Funtabulously Frivolous Friday Five 331

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the Funtabulously Frivolous Friday Five 331

Question 1

A 41-year-old woman presents with a right frontotemporal headache and drooping of the right eye. The previous day she rode a roller coaster ride. Examination revealed a right Horner syndrome with ptosis, meiosis, and no anhidrosis. What is the diagnosis?

Reveal the funtabulous answer

Roller Coaster Stroke (carotid artery dissection to be precise)

Roller coaster rides can generate force in excess of 4 “Gs,” which in combination with neck movements could potentially rip the carotid intima. Distension of the injured arterial wall compresses the adjacent sympathetic fibers, resulting in a Horner syndrome, which is typically without anhidrosis, in lesions above the bifurcation, where the fibres supplying the face leave to traverse with the external carotid artery. This case and explanation was taken from Neurology “A ripping roller coaster ride” by Blacker and Wijdicks.

The phenomenon of roller coaster stroke doesn’t just have to involve the carotid artery it can also involve the vertebrals. These phenomena mainly occur in a younger population without stroke risk factors. It is important to ask about minimal trauma weeks before an incident including minor MVAs (not just roller coaster rides) and for some, they can be unlucky and have spontaneous dissections.

Below is an excellent talk by Dr Sean Caine on 5 important headaches not to miss. Remember young people with focal neurological deficits that occur suddenly, even if not present in your emergency need acute work up for dissections.

References


Question 2

Professors Graham Teasdale and Bryan J. Jennett developed what commonly used score 47 years ago?

Reveal the funtabulous answer

Glasgow Coma Scale

The GCS has been rolled out to at least 80 different countries and is produced in 40 different languages. As with any large scale roll out they noted some variance in its use with clinician scores fluctuating due to the language they used and what one personal classifies as painful stimuli is different to the next.

With 40 years since its universal roll out, they changed the score in 2014 (well at least the language) and directed us on how to perform a painful stimuli (now called pressure).

Instead of painful stimuli, its now called pressure and sternal rubs are out (due to harm). The score is not cumulative if a component is not testable (NT) i.e. you have an intubated patient and they can not talk, this maybe E3,V NT,M4. You then monitor the trend. And perhaps the most helpful, the verbal score is now rated as orientated, confused, words, sounds and none.

And to reiterate the score should not be used cumulatively as discussed by neurosurgeon Michael Cearns (@MDCearns) on twitter. Their excellent post on the GCS (a 15 point tweetorial – I’m sure the fact their are 15 will not be lost on our FFFF fans) explains why the motor component is so vital. Abbreviated below and images from Michael Cearns:

M6 – You need your whole brain to be working to obey a command:

M5 – you’ve lost a few synapses but cortical processing is working and you can localise.

M4 – ‘almost’ localising but there is no motor planning so you dont quite get the target. It’s a simple motor cortex action without refinement.

M3 – now the corticospinal tracts are out and our more primitive motor tracts take over. Firstly flexion to harm i.e. protecting your face to some impending danger but you won’t localise or cover your face, patients simply flex at the elbow.

M2 – Now the midbrain is out and you act like a quadruped. Think like a dog – they extend all four limbs and neck – extensor posturing.

Finally M1 – nothing is getting through

References:


Question 3

What is the longest anyone has survived without food or water?

Reveal the funtabulous answer

18 days

As far as the FFFF team can find, Andreas Mihavecz holds the official title from the Guinness book of world records (well util they stopped publishing fasting records for fear people would die trying to break them). This was not an intentional record he wanted. On 1st of April 1979, at the age of 18 he was arrested and placed in a cell and was forgotten about by three policemen. A 4th police officer investigated 18 days later when they noticed a horrible smell in the basement. He lost 25kg and ingested condensed water off the walls.

The three policemen blamed each other, thinking that the others had released him and couldn’t hear his pleas because the cell was in the basement. The police officers had to pay Andreas 2000 EUR each and later the Austrian Government award 19,000 EUR in compensation.

Reference


Question 4

What disease and sign is demonstrated in the following video?

Reveal the funtabulous answer

Hypothyroidism demonstrating the Woltman sign of a slow ankle jerk.

Woltman did not publish any original research or descriptions regarding the delayed relaxation phases of the muscle stretch reflexes in patients with myxoedema. Chaney published the objectively measured delay of the relaxation phase of the muscle stretch reflex in patients with myxoedema, the first concise and objective description in the medical literature in his 1924 publication but did not mention Woltman. Chaney clearly stated that the finding had been used in the Mayo Clinic Section of Neurology for years prior to his publication and although Woltman’s name did not appear on the publication, it was not uncommon for him to mentor projects…

The eponym Woltman sign first appeared in the 1956 Mayo Clinic publication of Clinical Examinations in Neurology. A tome dedicated to Henry Woltman and Frederick Moersch, and was presented to Woltman at the time of his retirement. It is most likely that the eponym of Woltman sign of myxoedema is an homage to an esteemed colleague entering retirement, rather than the definitive designation of priority in discovery.

References


Question 5

What is a ‘cafe coronary’?

Reveal the funtabulous answer

Complete and abrupt upper airway obstruction by a bolus of food, often meat, which occludes theoesophagus and larynx, so named as the sudden onset of symptoms simulates acute myocardial infarction. Café coronariesvictims are speechless, breathless and, without assistance (e.g., Heimlich manoeuvre), will die.

Segan’s Medical Dictionary

And check out FFFF 197 to remember what Dr Henry Heimlich did to beagles to prove his method worked in choking victims.


…and Finally

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Funtabulously Frivolous Friday Five

Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Burnaby Hospital in Vancouver. Loves the misery of alpine climbing and working in austere environments. Supporter of FOAMed, toxicology, tropical medicine, sim and ultrasound

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