Exam 4- Neuro, seizures, mental disorders, + depression Flashcards
seizure-def
brief episode abnorm electrical act in brain cells
can be recurrent (epilepsy)
cause seizures
largely idiopathic
genetic predispos.
2ndary causes- etoh withdrawl, dev defects, metabolic dis, fever (kids), birth injury, acquired neuro dis (tumor or inc icp), hypoglycemia
partial seizure
simple or complex
simple seizure
partcial
have awareness/memory and conciousness
20-60 seconds
complex seizures
partial consciousness impaired (stare/motionless) 45-90 sec.- longer
generalized seizure
no specific part of brain (affects both sides)
tonic- clonic or absence (disconnect from world- common in kids)
status epilepticus
constant convulsions
life threatening- med immergency
tonic-clonic- several min at close intervals
status epilepticus complications
hypotension, hypoxia, cardiac dysrhythmias
high-risk brain damage
status epilep- causes
abrupt d/c anti-seizure drug brain tumor/trauma systemic or cns infection etoh withdrawl drug overdose
tonic v clonic
tonic- stiff
clonic- jerking
general anti-epileptic drugs (AEDs)- moa, therap effect
control act but do not cure disorder
moa- dec mvmnt ions into nerve cells (block na= dec excitability and inc stability of cells (higher seiz. threshold))
inc act. neurotrans (gaba- dec excitability)
aed- phenotoyin- indications, routes
indications- prevent/trt seziures, bipolar, neuropathic pain
routes- oral/ng- dec absorption w/ tube feeds (stop feed 1h b4 and 1h after, can dec absorb by 70%)- can lead to malnutrition
IV- lots d-d interactions, only compatible w/ ns (have to piggyb)
assess iv site before admin (can cause phlebitis)
no IM- poor absorb
aed- phenytoin- therap range and role of protein
protein bound (ng interaction), only unbound drug is active (protein or malnourished ppl need dec dose bc less drug is taken out of circulation)
5-20mcg/ml or 0.8-2.0 mcg/ml unbound
checked after start of therapy
aed- phenytoin- d-d interactions
enzyme inducer- inc activity of metab enzymes
inc metab drugs= inc rate inactive form= dec effect bc shorter half life
aed phenytoin- ae and rare rxns
ae- ataxia, nystagmus, diplopia, n/v w/ po, hypotension
serious- allergic rxn (dress, sjs, angioedema)
dress- skin rash + muc. mem.
sjs- skin peeling
hepatic failure (LFTs)
bone marrow depression (agranulocy, aplastic anemia)
cardiac arrest (suppress elect act of heart)
suicidal thoughts
aed phenytoin- s/s toxicity
dizziness, nystagmus, slurred speech, aphasia, confusion, ataxia
aed- phenytoin- contraindications/ cautions
hypersen (angioedema and epith dis) preg (terratogenic) heart block (dec conduction= dec hr) cns depression hepatic impairment 15:02 allele (assoc. w/ epith hypersen rxns)
aed- treats what type seizures
generalized seizures (tonic clonic or absence)
aed- fosphenytoin (cerebyx)
safer IV version phenyotin (less irritation and d-d rxns than phenytoin)
converted to phenytoin after IV injection (prodrug)
activated after liver metab
aed- carbamazepine (tegretol)
narrow therapeutic range (high risk toxicity)
black box warning- aplastic anemia and agranulocytosis (bone marrow dec)
assoc. w/ 15:02 allele disposition
aed- valpronic acid (depakote)
highest risk birth defects (avoid in women pregnant or planning to be)
aed- diazepam (valium), lorazepam (ativan)
pams
benzodiazepines
shorter acting
physical dependence w/ chronic admin (lead to w/drawl s/s)
aed-clonazepam (klonipin)- benzodiazepines
longer acting
inc gaba act
taper if long term use to avoid s/s withdrawl
aed- phenobarbital
long half life
3-4wks to reach steady state
can cause cns depression
aed- partial seizure- gabapentin or pregabalin- def and ae
trt neuropathic pain
half life inc w/ dec renal fun
ae- dizziness, drowsy, fatigue, tremor, n/v (dec overtime)
1st dose given at bedtime d/t dizziness
aed- partial seizure- lemotrigine-ae
dizzy, drowsy, ataxia, blurred vision, n/v, headachd
adjunct med
aed- partial seizure- levetiracetam (keppra)
used in combo therapy
less d-d interactions w/ o/ aed
*not metab in liver
aed- general assessment
hx seiz/drugs
monitor serum drug lvls (esp tegretol)
describe seizure
what to document- seizure
characteristics duration loss consciousness loss bowel/bladder control post-seizure beh
aed- intraseizure precautions
pillow underhead, do not restrain mvmnts, loosen tight clothing (neck or chest)
elevate hob, turn on side, have suction ready to dec aspiration
prevent hypoxia- o2 and resucu equip avaliable
aed- fast acting IV antiseizure drugs
trtmnt status epilepticus
IV benzos- lorazepam- followed by phenytoin or fosphenytoin
aed- pt ed
take meds as scheduled (maintain blood levels to prevent w/drawl (status epilep))
do not d/c meds abruptly
driving- 6m-1yr free and then at least 3mon free
d-d interactions
pregnancy- try taper if planning to be preg, if not possible, do not d/c meds, weight risk of birth defects v seizure
prevent falls- drugs cause ataxia and dizziness
brush and floss avoid gingival hyperplasia (phenyotin)
do not switch btw generic and brand names
aed- therapy goal
minimize seziure act. w/ miniimal ae
monotherapy preferred to dec risk d-d interactions
time span to d/c aed
if free 2yrs
slowly taper off
seizures- non-drug therapies- vagal nerve stimulator
if combo med therapy not working
can prevent / stop seizures (inc gaba)
expensive and high risks!
pulse generator under collarbone
seizures- non-drug therapies- keto
high fat, low cho or carbs
causes ketoacidosis, can dec act by 50%
seizures- non-drug therapies- cannabinoids
limited safety in adults v animals
ae- drowsy and diarrhea
schizophrenia- def
chronic psychotic illness
disordered thinking, dec ability compared reality
emerges during adolescence or early adulthood
*altered reality
schizophrenia- s/s- positive
exagger of norm function
hallucinations, paranoia, agitation
schizophrenia- s/s- negative
dec of norm function
lack motivation, blunt affect, withdrawl
schizophrenia- 1st and 2nd gen
1st- haloperiodol
2nd- clozapine, risperidone
schizophrenia- med duration
at least 12 mon. (tapered if no episodes)
25% not require additional trtmnt after 1st episode
schizophrenia- therapy goals
prevent acute episodes, maintain highest lvl function
schizophrenia- First gen (FGA)- haloperidol- action and indication
indic- trt schizophr, mania, severe agression
moa- supress dopamine, acetylcholine, histamine and norepinephrine
schizophrenia- First gen (FGA)- haloperidol-ae
extrapyramidal symptoms (EPS)- APAT acute dystonia (muscle rigidity, joint dislocation) parkinsonism (shuffling, tremors, drooling) akathisia (constant need move) tardive dyskinesia (abnorm mvmnt mouth toungue -chronic)
neuroleptic maliignant syndrome anticholinergic effects (blurred vision, dry mouth, urinary retention) orthostatic hypotension
schizophrenia- First gen (FGA)- haloperidol-ae- others
seizures, agrandulocy, severe dysrhytmias (qt prolong), inc risk stroke, mi or death if used for dementia-related s/s)
neuroleptic malignant syndrome (NMS)- manif
rare rxn to FGAs lead pipe rigidity sudden high fever, sweating, autonomic instability (dysrhythmias, fluctuations in bp) raise and fall LOC (confused or mute) seizure, coma
neuroleptic malignant syndrome (NMS)- complications
death d/t respir failure
cv collapse
dysrhythmias
renal failure d/t rhabdomyolysis
neuroleptic malignant syndrome (NMS)- trtmnt
withdrawl med, trt hyperthermia w/ antiphyretics and cooling blankets
benzos, muscle relaxants, iv fluids
schizophrenia- second gen (SGA)- clozapine- action and indication
indic- trt schizo
moa- block serotonin and dopamine recep, lower affinity for dopamine
*fewer extrapyramidal side effects
schizophrenia- 2nd gen (SGA)- ae
agranulocytosis- usually from spesis
EPS- APAT (dec compared to FGA)
metab effects- weight gain, dm, dyslipidemia
myocarditis (chest pain, inflamm)
seizures
ortho hypotension
dizziness, sedation
antichol effects (dry mouth, blurred v, constip)
inc risk stroke, mi, death when used for dementia
ventricular dysrhythmias (qt prolong)
neuroleptic malignant sydrome
antipsychotic considerations-1st gen
assess for eps - acute dystonia
parkinsonism, akathisia, tardive dyskinesia
antipsychotic considerations- 2nd gen
encourage reg exercise, monitor caloric intake
monitor weight, s/s hyperglycemia
assess bg, lipid panel, wbc and anc (agranulocy)
assess s/s infection r/t dm
notify provider immedi if s/s infection
antipsychotic considerations- 1st and 2nd gen
assess orthostatic hypotension and sedation
employ fall prevention
avoid use in elderly for dementia
assess for seizures
assess for neuroleptic malignant syndrome ( lead pipe rigidity, fever, loc)
cardiac monitoring for iv admin
antipsychotic- promote adherence
check for cheeking
involve family members on care
provide written and verbal instructions (dose size, timing)
* take as scheduled
ae and how to minimize
establish rapport
consider IM depot preparation for long-term therapy (q 2-3 wks or monthly)
antipsychotic- non drug trtmnt
behavioral therapy, vocational therapy
hospitalization for protection, support and high lvls care
depression- cause
monoamine deficiency hypothesis
dec monoamine neurotrans (norepi and serotonin)
depression- SSRI- fluoxetine
selective serotonin reuptake inhibitors
ex. sertraline and citalopram
depression- TCA- amitriptyline
tricyclic antidep
depression- maois- selegiline
monamine oxidase inhib
suicide risk w/ antidep
highest in 1st 2 wks after start
inc risk suicide if already suicidal bc in energy
depression and women
2x incidence underdiagnosed and trted
ssri- fluoxetine (prozac)- action, indication, pharmaco
moa- inhib serotonin reuptakes, inc transmission serotonergic synapses
indication- depression
pharm- metab liver, excreted kid
*4wks reach steady conc
ssri- ae
safer than tca or maois sexual dysfunction anxiety, tremor serotonin syndrome neuroleptic malignant syndrome suicidal thoughts seizures
serotonin syndrome
onset < 12hr after 1st dose
manifestations- altered mental status, incoord, myoclonus, hyperrefl, sweating, tremor and fever
death
inc risk w/ moais
ssri- considerations
assess suicide risk, avoid concurrent use moai (SS), educate pt on s/s of SS
monitor for NMS
assess sexual side e
tca- amitriptyline- action, indication
action- block reuptake norepi and serotonin (monoamine neurotrans)
indic- depression, bipolar dis, fibromyalgia, neuropathic pain
*not commonly used for depression
tca- amitriptyline-ae
orthostatic hypoten (blocks alpha recep) antichol effects sedation cardiac toxicity (qt prolong) suicidal thoughts highest risk death if OD
tca- amitriptyline- considerations
assess suicide risk ass orthostatic hypoten asse sedation (Falls) implement safety precautions monitor for dysrhythmias
maoi- selegiline- moa, indication
moa- inc amnt norepi and serotonin in nerve terminals
indication- not used anymore
risk htn crisis w/ foods high tyramine
d-d interactions w/ tca, ssris and indirect acting sympathomimetic drugs
maoi- selegiline- tyramine- patho and foods
inhib enzyme breakdown of med (accumulates)
foods high- aged cheese, beer, sausage, soy sauce, overripe avocados, bananas, meat
patho- tyramine unable be metabolized- inc norepinephrine- vasoconstriction- high bp
maoi- selegiline- ae
seizures, dizziness, headache, blurred vision, orthostatic hypotension
htn crisis
htn crisis- s/s and trtmnt
s/s- headache, tachycardia, palpitations, n/v, sweating
can lead to stroke and death
trtmnt- iv vasodilators (nitroprusside and labetalol)
maoi- selegiline- considerations and pt ed
consid- assess suicide risk, assess bp (htn crisis of orthostatic)
tyramine free diet
pt ed- foods to avoid, s/s htn crisis- seek immed med attention
orthostatic hypotension
drug interactions
