General neuro Flashcards
Sx of ETOH withdrawal
Tremor Confusion Agitation Diaphoresis Seizures Diarrhoea Headache Nausea Hypotension, tachycardia Fever Delirium tremens (psychiatric phenomenon rather than physical withdrawal) Wernicke's encephalopathy (memory loss)
3 features of Wernicke’s encephalopathy
1) Encephalopathy
2) Oculomotor dysfunction
3) Gait ataxia
Rx ETOH withdrawal
If history of seizures/DT, load with diazepam 100mg
If liver disease, use oxazepam 200-240mg (shorter acting)
Then 10-20mg Q2H as per AWS until symptoms subside
How to differentiate between serotonin syndrome and neuroleptic malignant syndrome?
- Causative agent
- Time of onset
- Relationship to drug dose
- Level of consciousness
- Pupils
- Other cranial nerves
- Tone
- Reflexes
- Clonus
- Temperature
- Salivation
- CV findings
- CK
- Acid-base
- FBC
- Bowel sounds
- SS caused by serotonin agents, NMS caused by antipsychotics (dopamine antagonist) or withdrawal of pro-dopaminergic drug used in Parkinson’s
- SS has rapid onset (hours), NMS has more gradual onset (days)
- SS is caused by overdose of serotonin, NMS can occur with normal dosing even after years of treatment with the same agent but usually in first 1-2 weeks or recent dose change
- SS causes agitation, delirium, NMS causes encephalopathy, stupor, coma, mutism
- SS dilated pupils, NMS normal pupils
- SS doesn’t affect cranial exams, NMS causes dyaphgia and aspiration
- SS and NMS both cause increased tone
- SS causes increased reflexes, NMS causes decreased reflexes
- SS causes clonus, NMS no clonus
- SS and NMS both cause raised temperature
- SS and NMS both cause excessive salivation
- SS causes tachycardia and hypertension; NMS cause haemodynamic instability (may be high or low)
- SS and NMS both cause CK rise with rhabdo
- SS has normal acid-base, NMS causes acidosis
- SS has normal FBC, NMS has leucocytosis
- SS has loud, vigorous bowel sounds, NMS has reduced, sluggish bowel sounds
Features of serotonin syndrome
Triad of mental status change, autonomic stimulation, neuromuscular excitation
Serotonin syndrome (RASCAL) Rhabdomyolysis Agitation/hypervigilance Seizures Clonus Autonomic overdrive - tachycardia, hypertension Large pupils Hyperreflexia Hyperthermia
Features of neuroleptic malignant syndrome
Tetrad of hyperthermia, extrapyramidal effects, autonomic dysfunction, CNS effects
MS (FEVER LAD) Fever Encephalopathy Vitals unstable - hyper/hypotension, brady/tachycardia Elevated enzymes - CK Rigidity of muscles (lead pipe), hypertonia Leucocytosis Acidosis Diaphoresis Tremor
Rx serotonin syndrome
Stop serotonergic agent
Supportive care (IV hydration, diazepam PRN)
Hyperthermia
- Aggressive cooling (if T>38.5)
- May require intubation and paralysis
- Anti-5HT agents (not indicated in minor toxicity) - chlorpromazine, cyproheptadine, olanzapine
Toxicity usually only lasts <24-48 hours
Rx neuroleptic malignant syndrome
Stop dopaminergic blocker
Supportive care (aggressive IV hydration especially if hypotensive)
Prevent VTE, rhabdomyolysis, AKI, aspiration pneumonia
Diazepam may help with agitation
Hyperthermia
- Aggressive cooling (if T>38.5) with tepid sponging, continuous fanning, icepacks
- Antipyretics are ineffective
Antidotes (must discuss with toxicologist)
- Most cases do not require this but in severe cases, can use bromcocriptine
Saturday night palsy is secondary to …
radial nerve palsy
What are the first things to go on NCS with nerve damage?
Sensory nerve action potential (SNAP)
If present, good prognostic sign
Peripheral neuropathy commonly affects which nerve first
sural sensory
Expect changes on NCS
Why should we not cease levodopa abruptly?
NMS like problem
Very dangerous
Which is the only antipsychotic(s) has evidence in hallucinations in PD?
Clozapine
Very low risk of neuromuscular side effects
However lots of side effects and difficult to use so try other things first! Try reducing dose of current medications that may be contributing.
Quetiapine has minimal evidence despite it being used in real life.
Selegiline side effects
MAO inhibitor
Usually don’t cause problems
BUT can cause confusion when added on top of other parkinsons medications
Consider stopping if someone with PD develops hallucinations/confusion
Which parkinsons medication is most likely going to cause hallucinations/psychosis?
DA agonist
