Exam 1 - Seizures, Status Epilepticus, & Acute Ischemic Stroke

Question 1

List provoked seizure etiologies? Unprovoked?

Answer 1

intoxication, withdrawal, trauma, meningitis, psychiatric, metabolic derangements; ???

Question 2

List inhibitor neurotransmitters? Excitatory?

Answer 2

GABA; glutamate, aspartate, acetylcholine

Question 3

Define status epilepticus?

Answer 3

a seizure lasting >5 minutes

Question 4

What are first line agents used to stop seizures?

Answer 4

benzodiazepines (lorazepam, diazepam, midazolam)

Question 5

What are first line agents used to prevent more seizures from occurring?

Answer 5

antiepileptics (phenytoin, fosphenytoin, leviteracetam, valproic acid)

Question 6

What are AEs of fosphenytoin? (2)

Answer 6

cardiovascular effects (Na+ channel blocker), extravasation

Question 7

What are AEs of phenytoin?

Answer 7

P-450 interactions, hirsutism/hypertrichosis, enlarged gums (gingival hyperplasia), nystagmus, yellow-browning of skin (hepatitis), teratogenicity, osteomalacia (Vitamin D deficiency), Interference with folate metabolism (anemia), neuropathies (vertigo, ataxia, HA), neutropenia, thrombocytopenia, hypotension, bradycardia, QT prolongation

Question 8

What is the goal phenytoin level?

Answer 8

10-20 mcg/dL

Question 9

What percent of phenytoin is protein bound?

Answer 9

90%

Question 10

What is the dose for leviteracetam in SE?

Answer 10

60 mg/kg IV bolus

Question 11

What is the dose for valproic acid in SE?

Answer 11

40 mg/kg IV bolus

Question 12

What are AEs of valproic acid? (5)

Answer 12

drowsiness, HA, thrombocytopenia, pancreatitis (pediatrics), hyperammonemia

Question 13

What does valproic acid interact with and what is the effect?

Answer 13

phenytoin, displaces and increases fraction unbound

Question 14

What is the dose for lacosamide?

Answer 14

100-200 mg IV BID

Question 15

What are AEs of lacosamide?

Answer 15

dizziness, abnormal vision (diplopia), ataxia

Question 16

When is SE considered refractory?

Answer 16

seizures that last >2 hrs or recurring despite treatment with conventional antiepileptic drugs

Question 17

What must be done as post-intubation treatment? (2)

Answer 17

IV infusion of antiepileptic (propofol or midazolam) and long-term monitoring EEG

Question 18

What is the dose for midazolam refractory SE treatment?

Answer 18

2 mg IV bolus

Question 19

Which drugs are used for inducing medical comas? (2)

Answer 19

phenobarbital, pentobarbital

Question 20

What are AEs of barbiturates?

Answer 20

respiratory depression, hypotension, lethargy, nystagmus, thrombocytopenia, immune suppression, decreased GI motility

Question 21

What is the goal of therapy for SE?

Answer 21

attain burst suppression on the LTM and maintain for 24-48 hrs

Question 22

What is treatment for super refractory SE?

Answer 22

ketamine 1.5-3 mg/kg IV bolus

Question 23

What score is considered a minor stroke on the NIHSS scale? Severe?

Answer 23

1-4; >21

Question 24

What are neurological stroke mimics?

Answer 24

seizure/post-ictal state, complicated migraine, other intracranial process (abscess, tumor, hemorrhage), vertigo, transient global amnesia, cranial/peripheral neuropathies (Bell’s palsy)

Question 25

What are metabolic stroke mimics?

Answer 25

hypo/hyperglycemia, hyponatremia, hepatic encephalopathy, drug overdose

Question 26

What are psychiatric stroke mimics?

Answer 26

conversion disorder, malingering

Question 27

If less than 4.5 hrs since onset, what is stroke treatment?

Answer 27

IV fibrinolytics +/- thrombectomy

Question 28

What is the dose for alteplase?

Answer 28

0.9 mg/kg with 10% as bolus over 1 min and rest over 1 hr, max 90 mg

Question 29

What is the dose for tenecteplase?

Answer 29

0.25 mg/kg, max 25 mg

Question 30

What is the blood pressure required for a thrombolytic bolus?

Answer 30

<185/110 mmHg

Question 31

What is the blood pressure required for a thrombolytic infusion?

Answer 31

<180/105 mmHg

Question 32

When is permissive hypertension allowed?

Answer 32

if patient meets exclusion criteria and alteplase is not given

Question 33

What are first-line antihypertensives for blood pressure control in acute ischemia? (2)

Answer 33

labetalol, nicardipine (preferred if HR <55)

Question 34

What are second-line antihypertensives for blood pressure control in acute ischemia? (3)

Answer 34

hydralazine, enalaprilat, clevidipine

Question 35

When may tenecteplase be preferred over alteplase?

Answer 35

large vessel occlusions

Question 36

What is treatment for symptomatic intracranial hemorrhage from fibrinolytic therapy? (3)

Answer 36

discontinue fibrinolytic (duh), IV cryoprecipitate 10 U over 10-30 min, IV tranexamic acid 1 g or ε-aminocaproic acid 4-5 g

Question 37

What is treatment for angioedema from fibrinolytic therapy? (6)

Answer 37

maintain airway, hold ACEi (major risk factor), IV methylprednisolone 80-100 mg , IV diphenhydramine 50 mg, IV ranitidine 50 mg or famotidine 20 mg, epinephrine 0.3 mL, "watch and wait"

Question 38

List the treatment recommendations for post-fibrinolytic care? (5)

Answer 38

neuro/BP monitoring, high-dose statin, aspirin (or dual-antiplatelet for those with stent), DVT prophylaxis (>24 hrs post-alteplase), anticaogulation (if cardioembolic stroke or Hx of a fib)

Question 39

List the recommendations for secondary stroke prevention?

Answer 39

lifestyle and nutrition mods, smoking cessation, limit alcohol consumption, counsel on substance abuse, manage medical conditions