose in the child after the transfusion of citrate blood?
A Hypermagnessium
B Hypercalcaemia
C Hypocalcaemia
D Kalipinya
E Hyponatremia.
VI. Literature:
15
1. Text of topic
2. Martin L. Kutcher, Gregory L.Holmes Children with seizures: A guide for parents,
theachers and professionals, Philadelphia, USA, 2006, p.34-67
3. Panayiotis Varelas Seizures in Critical care: A guide to Diagnosis and Therapeutics,
2009, Humana press 2009, p.1-179
4. Leppik I.E. Treatment of epilepsy in the elderly // Curr. Treat. Options Neurol. — 2008
Jul. — 10. — 4. — 239-45.
5. Seino M. Classification criteria of epileptic seizures and syndromes // Epilepsy. Res. —
2006 Aug. — 70, Suppl. 1. — S27-33.
Study guidelines prepared by_________________________________________________________
Discussed and approved in Department meeting № __ of_______________201_.
Department Head
V.I. Velichko, MD, PhD____________________