ORALS - NEURO

Question 1

MG Patient case

Answer 1

PATIENT: Diplopia, ptosis, fluctuating, fatiguable weakness, dysphagia, can’t tolerate secretions

1. PPE/MOVID
   => FVC/MIPS/MEPS Q2H x3
2. Exam - ice bag test (measure eye opening, ice bag 5min, then eye opening) + test = IMPROVE 2mm
3. Management
   If CXR shows PNA - don’t give azthm (macrolide) => just CTX
   Plex
   IVIG 1g/kg
   Neuro for pyridostigmine 60mg PO Q6H
4. Intubation
   preO2 normally (can consider BIPAP)
   Rocuronium - decr dose (0.6mg/kg) ?
   => indications for intubation:
   FVC/MIP/MEP (20-30-40) => intubate
   bulbar weakness
   resp distress
   incr PaCO2
   inadequate secretion clearance

Follow up questions
1. List triggers for MG crisis
Infection
Aspiration
Surgery
Preg and child birth
Thymoma
RA
BB – labetalol, metoprolol, propranolol
class 1 anti-arrythmics - procainamide, quinidine
NMB
Bolulinum toxin (don’t get botox)
MgSO4
Antibiotics:
* Aminoglycosides – gentamicin, tobramycin
* Fluoroquinolones – ciprofloxacin, levofloxacin
* Macrolides – azithro, clarithro
Lithium
Steroids
Phenytoin, phenobarb, carbamazepine

2. ddx for weakness / paralysis
   (ascending) Tick, GBS
   (descending) MG, botulism, paralytic shellfish, polio, hypokalemic periodic paralysis, lambert eaton, transverse myelitis, paralytic rabies
3. Pathophys
   MG - autoantibodies - nicotinic ACH receptor
   Lambert Eaton - autoantibodies - inadequate release of ACH

Question 2

SEIZURE CASE

(febrile seizure)

Answer 2

1. PPE/MOVID
2. MGMT
   (see image below)
   also consider
   => hypoglycemia 5cc/kg D10W
   => hyponatremia 3% NS 2cc/kg IV
3. Febrile seizure mgmt
   => Look for fever source
   => No AED or neuro referral
   => Simple and complex are managed the same
   => Risk of epilepsy increases from 1% to now 2%
   => 30% of these kids will have another one
   => 75% of these will be within the year

follow up questions

1. Criteria for febrile seizures
   Age 6m to 5 y
   Temp >38
   No evidence of alternative cause, CNS infection, acute metabolic abnormality, prior afebrile sz hx
   Simple= 15m, 1 in 24hrs, non-focal or GTC
   Complex = anything not above
2. Definition of status
   5min continous seizures
   OR
   2 discrete seizures - with incomplete recovery of consciousness

Question 3

ICH

Answer 3

SBP goal - 20% MAP drop in first 1st hr (140-160)

ICP :
HOB 30-45 deg
Hypertonic saline 3cc/kg
hyperventilate CO2 30-35
oxygenate well

Question 4

VERTIGO

Answer 4

HINTS EXAM
Head impulse => 20 deg side to side
- Central/normal: eyes stay fixed
- Peripheral – corrective saccade back to midline, eyes move w head
Nystagmus
- Central: bidirectional that changes direction
- Peripheral: unidirectional
- (slow – bad side / fast – good side)
Test of skew / cover / uncover test
- Central – eye realigns to fix vertical dysconjugate gaze
- Peripheral – both eyes fixed on you

DDX for central vertigo
- vertebrobasilar insufficiency
- CB hemorrhage
- ICH / CVA
- Dissection
- MS
- tumor
- infection - encephalitis, meningitis, brain abscess
- temporal lobe epilespy
- migraine

DDX for peripheral vertigo
- BPPV
- Vestibular labyringhtisi
- vestibular neuritis
- meniere’s disease
- perilymph fisutla
- acute OM
- motion sickness
- acoustic neuroma
- inner ear DCS
- trauma