Neuro

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c623tran
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147772
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Neuro
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2012-04-15 19:17:52
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Neuro
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  1. Abortive treatment for Migraine Headache
    • Triptans
    • Ergotamine-caffiene (Cafergot
    • Isometheptene-dichloralphenazone-acetaminophen (Midrin)
    • Butalbital-acetaminophen (Fioicet)
    • NSAIDs (ASA, ibuprofen, naproxen, ketoprofen)
  2. What are some preventive medications for migraine headaches
    • Topirmate (Topamax)
    • Propanolol
    • Timolol
    • Calcium channel blockers
    • TCA - used as off label
  3. What two classes of drugs are used to "abort" headaches:
    • Triptans (Serotonin 5HT1 receptor agonists
    • - Almotriptan (Axert)
    • - Naratriptan (Amerge)
    • - Sumatriptan (Imitrex)
    • - Zolmitriptan (Zomig)
    • Ergotamine -
    • - dihydroergotamine (Migranal)
  4. What are the prophylactic agents used to treate headaches:
    • Topiramate (Topomax)
    • Propanolol (inderal LA)
    • Timolol
  5. In what type of patients should you not describe "Triptans" to?
    Why?
    • patients with coronary artery disease
    • patients with poorly controlled hypertension
    • Triptans are vasoconstrictors therefore can cause rise in BP and increase risk for Stroke
  6. Can you use triptans and ergotamine together within a 24 hour period?
    No, avoid concomitant use of triptans and ergotamine within a 24 hour period
  7. Pregnancy/Lactation Considerations -
    What Pregnant Category are Triptans?
    What Pregnant Category are Ergotamine?
    • Triptans are Pregnancy Cat. C (benefits vs. risk must be weighed)
    • Ergotamine are Pregnancy Cat. X (Avoid use in pregnancy)
  8. What is Trigeminal Neuralgia?
    A disorder of the 5th cranial nerve (trigeminal nerve) which produces severe pain in the lip, gum, cheek, and/or face
  9. What is the etiology (cause) of Trigeminal Neuralgia?
    Compression of the 5th cranial nerve from unknown causes, tumors or vascular malformations
  10. What is the assessment findings of Trigeminal Neuralgia?
    • severe pain in the lip, face, mouth, gum, cheek
    • wincing
    • pain may be in "bursts", with pain free period after bursts
    • pain may be elicited by touch, changes in temperature or a light breeze on the cheek
    • lacrimation
    • flushing
    • salivation
    • May initially thought to be of dental origin. very unbearable
  11. What drug is used as first line treatment for Trigeminal Neuralgia?
    • Carbamazepine (anticonvulsants)
    • 100mg PO BID
  12. What Pregnant Category is Carbamazepine?
    What do you have to monitor?
    • Carbamazepine
    • Pregnant Category D (not safe to use)
    • Check carbamazepine levels
    • Check LFT and CBC
    • monitor for hyponatremia and decrease WBC or platelet counts, discontinue if evidence of bone marrow depression occurs
  13. Definition of Syncope
    A sudden, brief loss of consciousness with a spontaneous recovery
  14. List and explain the seven etiology of Syncope:
    • 1. Vasovagal - decrease cardiac output from peripheral vasodilation and bradycardia
    • 2. Orthostatic hypotension - due to medications, hypovolemia, autonomic dysfunction
    • 3. Situational Syncope - due to coughing, micturition or defecation
    • 4. Cardiac - due to sudden decrease in cardiac output (aortic stenosis, arhythmias)
    • 5. Carotid sinus syncope - manual pressure/stimulation of the carotid arteries
    • 6. other causes - depression, ETOH, Drug abuse, psychogenic, subclavian steal syndrome, cardiomyopathy
  15. What diagnostic studies needs to be done on a patient with syncopal episode?
    • CMP
    • ECG
    • BP in both arms (difference of 20 mm Hg or more considered abnormal)
    • Orthostatic Vital Signs
    • Flexion/Extension of neck 10 times to stimulate vertebrobasilar insufficiency
    • Flexion/extension of arms to stimulate sx of subclavian steal syndrome
    • Neuro exam (CT, MRI, EEG if abnormal)
    • Cardiac Exam
    • Tilt testing
  16. What is considered normal on orthostatic vital signs?
    • normal findings are systolic pressure decrease of less than 10 mmHg
    • increase in diastolic 2-5 mmHg
    • increase in heart rate 5-20 beats
    • (if HR does not increase, consider cardiac origin)
  17. What are some prevention and nonpharmacological managment for a patient with syncope?
    • Prevention - rise slowly from lying or sitting or standing
    • Nonpharmacologic Mgmt -
    • elevate patients leg if due to vasovagal or hypotension
    • elastic support stockings to prevent orthostatic hypotension
    • change position slowly
    • increased sodium intake to help expand volume
  18. Pregnancy/Lactation Consideration
    Why do pregnant woman experience synocpal episode?
    What position should they be in?
    • Vasovagal syncope may present in pregnant women from compression of the vena cava and aorta
    • positioning the pregnant woman on her left side should relieve the compression and the symptoms
  19. What is the definition of a Transient Ischemic Attack (TIA)
    TIA - a sudden onset of neurological deficits which is caused by cerebral ischemia and lasts less than 24 hours
  20. What are some causes of TIA
    • atherosclerotic disease within the brain and/or carotid arteries
    • microemboli from atrial fibrillation, cardiac valve disorders
    • hypercoagulable states
    • could be spontaneous
    • cerebral artery vasospasm
    • use of oral contraceptive
  21. What medicatons do you need to place patient who just experience a TIA on?
    • Antiplatelet therapy (clopidogrel 75mg QD)
    • ACE inhibitors
    • Statins
    • ASA or Ticlopidine (Ticlid 250mg BID)
  22. What kind of prevention and/or nonpharmalogical management can we do for patients with TIA?
    • control their blood pressure, lipids and diabetes
    • smoking cessations
    • endarterectomy
  23. Define seizures disorders (convulsion, epilepsy):
    seizures which are recurrent are termed:
    • a transient alteration in behavior with or without loss of consciousness, sensory perception, motor function and/or autonomic function.
    • seizures are due to excessive rate of neuronal discharges
    • seizures which are recurrent are termed epilepsy
  24. Which seizure disorder is considered a medical emergency?
    Status Epilepticus
  25. Name two types of seizures and their descriptions:
    • Partial - begins with motor symptoms characterized by recurrent contractions of muscles in one part of the body
    • - Simple - consciousness not impaired, Jacksonian-type seizures begin in one part of the body and progress to contiguous body parts over seconds or minutes
    • - Complex - consciousness impaired
    • - Mixed - begin as simple or partial and evolve into generalized tonic/clonic; consciousness impaired
    • Generalized - bilaterally symmetrical but without local onset
    • - Absence (Petit Mal) - brief arrest of activity and loss of consciousness
    • - Atypical absence
    • - Myoclonic - muscle movements are repetitive
    • - Tonic Clonic
    • - Tonic, clonic or atonic seizures
  26. Define Meningitis:
    Meningitis: inflammation of the brain and spinal cord caused by infection with bacteria, viruses and fungi. Occasionally parasites are responsible for meningitis
  27. List three etiologies of Meningitis:
    • Bacterial (strep pneumoniae - most common)
    • Viral (enterovirus- most common)
    • Fungal
  28. What is the most common meningitis seen in immunocompromised adults, especially those with AIDS
    Cryptococcal meningitis - most common meningitis seen in immunocomprised adults, especially those with AIDS
  29. Assessment findings of a patient with Bacterial meningitis:
    • recent URI
    • neck pain/stiff neck
    • headache, fever
    • nausea and vomiting, especially in children
    • decreased level of consciousness
    • seizures
    • meningococcemia rash
    • nuchal rigidity
    • postitive Kernig and Brudzinksi signs
  30. Assessment findings of an infant with Bacterial meningitis:
    • irritable
    • sleeping more than usual
    • cries when moved
    • cries inconsolably
  31. What is a Positive Kernig Sign?
    Kernig Sign - complete extension of leg causes neck pain and flexion
  32. What is a Positive Brudzinski sign?
    • Brudzinski sign - flexion of legs when neck is passively flexed.
    • (passively flex patient neck, if infection is present, patient will bend their legs)
  33. Assessment findings of a patient with viral meningitis:
    • Headache
    • fever
    • stiff neck
    • photophobia
    • rash
    • seizures
    • illness last 2-6 days
  34. Assessment findings of a patient with Fungal Meningitis:
    • worsening headaches over a period of days
    • vomiting for days or weeks
  35. Diagnostic findings of meningitits:
    Lumbar puncture
    CSF
    CSF Gram stain and cultures
    CBC
    Blood cultures
    • Lumbar puncture: CSF may be turbid, presence of WBC's and elevated protein levels
    • CSF decrease glucose if bacterial
    • CSF Gram stain and cultures: presence of infectious agent
    • CBC: elevated WBC
    • Blood cultures: positive 80% of time
  36. What is the pharmacological management of a patient with Meningitis:
    • Abx specific for culture
    • Empiric Treatment: Ampicillin PLUS 3rd generation cephalosporin; may need to add aminglycoside
    • Dexamethasone: may decrease morbidity and mortality
    • Antipyretics
    • Analgesics for headache
    • Antiemetics
    • Antivirals not recommended.
  37. Define Multiple Sclerosis:
    a disease of the central nervous system which is slow and progressive. It is characterized by demyelination of nerve cells in the brain and spinal cord which produces a variety of neurologi deficits
  38. Assessment findings of a patient with Multiple Sclerosis:
    • paraesthesias in extremities, weakness or clumsiness of a hand or leg
    • stiffness or unusual fatigability of a limb
    • transient blindness or pain in the eye
    • nystagmus common
    • speech may be slow with hesitancy at beginning of word
    • mild emotional disturbances (apathy, lack of judgment, emotional lability) due to scattered CNS involvment
    • difficulty with bladder control
    • deep tendon reflexes increased; superficial reflexes dimished
    • Charcot's triad (scanning speech, nystagmus, tremor) common in later stages of disease
  39. Management of a patient with Multiple Sclerosis:
    What are the goals of pharmacologic manangement?
    • avoid factors which precipitate attacks (hot weather, fatigue)
    • Goals of pharmacologic treatment are to slow disease progression, improve symptoms and decrease relapses.
    • No current therapy is completely effective

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