Mr Potter is a 66-year-old gentleman who lives alone independently. He has presented to his GP, accompanied by his daughter, who is concerned he “just isn’t himself”. She feels he is quieter than usual and has been sleeping for most of the past two days.
Screen for confusion
Use the abbreviated mental test score (AMTS) or other tools (e.g. six item cognitive impairment test):
- Time? (nearest hour)
- Address for recall at the end of the test (get patient to repeat back to ensure heard correctly e.g. “42 West Street”).
- Name of this place?
- Identification of two people (e.g. doctor / nurse)
- Date of birth
- Year of first world war?
- Name of the present monarch?
- Count backwards from 20 to 1
Address from question 3 recalled correctly?
Mr Potter remembers his name but struggles with his date of birth.
He believes the year is 1978 and he is at home.
His overall score is 5/10.
History of the presenting complaint
Do you feel confused? How long have you felt confused for?
Low mood? – symptoms may suggest depression
Weight change? – malignancy/hypothyroidism
Have you fallen or injured your head recently? – intracranial bleed
Any headache? – location / timing / worse when lying or standing?
Any pain anywhere at the moment? – ask SOCRATES if present
Recent infective symptoms? – productive cough / dysuria or urinary frequency / fever / abdominal pain
Past medical history
What other medical conditions do you have? – diagnosis of cognitive impairment?
Medications? – recent changes? / anticoagulants or antiplatelets? / analgaesia (opiates)?
Living situation – Who lives with this gentleman? / Is he coping?
Alcohol consumption? – How much and how often?
Recreational drug use?
Mr Potter denies any headache, but he appears rather blank as you continue to ask the further questions, failing to provide any meaningful answers.
What’s his normal level of function at home? – Is he coping?
Any history of falls or trauma?
Previous similar episodes of confusion?
Past medical history?
Medications? – recent changes?
Recreational drug or alcohol use?
His daughter states that Mr Potter is normally “fully with it” and hasn’t been confused in the past, remaining fully independent at home. She isn’t aware of any recent trauma, but has noticed he has become increasingly unsteady on his feet over the last 6 months. She knows her father is on some blood pressure tablets and also on Warfarin for “a funny heart rhythm”. She last took him to have a blood test to “check his Warfarin is working ok” about 4 weeks ago. She denies any knowledge of her father taking illicit drugs and he doesn’t drink alcohol.
On examination, Mr Potter is confused but alert.
He is able to obey commands and his eyes are opening spontaneously.
What is his GCS?
Neurological examination of the upper and lower limbs:
- Normal tone
- Power 4/5 in right arm
- Power normal in all other limbs
- Brisk right biceps and triceps reflex
- Reflexes normal in all other limbs
- Normal co-ordination
- Normal sensation
- Mild right pronator drift
Cranial nerves – no deficits noted
On general examination, you notice some scuffs to his left shoulder and left ear, with some mild bruising on his head just posterior to the ear.
What is the significance of the pronator drift?
Other investigations could include:
- Bloods (FBC / U&E/ CRP / Bone profile / Magnesium / TFTs) – useful to rule out any potential causes of confusion (e.g. electrolyte abnormality / infection / hypothyroidism)
- Urine dipstick – ?UTI – common cause of confusion in the elderly
Left subdural haematoma (no midline shift)
A little later that evening…
Whilst on the ward Mr Potter has another fall.
Afterwards, his GCS begins to deteriorate.
His eyes are now only opening to pain, he is demonstrating a withdrawal response to pain and making incomprehensible sounds.
Potential extension of the subdural haematoma causing raised intracerebral pressure.
He may have developed a separate intracerebral bleed (less likely).
He may be having a seizure – although he isn’t demonstrating any typical seizure symptoms.
GCS 8 or below indicates a significant risk of airway occlusion.
As a result, the airway needs to be secured.
- Extension of the left subdural haematoma
- Midline shift
- Extra-axial soft tissue swelling on the left
Burr hole evacuation of the acute subdural haematoma
- Warfarin works by inhibiting the recycling of active Vitamin K, reducing its availability
- This, in turn, decreases the availability of Vitamin K dependent clotting factors (II, VII, IX, & X.)
- Giving vitamin K, therefore, replenishes active vitamin K and allows production of the vitamin K dependent clotting factors.
- Administered orally it reduces the INR within 24-48hrs.
- Administered IV it reduces INR significantly within 12-14hrs.
- In this situation, there is active bleeding that needs to be managed using emergency surgery. As a result, Vitamin K would not be a sufficient solution in the hyper-acute situation, given it will take at least 12 hours to have an effect.
Beriplex – needs discussion with haematology
- Combination of blood clotting factors II, VII, IX and X, as well as protein C and S.
- If the bleeding is significant and requires urgent surgery, vitamin K alone is too slow acting. As a result Beriplex is used to directly replace the clotting factors.
- It is therefore very effective at reversing the effect of warfarin rapidly to allow emergency surgery to go ahead with a reduced risk of bleeding.
- In this situation, Beriplex would seem more appropriate. However this decision would not be up to you and instead the neurosurgical team would discuss this with haematology to decide on the best course of action pre-operatively.
1. CT Scan image – By Lucien Monfils (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons