exam 4

Management of Generalized Convulsive Status Epilepticus

Benzodiazepine lorazepam is recommended for first-line management

Intracerebral hematoma

Bleeding into the brain

Subdural hematoma

Blood between the dura mater and arachnoid membrane Usually venous bleed fast

mitoxantrone NON life threatening side effects

Blue-green skin Alopecia Amenorrhea

Congenital Hydrocephalus

Born with it Imbalance between the production and reabsorption of cerebrospinal fluid

Visceral pain

Broad (ex. Chest pain, heart pain, stomach pain, etc. i can't tell you exactly where it is) pain of internal organs, abdomen, not localized, referred pain

Tramadol (nonopioid acting analgesic)

CNS depression affect, IR, XR, takes a long time for it to work (an hour), suicide risk

Multiple sclerosis patho

CNS nerve fiber dymylenation

least likely adverse effect of opioid (dilaudid)

CNS stimulation

Cholinergic crisis

Characterized by extreme muscle weakness or frank paralysis and signs of excessive muscarinic stimulation Treatment with respiratory support and atropine Resembles myasthenic crisis but weakness occurs 30 to 60 minutes after taking cholinesterase inhibitor medication Happens due to treatment Giving too much Can't have cholinergic crisis in someone whos not being treated Can kill pts.

adverse effects of Cholinesterase Inhibitors

Cholinergic side effects Bronchoconstriction Gastrointestinal effects Dizziness Headache

Drugs for Cognitive Impairment

Cholinesterase inhibitors (Donepezil, galantamine, and rivastigmine) Memantine

Morphine toxicity manifestations

Classic triad Coma Respiratory depression Pinpoint pupils

Thrombotic ischemic stroke

Clot in brain Usually because of atherosclerosis Arterial occlusions are caused by thrombi formed in the arteries that supply the brain or in intracranial vessels. attributed to atherosclerosis and inflammatory disease processes.

Myelomeningocele

Contains neural tissue, spinal cord, or nerves.

Hemorrhagic Stroke

Is spontaneous bleeding into the brain. Usually due to poorly managed high blood pressure over time or cocaine use

Transtentorial Herniation

Is the downward shift of the diencephalon through the tentorial notch.

Cerebral infarction - White stroke

Ischemic

Epidural (extradural) bleed

Knocked out, conscious and fine for a while, then progressively becomes less and less progressing to coma Bleeding between the dura mater and the skull Usually arterial bleed and associated with skull fractures

Dopamine Agonists

Less effective than levodopa Not dependent on enzymatic conversion to be active Does not compete with dietary proteins Lower incidence of response failure Less likely to cause dyskinesias Two types of dopamine agonists - Derivatives of ergot - Nonergot derivatives

Opiate agonist adverse effects

Lightheadedness, dizziness, sleepy or sedation, sweating, confusion, disorientation; orthostatic hypotension (standing up too fast), nausea, vomiting, constipation, cough suppression (can be a problem when people can't clear their secretions), miosis (pupil constriction), biliary colic (spasm of bile ducts; chest pain)

Clinical Manifestations of Amyotrophic Lateral Sclerosis (ALS)

Limb cramping or weakness (due to upper motor neurons) Incoordination Slurring of speech Difficulty swallowing Single muscle group paresis that spreads Hypotonia Fasciculations, along with fibrillations Muscle spasms in a certain way

A grandmother is brought into the emergency room by her son. The grandmother is currently having a seizure and has no history of seizures. Which medication will the nurse predict the doctor will order. Lorazepam Diazepam Dilantin Levetiracetam

Lorazepam

Hallmark of severe brain injury

Loss of consciousness for 6 or more hours.

Chronic pain

May be persistent or intermittent May be sudden (& persist for a long time) or develop insidiously (creep up on people)

Symptoms of Alzheimer's Disease

Memory loss Confusion Feeling disoriented Imapired judgment Personality changes Difficulty with self care Behavior problems (ex. Wander, pacing, agitation and screaming) Sundowning Inability to recognize family members Inability to communicate

Lacunar stroke

Microinfarction is smaller than 1 cm in diameter and involves the occlusion of the small perforating arteries.

Cardiovascular effects of benzodiazepines

Minimal with oral dose, can be profound with IV medication (hypotension, cardiac arrest)

concussions

Momentary disruptions of brain function with or without loss of consciousness

_____ can compromise patients with impaired pulmonary function such as asthma, emphysema, kyphoscoliosis, chronic cor pulmonale, and extreme obesity

Morphine (Opiate/opioid Agonist)

Opiate agonist drugs

Morphine, codeine, hydrocodone, oxycodone, meperidine-like derivatives; methadone-like derivatives

Tension-Type Headache

Most common Mild-to-moderate bilateral headache with a sensation of a tight band or pressure around the head

chronic, inflammatory, autoimmune disorder that damages the myelin sheaths of neurons in the central nervous system (CNS)

Multiple Sclerosis

Mitoxantrone adverse effects

Myelosuppression Cardiotoxicity Fetal harm Reversible hair loss, injury to gastrointestinal mucosa, nausea and vomiting, amenorrhea, allergy symptoms, and blue-green tint to urine, skin, and sclera

Pure Opioid Antagonist

Naloxone (Narcan) Reversal of respiratory and central nervous system (CNS) depression caused by overdose with opioid agonists

types of hydrocephalus

Noncommunicating (intraventricular) - Caused by obstruction. Communicating (extraventricular) - Caused by impaired absorption.

medication to relieve acute or chronic moderate/severe pain

Opiate agonists

Respiratory effects of benzodiazepines

Oral - minimal risk-use caution in COPD, OSA (obstructive sleep apnea); can cause severe respiratory depression with IV dose

Perceptual dominance

Pain at one location may cause an increase in the threshold in another location

What is a major difference between migraines/cluster headaches that are more serious compared to tension headaches? (how would you tell them apart potentially?)

Pain is bilateral in tension headaches

Acute pain

Pain that exists to tell you something is wrong so you can do something about it. Stimulation of ANS increased HR, BP (can be high or low), diaphoresis, dilated pupils.

peripheral - Neuropathic Pain

Painful diabetic neuropathy

Overall symptoms of stroke - right brain

Paralysis on the left side of the body Vision problems Quick, inquisitive behavioral style Memory loss

Overall symptoms of stroke - left brain

Paralysis on the right side of the body Speech/language problems Slow, cautious behavior style Memory loss

Signs & Symptoms of Multiple Sclerosis

Paresthesias Weakness, clumsiness, ataxia, spasms, spasticity, tremors, and cramps Blurred vision, double vision, and blindness Incontinence, urinary urgency, urinary hesitancy, and constipation Sexual dysfunction Disabling fatigue Emotional lability, depression, and cognitive impairment Slurred speech and dysphagia Dizziness and vertigo Neuropathic pain

Fentanyl Transdermal Caution

Patches release medication over 48-72 hours Absorption dependent on body temp, skin type, amount of body fat, and placement of patch Peak effect in 24 hours Use PRN narcotics for breakthrough pain Have to give them pain medication for breakthrough pain

good pain medication option for opioid naive patients

Pentazopcine (Talwin)- Opiate Partial Agonists Can work as an antagonist only (gives narcan effect) on patients who use opioids regularly Not good for chronic pain; tolerance

central - Neuropathic Pain

Phantom limb

What is miosis

Pinpoint pupils

hallmark sign of overdose

Pinpoint pupils

pinpoint pupils vs dilated pupils

Pinpoint pupils - over dose Dilated pupils - acute pain

Pain threshold

Point at which a stimulus is perceived as pain

Late sign of increased ICP

Posturing Lack of ventilation

Amyotrophic Lateral Sclerosis (ALS)

Progressive degenerative disorder Movement is more affected than the brain. BOTH upper & lower motor neurons Lower - flaccid paralysis, floppy muscles, primary muscle atrophy Upper - spastic paralysis, weakness, overall paralysis eventually Leads to respiratory failure (2-5 years from symptom onset) Progressive and typically fatal

Alzheimer's Disease hallmark sign

Progressive memory loss (recent-distant memory)

Alzheimer's Disease signs

Progressive memory loss (recent-distant memory) Impaired thinking (disordered thinking) Neuropsychiatric symptoms (agitation, irritability) Inability to perform routine tasks of daily living Specific diagnosis can only be made by postmortem examination.

Myasthenia Gravis symptoms

Ptosis, dysphagia, and weakness of skeletal muscles Weakness and fatigue of muscles of the eyes and the throat, causing diplopia, difficulty chewing, talking, and swallowing Exertional fatigue and weakness that worsens with activity, improves with rest, and recurs with resumption of activity

Early sign of increased ICP

Pupil changes

What is the major side effect of giving an opioid antagonist for pain control?

Respiratory depression

Serious side effects of opiate agonist

Respiratory depression; urinary retention (can rupture bladder); excessive use or abuse, increased effect with CNS depressants (ex. Alcohol, other sedating drugs)

signs of cholinergic crisis (overmedication)

SLUDGE(M) (salivation, lacrimation, urination, diarrhea, GI upset, emesis) && miosis

medication for mild acute pain

Salicylates

Congenital Hydrocephalus treatment

Shunt insertion

therapy goals for parkinsons disease

Slow down neural degeneration improve the patient's ability to carry out the activities of daily life

Hemorrhagic stroke

Something pops in the brain

Embolic ischemic stroke

Something that moves to brain and cuts off blood flow Fragments break from a thrombus that is formed outside of the brain. A second stroke usually occurs. Usually because of Afib

Cerebral palsy

Static Encephalopathy Nonprogressive syndromes that cause motor deficits Causes: Prenatal or perinatal cerebral hypoxia Hemorrhage Infection Genetic abnormalities Low birth weight

Pentazopcine (Talwin)- Opiate Partial Agonists

Subject to ceiling effect AE: Clamminess, dizziness, sedation, sweating; nausea, vomiting, dry mouth (more typical), constipation (just like opioid agonists) Serious AE: Confusion, disorientation, hallucinations (more issues than with opioid agonists); respiratory depression; excessive use or abuse

Sundowning

Sun goes down; confusion, disorientation, agitation increases at night

Second Impact Syndrome

The reason drs. don't want people getting a second concussion before the first concussion is resolved, can result in loss of autoregulation of brain blood supply Overshooting and sending too much blood to the brain & causes brain edema.

Anencephaly

The skull and much of the brain is missing.

Non opioid Centrally Acting Analgesic

Tramadol [Ultram] - Suicide risk Clonidine [Duraclon] - Opioid withdrawal; death possible with withdrawal

herniation

Transtentorial - ipsilateral pupil dilation

Increased Intracranial Pressure Caused By

Tumor growth Edema Excessive cerebrospinal fluid Hemorrhage

Phenobarbital

USES: Reduces seizures Anticonvulsant barbiturate Potentiates the effects of GABA Makes people really tired and sedation Not the drug of choice if you want the patient to be functional. Phenobarbital withdrawal can be severe and may cause death (anxiety, muscle twitching sign)

Pramipexole (Mirapex) - Nonergeot Dopamine Agonists:

Used alone in early PD and with levodopa in advancing PD

Neostigmine [Prostigmin]

Used for myasthenia gravis. Cholinesterase inhibitor. Prevent cholinesterase from inactivating acetylcholine, resulting in improved transmission of nerve impulses. Precautions/interactions: do not administer if systolic BP is less than 90 mm Hg. Side effects: slow HR, chest pain, weak pulse, increased sweating and dizziness, feeling like need to pass out, weak or shallow breathing, urinating more than usual, seizures, and trouble swallowing. Monitor for cholinergic crisis.

Imitrex

Used for treatment of migraine or cluster headaches Side effects: Dizziness, vertigo, tingling warm sensation, injection site reaction

Methylnaltrexone

Used to treat opioid-induced constipation

Valproic Acid (Depakene, Depakote, Depacon)

Uses: Seizure disorders Bipolar disorder Migraine AE: Hepatotoxicity: Liver failure Pancreatitis Teratogenic effects

Neurotoxicity as a side effect of morphine & other opiates/opioid agonists

Usually in older adults, pts. with other psych disorders Delirium, agitation, myoclonus, hyperalgesia Risk factors renal impairment, pre-existing cognitive impairment, and prolonged high-dose opioid use Management Hydration and smaller dose

phases of pain - Modulation

What changes how pain is perceived/experienced. substances that alter the pain experience. Neuromodulators include prostaglandins, bradykinin, histamine, endorphin, endomorphins.

Migraine symptoms and diagnosis

When any two symptoms occur Unilateral head pain, pulsating pain Pain worsening with activity Moderate or severe pain One of the following symptoms Nausea or vomiting, or both, photophobia, phonophobia

phases of pain - Perception

When you are aware of the pain, this can be influenced by a lot of things such as - culture - sex - previous experience with pain - life experiences - expectations

treatment for cholinergic crisis (overmedication)

Withhold cholinesterase inhibitor drugs until blood toxic levels fall Provide ventilatory support Prevent respiratory complications

Migraine

Without and with aura, retinal, transformed trigger factors - Hormonal, certain foods, flashing lights

Phenytoin

cardiovascular effects, can't take while pregnant, interacts with birth control, diazepam and alcohol.

resembles myasthenic crisis but weakness occurs 30-60 minutes after taking cholinesterase inhibitor medication. has to do w tratement.

cholinergic crisis

Pain without any of the autonomic nervous system signs Increased irritability, depression, etc. more of the psychological symptoms

chronic pain

classic triad of overdose symptom

coma, resp depression and pinpoint pupils

Spinal Shock

complete loss of reflex function in all segments below the level of the lesion. Manifestations: flaccid paralysis, sensory deficit, and loss of bladder and rectal control. May persist for as short a time as a few days or as long as 3 months.

Alzheimer's disease patho - Degeneration of neurons early in hippocampus

consolidating short term memories

For which of the following is nystagmus and diplopia NOT a sign of toxicity? a. Phenytoin (Dilantin) b. Phenobarbital c. Levetiracetam (Keppra) d. Carbamazepine (Tegretol)

d. Carbamazepine (Tegretol)

Which of the following medications used to manage seizures has the potential to cause rickets and osteomalacia in children? a. Carbamazepine (Tegretol) b. Phenytoin (Dilantin) c. Valproic Acid d. Phenobarbital

d. Phenobarbital

chronic pain symptoms

Irritability decreased sleep

Epilepsy

Is a recurrence of seizures and a disorder for which no cause can be found. Phenytoin (Dilantin)

Meningocele

Is a saclike cyst of meninges filled with spinal fluid.

Cingulate Gyrus Herniation

Is shifting under the falx.

Clonidine (nonopioid acting analgesic)

2 applications High blood pressure (HTN) Analgesic (Epidural) AE: hypotension, bradycardia

MAO-B Inhibitors

#1 drug choice with mild parkinsons Later on given in combination with levodopa can reduce the wearing-off effect

tests required before Mitoxantrone

1. Perform complete blood counts at baseline and before each dose 2. Perform liver function tests at baseline and before each dose 3. Perform a pregnancy test before each dose 4. Determine left ventricular ejection fraction Before the first dose Before all doses after cumulative dose has been reached Whenever signs of congestive heart failure develop Have to check it again CBC, liver tests, pregnancy test, heart function; left ventricular ejection fraction before each dose

Fentanyl

100 times the potency of morphine Same AE as morphine Metabolized through liver CYP3A4 therefore can have increased level of fentanyl available in those taking "azoles"

dont give opiate if respirations are below __

12

How soon should I evaluate my patient after administering Morphine IV push for pain?

5 - 10 minutes

what percentage does carbidopa allow the dosage of levodopa to be reduced by?

75%

seizure lasting longer than 10 minutes

911 call

Encephalocele

A saclike herniation of various amounts of brain and meninges protrude through a defect in the skull; it requires surgery to correct.

Levetiracetam (Keppra)

AE: anger/irrational

signs of physical dependence of morphine

About 10 hours after last dose, the initial reaction occurs and includes - yawning, rhinorrhea, and sweating

Local Anesthetics: Lidocaine

Accumulates in blood, and can cause CNS and cardiovascular toxicity Also an antidysrhythmic, too much can cause dysrhythmias if you give too much Metabolized through liver; patients with liver damage might have problems

Major Risk Factors for Alzheimer's Disease

Advancing age Family history

Cerebral infarction

An area of the brain loses blood supply and becomes ischemic as a result of vascular occlusion (embolic or thrombotic).

drug treatment for myasthenia gravis and myasthenic crisis

Anticholinesterase drugs, corticosteroids, immunosuppressant drugs (Rituximab, a chimeric monoclonal antibody against the protein CD20, primarily found on B cells), azathioprine, cyclosporine

Psychological factors that decrease pain tolerance: (make pain worse)

Anxiety Depression Fear Anger

Cluster headache

Around the eye Pain: Unilateral, intense, tearing, and burning Sympathetic nervous system underactivity and parasympathetic overactivity

A 25 yo male has come to the clinic today in search for some answers about some recent symptoms he has been experiencing. Based on his medical history, he is in great condition with no past/recent procedures nor diagnoses. He takes no medications and has no allergies. Upon assessment, his temperature is 102 degrees Fahrenheit and he complains of a pounding headache and some slight neck pain. On a scale of 1 to 10, the pain is about a 5. When you go to check his pupils, he asks if you could turn down the light or turn it completely off as it is bothering him. You also notice some stiffness in his limbs which he states is not normal as he is relatively mobile. How would you diagnose this patient? What treatments would you prescribe? A. Bacterial Meningitis B. Viral Meningitis C. Fungal Meningitis D. Aseptic Meningitis

B. Viral Meningitis

A patient has a herniation of the brain from increased intracranial pressure, what is this patient most at risk for? A) Heart attack B) Loss of peripheral vision C) insomnia D) Stroke

D) Stroke

Alzheimer's disease patho

Degeneration of neurons Reduced cholinergic transmission

Dementia vs Delirium

Dementia- slow/progressive and irreversible Delirium- sudden and can be reversed

signs of tolerance of morphine

Develops with analgesia, euphoria, sedation, and respiratory depression

Seizure

Disorganized discharge of neurons symptom of disease, not a specific disease. is a sudden, transient alteration of brain function caused by an abrupt explosive, disorderly discharge of cerebral neurons.

stroke symptoms

Dizziness, nausea, or vomiting Unusually severe headache Confusion, disorientation or memory loss Numbness, weakness in an arm, leg or the face, especially on one side Abnormal or slurred speech Difficulty with comprehension Loss of vision or difficulty seeing Loss of balance, coordination or the ability to walk

drugs for parkinsons disease

Dopaminergic Agents (most commonly used) Anticholinergic Agents Monoamine oxidase-B (MAO-B) inhibitor

Ropinirole (Requip) - Nonergeot Dopamine Agonists

Drug should not be used during pregnancy Most common AE: nausea, dizziness, somnolence, and hallucinations

Pain tolerance

Duration of time or the intensity of pain that a person will endure before initiation of pain responses

Methadone (opioid agonist)

Elongated Q-T interval (use cautiously with other meds) Dysrhythmias Used to treat opioid addiction and pain Metabolized through liver Respiratory depression-death if OD or crushed and snorted

Signs of Congenital Hydrocephalus

Enlarged fontanels that become full and bulging Sunsetting eyes Inability to hold the head upright Dramatic head growth If increased intracranial pressure develops (if it happens fast, if it happens slow don't really see this) High pitched cry; irritability, lethargy, and vomiting

Supratentorial Herniation

Involved the temporal lobe and hippocampal gyrus, shifting from middle fossa to posterior fossa

Infratentorial Herniation

Involves a shift of the cerebellar tonsils through the foramen magnum.

Hydrocephalus

Excess fluid in cerebral ventricles

Hemorrhagic stroke treatment

Fast - Needs to be initiated within 3 to 4 hours of symptom onset. Prevent hematoma from getting bigger Prevent or control seizures and cerebral edema. Blood irritating tissues

Hemorrhagic stroke clinical manifestations

Focal neurologic deficits, altered consciousness, headache

Neural Tube Defects are found to be caused by

Folic deficiency in mom

Impaired awareness is always present in which type of seizure? Focal Partial Generalized Secondary Generalized

Generalized

phases of pain - Transmission

Goes up to spinal cord & then to the brain

Cerebral infarction - Red stroke

Hemorrhagic

Myasthenic crisis

If left untreated, myasthenic crisis can result in death as a result of paralysis of the muscles of respiration Severe muscle weakening, leading to respiratory distress Muscles not working, muscles have a part in breathing Happens due to the disorder itself

Benzodiazepines (sedative hypnotic drug) adverse effects

If taking it chronically; can have seizures if stop taking CNS depression - daytime sleepiness

Alzheimer's disease symptom that is often overlooked

Imapired judgment people can get very impulsive

Mitoxantrone

Immunosuppressant used in multiple sclerosis Decreases neurologic disability and clinical relapses

Meningitis

Inflammation of the brain or spinal cord (inflammation of the meninges)

Drug Therapy for Multiple Sclerosis

Interferon Beta Mitoxantrone

Focal/partial seizures

Involve a focused area of part of the brain Motor - with movement Non motor - staring spells (abscence seizures)

General seziures

Involve both sides of the brain

Somatic pain

You can pinpoint where it is (ex. If i broke my arm, i can tell you where my pain is) superficial arising from skin, connective tissue, bone, well localized

Epidural hematoma

a collection of blood in the space between the skull and dura mater

Which of the following is(are) a manifestation for increased intracranial pressure? a. Headache b. Vomiting c. Hypotension d. Abnormal pupillary response e. Tachypnea

a. Headache b. Vomiting d. Abnormal pupillary response

Dementia or unexplained encephalopathy is a sign of which type of meningitis? a. Fungal b. Viral c. Bacterial d. Aseptic

a. fungal

Tegretol has many interactions. One of the ones most easily missed when providing patient education is a. grapefruit juice b. aged cheeses c. red wine d. dairy products

a. grapefruit juice

Which of the following statement about spinal and neurogenic shock is incorrect? a. Neurogenic shock is the complete loss of reflex function and sensation below the level of injury. b. The clinical manifestations of spinal shock include sensory deficit and flaccid paralysis. c. Neurogenic shock occurs with head trauma, cervical or upper high thoracic cord injuries. d. The signs and symptoms of spinal shock may exist for as long as 3 months.

a. neurogenic shock is the complete loss of reflex function and sensation below the level of injury

pain with autonomic nervous system signs

acute pain

degeneration of neurons

alzheimers

medication that reverses adverse effects of opiate agonists

antagonists (Narcan/Naloxone)

Hallmark signs for phenobarbital withdrawal

anxiety and twitching

Use glasgow coma scale to

assess severity of brain injury 13-15

Levetiracetam (keppra) side effects

atypical anger

A 25 year old patient was just started on a broad spectrum anti-seizure medication. A few days into her treatment she began to feel like she had the flu and soon after her skin started to turn a reddish purple. Eventually it became very painful and the new skin lesions were blistering and peeling. Which anti-seizure medication most likely caused this adverse reaction? a. Levetiracetam b. Lamotrigine c. Phenytoin d. Valproic Acid

b. Lamotrigine

Rob sustained a concussion during his basketball game. A week later, he fell and bumped his head in the shower. He deteriorated rapidly and was rushed to the ED. He ended up severely disabled with compromised brain function. What happened to Rob? a. Post-concussive Syndrome b. Second Impact Syndrome c. Chronic Traumatic Encephalopathy d. Spinal Shock

b. Second Impact Syndrome

phases of pain - Transduction

begins when tissue is damaged; activates nociceptors

Status epilepticus treatment

benzodiazepines (lorezapam, IV)

Gabapentin (neurontin) side effects

better for neuropathic pain than seizures

Multiple sclerosis vs. Guilliane Barre

both - lead to demylenation of nerve fibers from an immune reaction MS - central GB - peripheral nerves.

Cholinesterase inhibitors can cause

bradycardia, bronchial constriction, urinary urgency, increased glandular secretions, increased tone and motility of gastrointestinal smooth muscle, miosis, and focusing of the lens for near vision

A nurse is reviewing a new prescription of Carbamazepine [Tegretol] with her patient. Which statement made by the patient requires intervention? a. "I will need routine blood labs while on this medication" b. "This medication can decrease the effectiveness of my oral contraceptive " c. "I will take this medication in the morning with grapefruit juice" d. "This medication may cause me to sunburn more easily"

c. "I will take this medication in the morning with grapefruit juice"

A patient comes into the emergency department following a head injury and is complaining of a headache. Upon assessment, it is found that the patient is agitated, has ipsilateral pupil dilation, and is showing signs of cheyne-stoke respirations. This patient most likely has which of the following conditions? a. Mild Concussion b. Autonomic Hyperreflexia c. Brain Herniation d. Extradural (Epidural) Hematoma

c. Brain Herniation (headache, agitation, ipsilateral pupil dilation, cheyne-stokes respirations)

A 75 year old woman tripped while in her house and she caught herself without ever hitting her head on anything. A few weeks went by with no symptoms, but then the woman started to gradually get headaches that got worse as time went on. Very little could relieve the pain. What is the most likely underlying problem this woman is experiencing? a. Acute Subdural Hematoma b. Subacute Subdural Hematoma c. Chronic Subdural Hematoma d. Intracerebral Hematoma

c. Chronic Subdural Hematoma

Phenytoin is a medication used to treat and prevent seizures. However, this medication can cause toxic adverse effects which need to be monitored closely. Which of the following is NOT an adverse effect of Phenytoin? a. Sedation b. Gingival hyperplasia c. Nystagmus d. Photosensitivity reactions

d. Photosensitivity reactions

Neuropathic Pain

damage to the nerves, burning pins and needle type feeling Result of trauma or disease of nerves (non-nociceptors) Most often chronic

Benzodiazepine often used as

date rape drug

carbidopa is given with levodopa to

decrease the breakdown of levodopa

Alzheimer's Disease is the leading cause of

dementia

Guillain Barre Syndrome

demyelination of the peripheral nerves or axonal disorder bottom to top affected Acute onset, ascending motor paralysis

Alzheimer's disease (AD)

diagnosis of exclusion (definitive diagnosis happens on autopsy) other causes of dementia would need to be ruled out before a diagnosis of Alzheimer's was made

what is NOT a common side effect of opiods

diarrhea

what is not a side effects of opioids (fentanyl)

diarrhea and hypertension are NOT side effects of opioids (fentanyl)

Benzodiazepines (sedative hypnotic drug)

diazepam [valium] lorazepam [ativan] alprazolam [xanax]

do not do what in Acute ischemic stroke

do not drop their blood pressure. If u drop their blood pressure u lower blood flow to their brain

what are the first-line drugs for PD?

dopamine agonists

Cardinal symptoms of Parkinson's

dyskinesias (resting tremor, rigidity, bradykinesia, difficulty standing up; postural instability) motor symptoms Autonomic disturbances Depression Psychosis and dementia (look like schizophrenia) Wide-eyed, unblinking, staring expression with immobile facial muscles Frequent drooling Slow gait Short, shuffling steps Flexed and abducted arms held stiffly at the side Slightly forward bending trunk

Parkinson's disease is characterized by

dyskinesias and akinesia (disordered movement/no movement)

thrombolysis IS treatment for what

embolic stroke only NOT a treatment for a hemorrhagic stroke.

tension headache

ex. from studying for exam

complications of constipation as a side effect of morphine & other opiates/opioid agonists

fecal impaction, bowel perforation (life threatening because it can cause peritonitis), rectal tearing, and hemorrhoids

tension headaches

feel like a band around the head. bilateral

Referred pain

felt in an area removed or distant from its point of origin

drug interactions: levodopa

first-gen antipsychotic drugs MAO inhibitors anticholinergic drugs

Myasthenia Gravis

fluctuating muscle weakness and predisposition to rapid fatigue

benzodiazepines antidote

flumazenil [Romazicon]

Cholinesterase Inhibitors

for mild to moderate alzheimers disease Prevent breakdown of acetylcholine May help to slow progression of disease

Selegiline (Elderpryl, Zelapar)

for parkinsons Monotherapy or used with levodopa Can suppress the destruction of dopamine derived from levodopa and prolong the effects of levodopa

Dilatin (phenytoin) side effects

gingival hyperplasia Double vision Nausea

Lamotrigine

have to monitor for suicide risk

gun violence, → big problems with

head and spinal cord injury

thrombolysis is not a treatment for a _____ stroke.

hemorrhagic thrombolysis is NOT a treatment for a hemorrhagic stroke.

spontaneous bleeding into the brain

hemorrhagic stroke

what types of food can reduce the therapeutic response of levodopa?

high protien neutral amino acids

Neurogenic Shock

higher up Occurs with cervical or upper thoracic cord injury.

Adverse effects from prolonged use of morphine

hormonal changes Altered and suppressed immune function

what is the greatest risk factor for CVA (Cerebrovascular accident; stroke)

hypertension

Most common/serious side effect of clonidine

hypotension, bradycardia

Parkinson's patho

imbalance between dopamine and acetylcholinedopamine is inhibitory and Ach is excitatory atrophy of neurons in the substantia nigra that produce dopamine

Imitrex caution

in patients taking SSRI, SSNRI risk for serotonin syndrome

Encephalitis

inflammation of the brain Acute febrile illness, usually of viral origin with nervous system involvement Most common forms: Caused by arthropod-borne viruses and herpes simplex virus Clinical manifestations: Fever, delirium, or confusion progressing to unconsciousness; may become life threatening

Multiple sclerosis drugs

interferon beta

Levetiracetam (Keppra)

irrational anger is the biggest side effect, low side effects, can use with other seizure drugs, does not interact with other AEDs.

which stroke is a clot

ischemic

Hypertension is NOT aggressively treated UNLESS

it's a hemorrhagic stroke

Alzheimer's disease patho - Degeneration of neurons later in cerebral cortex

judgment, speech, perception, reasoning, and other higher functions Subsequent decline in cerebral volume

Convulsive status epilepticus

lasts 20-20 minutes, have to look at their glucose

Dilaudid over hydromorphone because →

less nausea and vomiting

impulse control things are important to think about with what drug?

levodopa

Valproic Acid

liver failure, pancreatitis, need to look at liver and pancreas enzymes before administering this medication, can't take while pregnant

what is the new theory of alzheimers

low levels of beta-amyloid 42 and abnormal tau and neurofibrillary tangles folding

First priority in seizures

maintain airway

what usually goes first in Alzheimers

memory

typical side effects of opiods

miosis, emesis, cough suppression

severe muscle weakening, leading to respiratory distress

myasthenic crisis

two ADRs of mixotranoxone

myelosuppression cardiotoxicity

mitoxantrone life threatening side effects

myelosuppression and cariotoxicity

Carbamazepine

need to do CBC before administering, can't take while pregnant, interacts with birth control, warfarin, & grapefruit juice

Myasthenia gravis drugs

neostigmine

Autonomic hyperreflexia (dysreflexia) - treatment:

nitroglycerin paste has to be given above the lesion

Static Encephalopathies

non progressive, causes motor defects

Levodopa can cause a hypertensive crisis if administered to an individual taking a _____________ ________ inhibitor.

nonselective MAO

Phenytoin (dilantin) - toxicity sign

nystagmus

When levodopa is combined with carbidopa, abnormal movements and psychiatric disturbances can ___

occur sooner and be more intense than with levodopa alone

migraines

often have auras cause photophobia, nausea and vomiting

opioids =

opioid agonsists

narcan

opioid antagonist used to treat overdoses

the class of drugs to reverse opioid side effects

opioid antagonitsts

right brain infarction

paralysis on left side of the bodyvision problemsquick, inquisitive behavioral stylememory loss

left brain infarction

paralysis on right side of bodyspeech/language problemsslow, cautious behavioral stylememory loss

what disorder am I: neurodegenerative disorder of the EPS associatde with the disruption of neurotransmission in the striatumtoo much Ach. too little dopamine dopamine inhibitory, Ach excitatory

parkinsons

neuropsych symptoms very common in _____ (can look like schizophrenia)

parkinsons disease

what do you need to do before administering mitoxantrone?

perform CBCs at baseline and before each doseperform liver function tests at baseline and before each doseperform a pregnancy test before each dosecheck heart function. if they look like they are going into heart failure, check it again.

which injury is caused by the impact; involves neural injury, primary glial injury, vascular responses, and shearing and rotational forces: primary injury secondary injury tertiary injury

primary injury

acute pain symptoms

pupil dilation increased heart pain decreased gut motility ** think fight of flight symptoms

which opioid side effect is priority to treat and what do you use to treat this

respiratory depression Narcan/nalaxon

classic sign of Parkinson's disease

resting tremors

parkinson's disease symptoms

resting tremors Difficulty initiating movement (slow shuffling gait, stiff muscles, difficulty standing, difficulty walking, difficulty with bodily movements, involuntary movements, muscle rigidity, problems with coordination, rhythmic muscle contractions, slow bodily movement) hallucinations, too much sleep or too little sleep, neuropsych symptoms very common (can look like schizophrenia) difficulty speaking, soft speech, or voice box spasms blank stare

ALS drugs

rilozule

Treatment of Amyotrophic Lateral Sclerosis (ALS)

riluzole (Rilutek)

indirect consequence of the primary injury; includes a cascade of cellular and molecular brain events. primary injury secondary injury tertiary injury

secondary injury

Phenobarbital

sedation, affects bone development (ricketts & osteomalacia), nystagmus and ataxia are the signs that they are starting to get toxic. Have to be tapered off, withdrawal is very severe and can cause them to die. Cannot abruptly stop.

Status epilepticus

seizure lasting 20+ minutes; treat with benzodiazepines (lorezapam, IV)

Frontotemporal Dementia

severe degenerative disease of the frontal and anterior frontal lobes. Produces death of tissue and dementia. Age of onset: Is younger than 60 years of age. difficult to distinguish from Alzheimer disease.

Parkinsons drugs

sinemet

First indication of brain compression (herniation)

sluggish pupils Unilateral pupil dilation Later sign of increased ICP but early sign of herniation

Blown pupils

stage 4

Headaches are triggered by

stress, fatigue, acute illness, sensitivity to tyramine (red wine), MSG, ETOH, etc.

Lamotrigine (lamictal) side effects

suicide risk

Autonomic hyperreflexia (dysreflexia)

syndrome of sudden massive reflex sympathetic discharge associated with a spinal cord injury Clinical manifestations Hypertension (up to 300 mm Hg systolic) Bradycardia (30 to 40 beats/min) Pounding headache, blurred vision, sweating above the lesion with flushing of skin, piloerection Treatment Elevate the head of the bed.

cluster headache

tearing burning ulilateral temporal (or around the eye)

DAI (Diffuse Brain Injury)

tearing/shearing that would lead to more significant injuries like bleeds or more severe diffuse axonal injury Increased intracranial pressure sign - 1 pupil dilates, 1 pupil stays the same

Four phases of pain

transduction, transmission, perception, modulation

true or false opioids can increase intracranial pressure

true

Gabapentin (Neurontin, Gralise)

use: partial seizures, neuropathic pain ae: Sleepiness

Levodopa/Carbidopa (Sinemet)

used for Parkinson's (dopaminergic) Can cause N/V, dyskinesias, orthostatic hypotension, CV stimulation, psychosis, discolored sweat/urine Do not use w/ MAOIs Proteins interfere w/ absorption

Interferon Beta

used for multiple sclerosis reduces the size and amount of sclerosis lesions Adverse effects - More vulnerable to infection (Myelosuppression) - Neutralizing antibodies

Ergotamine

used to treat vascular headaches. Causes vasoconstriction AE: Dizziness rhinitis, HTN, abdominal pain, N/V

Lamotrigine (Lamictal)

uses: Broad spectrum of anti seizure activity Bipolar disorder risk for suicide

Phenytoin (Dilantin)

uses: Epilepsy (partial and tonic-clonic seizures) Cardiac dysrhythmias Cardiovascular effects - dysrhythmias Effects in pregnancy

Carbamazepine (Tegretol)

uses: Seizures/ Epilepsy Bipolar disorder Trigeminal and glossopharyngeal neuralgias AE: Hematologic effects: Leukopenia, anemia, and thrombocytopenia Neurologic effects: Nystagmus and ataxia Birth defects Dermatologic effects: Rash and photosensitivity reactions

Phenobarbital side effects

withdrawal can cause death

Can I induce withdrawal symptoms in opioid tolerant users by giving them an opioid partial agonist?

yes

you MUST know what kind of ______ someone is having BEFORE _____

you MUST know what kind of stroke someone is having BEFORE treatment hemorrhagic stroke treated with TPA will KILL someone possibly