Day 1 - Neuro Part 1 Infx & HA Flashcards Preview

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Flashcards in Day 1 - Neuro Part 1 Infx & HA Deck (25):

Common etiologies in empiric IV antibiotics choices for bacterial meningitis based on age; Important adjunct tx

(1) Less than one month - 1. E. Coli, 2. GBS, 3. Listeria = Ampicillin (Listeria); Cefotaxime/Gentamycin; (2) 1 month - 60 yr. - 1. S. pneumo, 2. N. meningitidis = Cefotaxime/Ceftriaxone (Vancomycin may be used empirically to cover S. aureus); (3) 60+ year - S. pneumo, Listeria, N. meningitidis, & Gram (-) bacilli = Ampicillin (Listeria), Cefotaxime/Ceftriaxone (N. meningitidis), Vancomycin (in case of S. aureus) (discontinue based on dx) ; Dexamethasone IV q 6 h for 4 days if > 6 months of age prior to or along with first dose of antibx (CHILDREN - reduces risk of neurologic sequalae such as hearing loss, especially in cases of HiB or Tb meningitis; ADULTS - reduces morbidity and mortality, especially in cases of pneumococcal meningitis )


Tx approach for suspected viral meningitis

Tx symptomatically: Acetaminophen for pain, IV fluids PRN, Empiric antibx until bacterial meningitis excluded; Excluding bacterial meningitis: (1) If younger than 3 years, severely ill, or immunocompromised - continue antibx until culture results confirm (2) if outside above criteria - CSF profile negative & positive viral antigen; Acyclovir - if suspect HSV or signs of encephalitis, such as focal neurologic findings; discontinue if HSV PCR and cultures negative or if alternative dx made


Tx Reye

Discontinue ASA/Salicylate; Hospitalization - ~ ICU for cardiorespiratory monitor & possible ventilation, supportive care, fluid/electrolyte management, maintain isovolemia, reduce brain swelling, avoid hypo-osmotic fluids (e.g., free water induce swelling) - give iso-osmotic fluids (e.g., LR, NS), elevate head of bed; Possibly corticosteroids, intracranial pressure monitor; If seizures, given phenytoin (not prophylactically)


Differences in acute tx for tension, migraine, & cluster HA

(1) Tension: Oral NSAIDs, Ketorlac, Ergotamines, Triptans (2) Cluster: 100% O2, Ergots (vasoconstrictor), Triptans (3) NSAIDs, Ergots, Sumatriptan, Anti-emetics (e.g., chlorpromazine, perchlorpromazine, metoclopramide) ; Do NOT combine vasoconstrictors, but may combine vasoconstrictors with anti-emetics; Contraindications to vasoconstriction - CAD, Prinzmetal angina, Pregnant


Ppx migraine HA

(1) CCB - verapamil *first line* (2) Beta blockers - propanolol, metoprolol (especially if comorbid HTN/Thyroid disease) (3) Antidepressants - TCAs like amitriptyline (Elevil?), nortriptyline (especially comorbid depression, insomnia, or pain syndrome); Note: Nortriptyline has less anticholinergic effects (more dementia) (4) NSAIDs - not first line due to complication of NSAID-induced (comorbid menstrual migraine or osteoarthritis) (5) Anticonvulsants - Valproic acid (especially comorbid bipolar disorder), Topiramate, Gabapentin


HA: Made worse w/ foods containing tyramine

Migraine HA


HA: besity now w/ papilledema

Pseudotumor cerebri


HA: Jaw muscle pain when chewing

Temporal arteritis


HA: Periorbital pain with miosis and ptosis

Cluster HA


HA: phonophobia &/or photobia

Migraine HA


HA: bilateral occipital/frontal pressure

Tension HA


HA: Lacrimation &/or Rhinorrhea

Cluster HA


HA: Elevated ESR

Temporal Arteritis


HA: Worse headache of life

SAH (e.g. 2/2 berry aneurysm rupture)


HA: Extraocular muscle palsies

Cavernous sinus thrombosis


HA: Scintilating scotomas prior

Migraine HA


HA: before or after orgasm

Post coital cephalgia


HA: responsive to 100% O2 supplementation

Cluster HA


HA: Head trauma, HA begins days after event, persists over a week, does not go ahead

Subdural Hematoma


HA: 10 Sx suggesting brain tumor

(1) Mild HA progressively worsens over days to weeks (2) New onset HA after age 50 (3) Papilledema (elevated ICP) (4) Worsened by lifting, bending, cough, or valsava (due to elevated ICP) (5) Associated seizures, confusion, AMS (6) Abnormal neuro s/sx (7) Disturb sleep (8) Upon awakening (9) Vomiting preceding (10) Known systemic illnesses (e.g., collagen vascular diseases, HIV)


Pseudotumor cerebri p/w

Young, obese female ; HA daily, worse in AM, pulsatile, possible n/v/EOM pain, papilledema


Pseudotumor cerebri most worrisome complication

Vision loss


Pseudotumor cerebri CT scan result

Absence of ventricular dilation = Normal CT


Dx Pseudotumor cerebri

CSF pressure elevated > 200 mmHg in non-obese or > 250 mmHg in obese; (Check CSF pressure w/ patient lying down to equalize pressure)


Tx approach Pseudotumor cerebri

(1) Confirm/Rule out other pathologies w/ CT or MRI (central venous thrombosis, brain tumors) (2) Discontinue offending agents - Vitamin A excess, Tetracycline, Withdrawal from corticosteroids (3) Weight loss (4) Acetazolamide (carbonic anhydrase inhibitor, diuretic - also tx altitude sickness, glaucoma) (5) Serial LPs (6) Optic nerve sheath decompression (7) Lumboperitoneal CSF shunting

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