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