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Test #1 Flashcards

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1
Q

Huntington’s Disease

A

Cerebral and caudate nucleus atrophy -> GABA and acetylcholine deficiency

Chronic, progressive chorea w/ impulsive and antisocial behavior from dopamine surplus

Dx: MRI (caudate atrophy), PET (caudate metabolic abnormalities), Genetic testing - gold standard

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2
Q

Huntington’s Disease Treatment

A

Goal: Downregulate dopamine, suppress chorea

Neuroleptic and Tetrabenazine to suppress and breakdown Dopamine

Anticonvulsants: Clonazepam, Valproic Acid

Antipsychotic: Risperidone, Olanzapine

Antidepressants: Fluoxetine, Sertraline, Nortriptyline (TCA)

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3
Q

Huntington’s Treatment Side Effects

A

Hyper-excitability, fatigue, restlessness

Antipsychotic SE mimic signs of Parkinson’s - dull facies, tardive dyskinesia

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4
Q

Essential Tremor

A

Most common tremor cause - inherited

Bilateral, occurs w/ action, constant frequency w/ variable amplitude

Have to r/o Parkinson’s - should be only abnormal thing on exam

Relieved by ETOH

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5
Q

Essential Tremor Treatment

A

Propanolol - 1st line (Atenolol w/ asthma/bronchospasm)

Mysoline/Gabapentin - anticonvulsants

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6
Q

Parkinson’s Disease

A

Progressive neurodegenerative disorder -> substantia nigra breakdown causes dopamine deficiency

TRAP, fixed facial expressions, Myerson’s sign (repeated tapping of the nose causes blinking), Lewy bodies

Onset usually after 50 years old

Tremor @ rest, disappears during sleep, cog-wheel/rachet-like motions

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7
Q

TRAP

A

Tremor - resting and postural = unilateral, @ rest

Rigidity = increased resistance to passive movement, unilateral -> bilateral

Akinesia (Bradykinesia) = difficulty/slow initiation movements, get “frozen or stuck” - huge fall risk

Postural instability = late stage, lean forward w/ shuffling gait, prone to falling backwards

  • All DTRs intact w/ no weakness
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8
Q

Parkinson’s Therapeutic Treatment

A

Depression: SSRI

Hallucination: Decrease Sinemet, Zyprexa

Orthostatic HOTN: TED hose, slow rising

Sexual dysfunction: Viagra, Dopamine agonist

Constipation: Cease causative medication; Reglan is CI - Dopamine antagonist

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9
Q

Deep Brain Stimulation

A

No more effective than highest med dose, no SE

Use in pts w/ drug-induced dyskinesias who lack any complicating med/psych conditions

Pulse generator at the STN and Thalamus - replace every 5 years

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10
Q

Restless Leg Syndrome/Wittmaack-Ekbon’s Syndrome

A

Uncontrollable urge to move limb to stop uncomfortable/painful/odd sensation - mot common in legs

Often have varicose veins, less common among Asian pop

Always get a CBC to r/o iron deficiency anemia

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11
Q

Causative agents of RLS

A

Meds: Anti-nausea, H2 Blocker, antihistamines, SSRI/anti-psych

Food: Diet soda/aspartame, ETOH

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12
Q

RLS Treatment

A

Tx underlying cause, OTC Ibuprofen, baths/massages, warm/cool packs

Pramipexole, Ropinirole, Sinemet, Lyrica (w/ Parkinson’s)

Gabapentin, Opioids

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13
Q

Parkinson’s Treatment

A

GOAL: Restore dopamine activity, manage SE of therapy

Selegiline (MAO-B) may slow progression w/ early therapy

All other meds replenish Dopamine or block Acetylcholine/GABA

Apomorphine (NMDA) is used only for emergent freezing instances

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14
Q

Levodopa/Carbidopa (Sinemet)

A

Gold standard, generally 1st line (>70 yo, dementia)

Levodopa = dopamine precursor, Carbidopa = prevent peripheral breakdown

Best for rigidity and slowness, less for tremor/balance/gait

Short acting, high doses cause dyskinesias

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15
Q

Sinemet side effects and contraindications

A

SE: Vivid dreams, hallucinations, HOTN, Dyskinesia

Wearing off effect - after 4-6 yrs, gets progressively worse

  • initial bradykinesia, tremor before next dose

CI: MAOI, psychotics, angle-closure glaucoma, history of melanoma

Use caution w/ cardiac dx, PUD

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16
Q

Monoamine Oxidase-B Inhibitors (MAO-B)

A

Selegiline/Rasagiline = stop dopamine breakdown, penetrate BBB

May slow progression if given @ early onset in young pt

1st line for mild dx, also to decrease Sinemet wearing off effect

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17
Q

MAO-B side effects and contraindications

A

SE: Insomnia, Jitteriness, Dyskinesias, Increases Sinemet SE

CI: TCA, SSRI, Demerol

Caution: Liver impairment, cardio/CV dx, seizure, hypothyroidism, DM, psych disorders

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18
Q

Dopamine Agonists

A

Older, Ergo derivatives: Bromocriptine

Newer, synthetic: Pramipexole, Ropinirole

Stimulate dopamine receptors in substantia nigra

  • Improve akinesia, postural instability

1st line in young pts w/ moderate symptoms

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19
Q

Dopamine agonist side effects and contraindications

A

SE: poorly tolerated - drowsiness/sleepiness, HA, constipation, nightmare/psychosis/dyskinesias

CI: psychotic illnesses, recent MI, PUD

Avoid ergo derivatives in pts w/ PVD

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20
Q

Apomorphine (Apokyn)

A

Emergent only, NMDA agent

Treats episodes of freezing/hypermobility

Give SQ, expensive

SE: N/V, yawning, dyskinesia, sedation, dizziness

  • give w/ antiemetic that is not Zofran/Kytril
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21
Q

Catechol-O-Methyltransferase Inhibitors (COMT-I)

A

Entacapone (Comtan, Tolcapone (Tasmar)

Inhibit enzyme that metabolizes levodopa in periphery

Only use w/ Sinemet - improves wearing off effect

SE: Happen immediately, poorly tolerated - dyskinesias, confusion/hallucinations, urine discoloration, cramps, N/D, HA, insomnia

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22
Q

Amantidine

A

Antiviral, MOA unknown, Adjunct only

Use for early mild sx, short-lived

No effect on tremor

SE: sedation, vivid dreams, dry mouth, depression

Caution w/ renal dysfunction

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23
Q

Anticholinergic Acetylcholine-blocking drugs

A

Trihexyphenidyl, Benzotropine

Target Acetylcholine to prevent dopamine inhibition

Primarily for tremor, helps w/ rigidity - no effect on akinesias

SE: CNS and systemic, SE usually outweigh any benefit

  • CV, IOP, AMS

CI: BPH (causes retention), obstructive GI, angle-closure glaucoma

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24
Q

COMT uses

A

Try to improve on-off syndrome

Take off if not effect in a few weeks due to SE

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25
Epidural hematoma
Most commonly skull fx - high force trauma Arterial blood from venous sinus or dural artery Dyperdense biconcave, respects suture lines Acute presentation
26
Subdural Hematoma
Venous blood - from venous plexus Cresent shaped, doesn't respect suture lines Low force trauma Insidious presentation - worsening HA over days
27
Subarachnoid Hemorrhage
Below arachnoid/Within the brain Arterial blood from circle of Willis - aneurysm rupture or high-force trauma Acute presentation - thunderclap HA
28
Glasgow Coma Scale components
Eye Opening - 4 points Best Verbal Response - 5 points Best Motor Response - 6 points GCS 13-15 = Mild TBI GCS 9-12 = Moderate TBI GCS \<8 = Severe TBI GCS 3 = Totally unresponsive, lowest possible score
29
GCS Eye opening
Spontaneous = 4 Response to verbal command = 3 Response to pain = 2 No eye opening = 1
30
GCS best verbal response
Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 No verbal response = 1
31
GCS best motor response
Obeys commands = 6 Localizing response to pain = 5 Withdrawal response to pain = 4 Flexion to pain = 3 Extension to pain = 2 No motor response = 1
32
Seizure and Types
Sudden, excessive disorderly discharge of neuronal activity in brain 1. Sudden, transient 2. Motor/sensory/autonomic/psychic manifestations 3. Temporary alteration of systemic arousal 4. Often manifests as convulsions; different kinds of seizures
33
Seizure disorder/Epilepsy
Recurrent seizures without any immediate treatable cause such as hypoglycemia or ETOH withdrawl
34
Convulsion
Rapid contraction and release of muscle causing an uncontrollable shake
35
Epilepsy
Occurrence and reoccurrence of seizures without know or correctable cause Can get strange sensations/emotions/behavior -\> convulsions, spasms, LOC Idiopathic or primary generalized epilepsy usually present by puberty Seizures after 20 yo -\> usually focal process/metabolic derangement Cancer, stroke, degenerative brain disorders cause seizures later in life
36
Epilepsy Pathophysiology
A. Complex gene mutations or environmental factors = abnormal connections B. Hypersensitive neurons have sudden, violent depolarizations -Temperature, electrolyte imbalances set off C. Epilectogenic neurons fire more often and intensly w/ greater amplitude than normal
37
Provoked vs Unprovoked Seizures
Provoked = triggered by provoking factors in healthy brain - metabolic, ETOH, drugs, high fever Unprovoked = occur with persistent brain pathology -repeat seizures may be similar or different, get a complete H&P after initial seizure to r/o other conditions
38
Sudden unexpected death (SUDEP)
Sudden, nontraumatic, nondrowning death of a person w/ epilepsy Happens in refractory epilepsy or poorly controlled seizure disorder
39
Seizure phases
Prodrome (1st phase) = hours/days before seizure -deja vu, smell/sounds/taste, fear, dizzy, HA, nausea Aura = 1st seizure sx, beginning of seizure Middle "ictal phase" = from Aura to end of seizure - awareness lost, confused/daydreaming, can't talk/swallow Ending "postictal" = recovery can be immediate or takes minutes/hours -sleepy, slow to respond, confused, HA, nausea
40
Loss of consciousness
Complete/partial unawareness or lack of response to sensory stimuli Induced by hypoxia, metabolic or chemical depressants, brain pathology, trauma
41
Focal Seizures
Occur on one side of the brain Occur w/ and w/out consciousness impairment w/out: Jacksonian March (motor), Todd's Paralysis, sensory, autonomic, psychic w/: pt unresponsive, may evolve from w/out - most common, arise from temporal lobe - pt appears to be "daydreaming" - 30 seconds to 1 minutes w/ confusion and tired 15 min postictal
42
Jacksonian March
Motor focal seizure w/out consciousness impairment Starts at fingers and works its way up limb Abnormal activity in primary motor cortex Also get sudden head & eye movement, tingling, numbness, lip smacking, and muscle spasms
43
Todd's Paralysis
Focal seizure w/out impaired consciousness - Postictal state Temporary (30 min to 36 hours), unilateral paralysis of limb **Have to r/o stroke**
44
Generalized Onset Seizures
Disturbed consciousness, bilateral cerebral cortex malfunction Absence, Atypical, Myoclonic, Atonic, Febrile, Tonic-Clonic, and Secondary seizure types Can develop from focal seizures
45
Absence seizure
"petit mal seizure" Looks like daydreaming, disturbed consciousness w/o convulsions Typically in childhood Abrupt onset and termination w/ brief impairment ~10 seconds May have mild tonic-clonic, or atonic components; no postictal
46
Atypical Absence Seizures
Lapse in awareness w/ gradual onset and resolve Autonomic features and muscle tone lost Often occurs in mentally impaired kids Doesn't respond well to AED therapy
47
Myoclonic Seizures
Rapid, recurrent muscle spasms Bilateral or unilateral, synchronous or not Often terminate into generalized tonic-clonic (grand mal) Often cluster after waking or while falling asleep
48
Atonic Seizures
"drop attacks" Abrupt muscle tone loss, pt just collapses Often seen in kids w/ diffuse encephalopathies
49
Febrile Seizures
Most common convulsion cause in kids 6 mo to 5 years Temp \> 38C (100.4 F), simple or complex Have to r/o brain infection, metabolic issue, hx previous seizure w/o fever No association/cause from mental impairment, behavioral problems, or poor school performance Sx: Body stiffens, arm/leg twitch, vomit, foam @ mouth, incontinence
50
Tonic-clonic Seizures
"Grand mal" Sudden LOC and involves all extremities Primary deep brain structure or secondary focal generation Tonic: \<1min, sudden LOC and collapse, respiration arrested Clonic: 2-3 min, muscle jerking and AMS May recover, sleep, or go into status epilepticus Postictal = HA, disorientation, drowsiness, N, muscle soreness
51
Secondary Generalized Seizure
Focal seizure that becomes generalized - 30% focal episodes 1-3 minutes, longer recovery time Sx: muscle stiffening, LOC, bite tongue/cheek, tonic/clonic phases Dx: EEG, MRI Tx: Carbamazepine
52
Post-traumatic Epilepsy
Degree of injury matters Many develop seizures by 1-2 yrs, mostly focal or secondary generalized Penetrating, cerebral contusions, intracerebral hematoma, unconsciousness, or amnesia \>24 hours
53
Seizure Diagnosis - 3 Objectives
1. Determine if pt has epilepsy 2. Classify seizure and type 3. Identify (if possible) specific underlying cause PE should be normal between seizures -Look for lateralized sx, Todd's, bruits, heart murmur
54
4 Conditions that mimic seizures
REM behavior disorder = sudden arousal from REM, aggressive behavior -Dx w/ overnight sleep test Transient Ischemic Attack = lateralizing weakness/vision loss Transient Global Amnesia = vascular, \>50yo, recurrent short-term amnesia w/o other impairments Migraine = aura w/ AMS, mimics complex partial seizure, tonic-clonic postictal
55
Seizure Workup
EEG: Most important, get during active seizure and during sleep MRI: study of choice, used to identify brain pathology -get in all kids and in pts \>20 w/ suspected neoplasm and seizures Labs: baseline and to r/o systemic causes
56
Status Epilepticus
Seizure \>30 min, or prolonged series of seizures w/o consciousness recovery between Life-threatening, caused by drug noncompliance/withdrawal, fever Tx: Give Thiamine, glucose, Ativan (lorazepam if fever), Fosphenytoin No response in 20 min = Phenobarbital and Pepacon Still nothing = General anesthesia w/ vent and neuromuscular junction block
57
Seizure Treatment Guidelines
Unprovoked - typically don't treat until 2nd or 3rd seizure Referral to Neurology for further surgery/treatment/workup 60% controlled w/in 1st year, 15% controlled later 25% have seizures despite treatment
58
Seizure Medications - 3 MOA
1. Affect voltage-dependent Na or Ca Channels - Na: Effective for tonic-clonic and partial seizures - T-type Ca: absence seizures 2. Increase inhibitory neurotransmission (GABA) 3. Decrease excitatory neurotransmission (glutamate, aspartate)
59
1st line for Generalized Tonic-Clonic
Carbamazepine (Tegretol) Phenytoin (Dilantin) Valproic Acid (Depakote)
60
2nd line for Generalized Tonic-Clonic
Levetiracetam (Keppra) Gabapentin (Neurontin) Phenobarbital Felbamate (Felbatol)
61
1st line for Focal seizures
Carbamazepine (Tegretol) Phenytoin (Dilantin) Valproic Acid (Depakote) Lamotrigine (Lamictal) Topiramate (Topramax) Oxcarbazepine (Trileptal)
62
2nd line for Focal seizures
Gabapentin (Neurontin) Phenobarbital Zonisamide (Zonegram) - Adjunctive tx only for focal w/o consciousness impairment Felbamate (Felbatol) Tiagabine (Gabitril)
63
1st line for Absence Seizures
Lamotrigine (Lamictal) Ethosuximide (Zarontin)
64
Seizure drugs Pregnancy category D
Carbamazepine (Tegretol) Phenytoin (Dilantin) Valproic Acid (Depakote) Phenobarbital So all 1st line for Generalized tonic-clonic
65
Lumbar Puncture Contraindications
Site skin infection Increased intracerebral pressure - except w/ pseudotumor Spinal cord mass/intracranial mass lesion Bleeding/coagulation defect Spinal column deformities Spinal epidural abscess Noncompliant pt
66
Rule out ICP
Get a CT on pts w/: Altered mental status Focal neurologic signs Papilledema Seizure w/in 1 week Impaired cellular immunity
67
CSF normals: Pressure Appearance Total protein Glucose Cell count
Pressure: 70-180 Appearance: clear, colorless Total protein: 15-45 Glucose: 45-85 Cell count and diff: 0-5 wbc/uL, 0 rbc
68
69
Elevated ICP DDx
Meningitis Intracerebral Hemorrhage (ICH) Neoplasm
70
Xanthochromia DDx Yellow Orange Pink Green Brown
Occurs w/in 2 hours, lasts 2 weeks Yellow: Blood lysis, hyperbilirubinemia, protein \> 150, rbc \>100,000 (hemorrhage) Orange: rbc lysis, high carotenoid ingestion Pink: rbc lysis products Green: Hyperbilirubinemia, purulent CSF Brown: Meningeal melanomatosis (CNS melanoma)
71
Protein DDx
One of the most sensitive CNS pathology indicators 150 in newborns, normalizes around 6-12 months Low: repeat LPs, CSF leak, acute water intoxication High: Infection, ICH, Guillain-Barre, Neoplasm, endocrine, inflammatory Can be falsely elevated w/ traumatic tape -\> -1 protein/1000 rbc
72
Glucose DDx
Normal w/ viral Low w/ bacterial/fungal/neoplasms High if peripheral glucose is also elevated
73
Cell count and Differential
Wbc: Meningitis - \<1000 = viral, \> 1000 = bacterial -increased post-seizure, ICH, malignancy, inflammation Rbc: Traumatic tap = #rbc decreases in consecutive tubes -ICH = no consecutive decrease in #rbc Cell differential: Normally 70% lymphocytes, 30% monocytes -Meningitis: neutrophils = bacteria, lymphocytes = viral/fungal/TB, eosinophils = parasites
74
LP Microscopic DDx
India Ink + = cryptococcus Wright/Gimesa + = toxoplasmosis
75
Other LP findings Latex agglutination and PCR
Latex agglutination = rapid detection of bacterial antigens in meningitis PCR for viral: HSV, EBV, enterovirus, CMV, TB, acute neurosyphilis
76
Nerve Fibers A-alpha A-delta C fibers
A-alpha = large, myelinated; touch, vibration, position A-delta = small, myelinated; cold, pain C fibers = unmyelinated; warm, pain
77
Nerve Conduction Velocity
Only studies A-alpha fibers Can miss polyneropathies in small fibers Measures quality and speed of the signal sent to peripheral fibers Used to study demyelinating polyneropathy (Guillain-Barre) or focal demyelination (carpal tunnel)
78
Nerve Conduction Studies
Test peripheral nerves to diagnose focal or generalized disorder Can differentiate muscle from nerve disorders depending on whether nerve signal or muscle response is altered or appropriate Indicated w/ paresthesias/weakness of limbs, or nerve conduction disorders
79
Electromyography (EMG)
Measures muscle electrical activity @ rest and contraction Indicated for disease that damage muscle, nerve, or nerve-muscle junction - herniated disc, amyotrophic lateral sclerosis (ALS), MS
80
Electroencephalogram (EEG)
Distinguish epileptic seizures from: -psychogenic spells, syncope, movement disease, migraine variants Differentiate between organic or psychiatric encephalopathy or delirium Test for brain death, or for discontinuation of antiepileptic drugs (AED)
81
EEG waves and amplitude
Delta: 0-4 Hz Theta: 4-8 Hz Alpha: 8-12 Hz Beta: \>12 Hz Increased slow waves (Delta and theta) in awake patients = focal brain lesion/abnormality A normal EEG does not r/o epilepsy
82
Head CT: Contrast or no
Contrast: Neoplasm, infection, vascular or inflammatory disease -contrast lights up the blood vessels No Contrast: trauma, stroke/hemorrhage r/o, hydrocephalus, dementia, epilepsy, congenital malformations
83
CT Scan interpretation
Look for 1. Fluid 2. Mass 3. Shift 4. Compare both sides for symmetry Water is dark, skull is white More dense the tissue, the brighter it is
84
CT Angiography indications
Atherosclerosis Thromboembolism Vascular dissection Aneurysm Vascular malformations Penetrating trauma Carotid evaluation
85
MRI T1 and T2 indications
T1: Look at normal brain function - fat is bright, water is dark T2: Look for abnormal processes or brain pathology - water and blood are bright, white matter is dark Indications: subacute/chronic hemorrhages, stroke f/u, metastasis, intracranial abscesses, MS/demyelination, vasculitis, new onset/refractory seizure
86
Basilar skull fracture indications
Raccoon eyes Battle's Sign CSF Leak Hemotympanum - get an MRI to evaluate
87
TBI Hospitalization
GCS \<15 or deteriorating Abnormal CT or bleeding parameters Seizure
88
Decorticate vs Decerebrate
Decorticate = elbows and fingers flexed w/ UE adduction -Cerebral cortex or thalamic dysfunction, better prognosis Decerebrate = UE adduction w/ extension -Caudal diencephalon, pons, or midbrain injury LE Extension w/ plantar flexion and inversion occur w/ both
89
Coma Respiratory Patterns Cheyne-Strokes Hyperventilation Apneustic breathing Ataxic breathing
Cheyne-Strokes: cyclic hyperpnea and apnea from bilateral hemisphere or diencephalic insult Hyperventilation: pontine or midbrain tegmentum injury Apneustic: prolonged pause @ inspiration end from mid and caudal pons lesion Ataxic: irregular rate and tidal volume from medulla damage
90
Mini-Mental Status Exam Rankings
24/30 = suggestive of dementia 20-26 = functional dependence 10-20 = moderate, immediate dependence \<10 = severe, total dependence
91
Neuropathologic Hallmarks of Alzheimer's Disease
Begin years before symptom onset Amyloid-rich senile plaques Neurofibrillary tangles Neuronal degeneration
92
Alzheimer's Disease Diagnosis
Definite: Histopathological evidence (autopsy), course and exam have AD characteristics Probable: 2 or more cognition deficits, 40-90 yo onset w/ progressive course and no other explanation Possible: Deficit in 1 cognition area, atypical course, other dementia causes present Unlikely: Sudden onset, focal signs, early seizures or gait disturbances
93
Alzheimer's Disease Clinical Course Stages 1-4
1: Normal, symptom free but pathology underway 2: Normal forgetfulness with age, concentration difficulty 3: Mild cognitive impairment, subtle deficits noted by close contacts - repeated questions, cannot master new tasks, performance decline 4: Mild AD - can Dx w/ accuracy, pt less able to manage complex ADLs (finances, cooking) - Lasts ~2 years
94
Alzheimer's Disease Clinical Course Stages 5-7
5: Moderate AD - independent survival limited, struggle w/ basic ADLs - cannot recall major events, current life events, lasts ~1.5 yrs 6: Moderately severe AD - cannot do basic ADLs (dress themselves, live alone) - lasts ~2.5 years 7: Severe AD - speech and facial expression lost, cannot ambulate/sit independently, primitive/infantile reflexes restored - Can last several years
95
Medications to avoid w/ Alzheimer's Disease
Benzodiazepines Antihistamines Anticholinergics These all worse symptoms, provide no benefit
96
Vascular Dementia
Cognitive deficit onset w/ CVA and stepwise deterioration May be present or a predisposition for AD
97
Frontotemporal Dementia (FTD)
Focal atrophy of frontal and temporal lobes w/o AD pathology -Pick's Disease = subtypes w/ Pick bodies in neocortex and hippocampus 35-75 yo Insidious onset w/ gradual progression resulting in early decline of emotions, conduct, and insight
98
Normal-Pressure Hydrocephalus
Pathologically enlarged ventricles w/ normal LP opening pressures Triad: dementia, gait disturbances, urinary incontinence -Wacky, wobbly, wet Reversible w/ ventriculoperitoneal shunt Dx w/ MRI and Miller Fischer gait test
99
Dementia with Lewy Bodies (DLB)
Associated w/ Parkinsonisms Most common dementia syndrome, 2nd most common neurodegenerative dementia after AD - pronounced variable attention/alertness, recurrent visual hallucinations, spontaneous motor features (Parkinsonisms) Distinguish from Parkinsons? Dementia is presenting feature of DLB, occurs in the last 1/2 of Parkinson's clinical course
100
Progressive Supranuclear Palsy (PSP)
Rare, mimics PD early on Restricted up and down eye movement - head is either straight or tilted back Postural instability w/ frequent falls backwards Distinguish from PD = PD pts lean forward, PSP pts head tilts back
101
Delirium
Treatable, attention impaired at onset Consciousness and effect on memory varies Have attention deficit and psychomotor disturbances Risk: Post-op, Elderly, AIDS, burns, withdrawal High indicator for death w/in 6 months, death if hospitalized Lasts 10-12 days or up to 2 months
102
Delirium Causes
I WATCH DEATH Infection Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia Deficiency, Endocrinopathies, Acute vascular, Toxins/drugs, Heavy metals 44% have 2 or more pathologies
103
Agitation Pharmacological management
Haloperidol (neuroleptic), Risperidone (anti psych), Inapsine (sedative) Haloperidol and Inapsine associated w/ Torsades and prolonged QT - monitor via telemetry Benzodiazepines TOC for ETOH/benzo withdrawal - may worsen delirium, cause respiratory depression - CI w/ hepatic failure
104
Sleep-promoting and arousal promoting neurotransmitters
Sleep: GABA from VLPO Arousal: Norepinephrine from LC, Serotonin from Raphe, and Histamine from TMN
105
Sleep Stages and breathing
1: light sleep, between conscious and asleep 2: Intermediate; HR slows, brain only does simple tasks Breathing in 1&2 - cyclic waning and waxing of TV and R w/ brief apneic periods (periodic breathing) 3&4: Slow wave sleep; 3- body repairs, 4- temp and BP decrease Breathing is 3&4 is regular, slower REM: Eye movements; HR, BP, breathing and temp increase Breathing is irregular +/- apneic periods, not periodic
106
Blood gases in sleep
PCO2 increases 2-8 PO2 decreases 5-10 pH decreases 0.03 - 0.05
107
Insomnia medications - Trouble falling asleep
Zolpidem (Ambien) - 1st line Zaleplon (Sonata) MOA: Interact w/ GABA-benzodiazepine receptor complexes
108
Insomnia medications - Trouble maintaining sleep
Eszopiclone (Lunesta) - 1st line Benzodiazepines (Triazolam, Lorezepam, Estazolam) Melatonin Agonists (Ramelteon) Orexin receptor Antagonists (Suvorexant, Belsomra)
109
Hypersomnolence Disorder
Recurrent excessive daytime sleepiness or prolonged nighttime sleep - common in adolescents and young adults Dx: excessive sleepiness for 1 month (acute) or 3 months (persistent) w/ prolonged sleep or daytime sleepiness at least 3x/week Tx: Modafinil (Provigil) 1st line, Dextroamphetamine 2nd line -Dextro has BBW for high abuse potential
110
Narcolepsy Tetrad and Meds
1. Extreme drowsiness w/ sleep attacks - 15 mins, wake up refreshed 2. Sleep paralysis = muscle flaccidity between asleep and awake 3. Cataplexy - 30 seconds to a few minutes 4. Hypnagogic Hallucinations - preceding sleep or during a sleep attack Tx: Modafinil (Provigil) 1st line, Dextroamphetamine
111
Non-24 hour sleep-wake phase and treatment
Common in blind Internal day is longer than 24 hours Tx: Hetlioz for blind pts MOA: Binds melatonin to MTI and MT2 receptors Pregnancy C, SE: HA, abnormal dreams
112
Non-REM sleep arousal disorders
Sleepwalking Night terrors Enuresis (Parasomnias)
113
REM Sleep Behavior Disorder
Dream enactment during REM w/ sleep atonia loss Antidepressants, Narcolepsy, Alpha-synuclein neurodegeneration (elderly) Tx: Melatonin 1st line -prepares body for sleep Clonazepam 2nd line
114
RLS treatment
Dopamine agonist (Ropinirole) OR Alpha-2-delta Ca channel ligand (Gabapentin)
115
Bruxism
Teeth grinding Jaw soreness, teeth flattening, radiating AM HA Tx: Clonazepam, Botox, oral appliances
116
Periodic Limb Movement Disorder (PLMD)
Unilateral or bilateral involuntary limb movement in sleep Pt is unaware, may be related to PD or narcolepsy Tx: Dopamine agonist 1st line Anticonvulsants, Benzodiazepines

Neurology (5 decks)

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