Exam 1 - Seizures, Status Epilepticus, & Acute Ischemic Stroke Flashcards
List provoked seizure etiologies? Unprovoked?
intoxication, withdrawal, trauma, meningitis, psychiatric, metabolic derangements; ???
List inhibitor neurotransmitters? Excitatory?
GABA; glutamate, aspartate, acetylcholine
Define status epilepticus?
a seizure lasting >5 minutes
What are first line agents used to stop seizures?
benzodiazepines (lorazepam, diazepam, midazolam)
What are first line agents used to prevent more seizures from occurring?
antiepileptics (phenytoin, fosphenytoin, leviteracetam, valproic acid)
What are AEs of fosphenytoin? (2)
cardiovascular effects (Na+ channel blocker), extravasation
What are AEs of phenytoin?
P-450 interactions, hirsutism/hypertrichosis, enlarged gums (gingival hyperplasia), nystagmus, yellow-browning of skin (hepatitis), teratogenicity, osteomalacia (Vitamin D deficiency), Interference with folate metabolism (anemia), neuropathies (vertigo, ataxia, HA), neutropenia, thrombocytopenia, hypotension, bradycardia, QT prolongation
What is the goal phenytoin level?
10-20 mcg/dL
What percent of phenytoin is protein bound?
90%
What is the dose for leviteracetam in SE?
60 mg/kg IV bolus
What is the dose for valproic acid in SE?
40 mg/kg IV bolus
What are AEs of valproic acid? (5)
drowsiness, HA, thrombocytopenia, pancreatitis (pediatrics), hyperammonemia
What does valproic acid interact with and what is the effect?
phenytoin, displaces and increases fraction unbound
What is the dose for lacosamide?
100-200 mg IV BID
What are AEs of lacosamide?
dizziness, abnormal vision (diplopia), ataxia
When is SE considered refractory?
seizures that last >2 hrs or recurring despite treatment with conventional antiepileptic drugs
What must be done as post-intubation treatment? (2)
IV infusion of antiepileptic (propofol or midazolam) and long-term monitoring EEG
What is the dose for midazolam refractory SE treatment?
2 mg IV bolus
Which drugs are used for inducing medical comas? (2)
phenobarbital, pentobarbital
What are AEs of barbiturates?
respiratory depression, hypotension, lethargy, nystagmus, thrombocytopenia, immune suppression, decreased GI motility
What is the goal of therapy for SE?
attain burst suppression on the LTM and maintain for 24-48 hrs
What is treatment for super refractory SE?
ketamine 1.5-3 mg/kg IV bolus
What score is considered a minor stroke on the NIHSS scale? Severe?
1-4; >21
What are neurological stroke mimics?
seizure/post-ictal state, complicated migraine, other intracranial process (abscess, tumor, hemorrhage), vertigo, transient global amnesia, cranial/peripheral neuropathies (Bell’s palsy)
What are metabolic stroke mimics?
hypo/hyperglycemia, hyponatremia, hepatic encephalopathy, drug overdose
What are psychiatric stroke mimics?
conversion disorder, malingering
If less than 4.5 hrs since onset, what is stroke treatment?
IV fibrinolytics +/- thrombectomy
What is the dose for alteplase?
0.9 mg/kg with 10% as bolus over 1 min and rest over 1 hr, max 90 mg
What is the dose for tenecteplase?
0.25 mg/kg, max 25 mg
What is the blood pressure required for a thrombolytic bolus?
<185/110 mmHg
What is the blood pressure required for a thrombolytic infusion?
<180/105 mmHg
When is permissive hypertension allowed?
if patient meets exclusion criteria and alteplase is not given
What are first-line antihypertensives for blood pressure control in acute ischemia? (2)
labetalol, nicardipine (preferred if HR <55)
What are second-line antihypertensives for blood pressure control in acute ischemia? (3)
hydralazine, enalaprilat, clevidipine
When may tenecteplase be preferred over alteplase?
large vessel occlusions
What is treatment for symptomatic intracranial hemorrhage from fibrinolytic therapy? (3)
discontinue fibrinolytic (duh), IV cryoprecipitate 10 U over 10-30 min, IV tranexamic acid 1 g or ε-aminocaproic acid 4-5 g
What is treatment for angioedema from fibrinolytic therapy? (6)
maintain airway, hold ACEi (major risk factor), IV methylprednisolone 80-100 mg , IV diphenhydramine 50 mg, IV ranitidine 50 mg or famotidine 20 mg, epinephrine 0.3 mL, “watch and wait”
List the treatment recommendations for post-fibrinolytic care? (5)
neuro/BP monitoring, high-dose statin, aspirin (or dual-antiplatelet for those with stent), DVT prophylaxis (>24 hrs post-alteplase), anticaogulation (if cardioembolic stroke or Hx of a fib)
List the recommendations for secondary stroke prevention?
lifestyle and nutrition mods, smoking cessation, limit alcohol consumption, counsel on substance abuse, manage medical conditions
