"High Yield" Stuff that I think is important but Hoppe and Esper probably think otherwise Flashcards
Focal seizures with altered mental status sx
Usually frontal or temporal lobe involvement with automatism and impaired memory
Phenytoin MOA and use
Na+ channel blocker, for tonic-clonic seizures, high drug-drug interaction (oral contraceptives)
Side effects of phenytoin
gingival hyperplasia, hirsutism and others
Carbamazepine MOA and use
Na+ channel blocker, for focal seizure tx, induces own metabolism (increase dose over time to compensate
Lamotrigine MOA and use
Na+ channel blocker, 3rd choice for absence seizures, can cause Steven Johnsons syndrome, rash and other side effects
Lacosamide MOA and use
Na+ channel blocker, modulates NMDA receptor, adjunct for focal seizures
Ethosuximid MOA and use
decreases threshold for Ca2+ T-type currents (closer to depolarized state), used for 1st line absence seizures
Valproic acid MOA and use
Na+ and Ca+2 T-type channel blockers, increases GABA an d for both absence and focal seizures
Gabapentin MOA and use
increases GABA in synaptic cleft, not as potent/not 1st line
Pregabalin MOA and use
decreases excitatory NT’s, affects calcitonin, more potent than gabapentin, METABOLIZED by KIDNEYS (not liver)
Benzodiazepine use
chronic inhibition of seizures
Clonazepam MOA and use
is a BZ, indirectly inhibits Ca2+ T-type so used for tx of absence seizuires, lots of side effects=4th choice for tx
Phenobarbital use
focal, tonic-clonic, and resistant seizures. CAN MAKE ABSENCE SEIZURES WORSE
Vigabatrin MOA and use
increases GABA by GABA transaminase inhibition, for infantile seizures and focal epilepsy. Side effect=VISION LOSS
Tiagabine MOA
GABA inhibitor for reuptake (increases synaptic GABA)
Felbamate MOA and use
Inhibits NMDA receptors, tx for refractory epilepsy, CAN CAUSE APLASTIC ANEMIA AND LIVER FAILURE
Rufinamide MOA and use
inhibits mGluR5 in high doses/prolongs Na+ channels, tx for focal seizures, Lennox-Gastaut, and refractory seizures
Drug hierarchy for tx of status epilepticus
lorazepam/diazepam, fosphenytoin, phenobarbital, general anesthesia (propofol/midazolam)
Sign of absence seizure on EEG
3Hz spike and wave
Atonic vs myoclonic seizure
Atonic has brief impaired consciousness, myoclonic does not
Simple vs complex partial seizure
comples has LOC, simple does not, complex also has aura and amnesia
Sign of partial seizure with 2nd generalization
eye deviation
Benign febrile convulsions sx/age
4mo to 4 years, from rapid increase in temp
Tx for absence seizure (1st and 2nd line)
ethosuxamide and valproic acid
Tx for juvenile myoclonic epilepsy
depakote
West syndrome sx
infantile spasms, severe developmental delay
Lennox-Gastout syndrome sx
multiple seizure types (intractable), developmental delay
Diet for tx of seizures
ketogenic diet
Cause of cerebral palsy generally
nonprogressive injury to the brain
Specific causes of cerebral palsy (3)
intraparenchymal hemorrhages (thalamus/caudate), periventricular leukomalacia (infarcts), multicystic encephalopathy
Sx of Chiari Malformation type I
loss of pain/temp/m. strength of upper extremities
Assc with Chiari malformation
meningomyelocele anchoring spinal cord, increased intracranial pressure
Pachygyria
broad gyri with decreased number
Lissencephaly
smooth gyri surface, failure of cell migration
Assc with Down’s syndrome
Alzheimer’s by 4th decade
Trisomy of chromosomes 13-15 sx
midline defects/holoproencephaly
Developmental Reflexes/disappearance (8 of them)
stepping at 1-2m, galant at 1-2m, grasp at 3m, moro at 3-6m, tonic neck at 3-6m, root/suck at 4-7m, babinski at 1-2 yr, parachute starts at 8-9m and stays
Developmental milestones/appearance (7)
smile/recognize parents at 2m, roll back to front at 4m, roll front to back 5m, sit/recognize stranges at 6m, walk alone/use 2 words at 12 m
Only neuroprotective tx for neonates
hypothermia
Tx to prevent neonatal hemorrhages
antenatal corticosteroids
Assc of cerebral palsy (common cause)
periventricular leukomalacia
Aicardi syndrome causes/sx
absence of corpus callosum, more in females (X chromosome defect), seen infantile spasms
Possible cause of ADHD
prenatal tobacco exposure
Dx of ADHD
in more than 1 setting, longer than 6 months, before 7 yrs, some type of impaired function
Tx for ADHD
methylphenidate/dextroamphetamine (stimulants), atomoxetine (NE reuptake inhibitor)
Autism sx
enlarged head, regression/no attainment of language
Rett syndrome cause (genetically) and sx
MECP 2 gene mutation on Xq28. See smaller head, stereotypic hand movements and dementia. More in females
Sx of Neurofibromatosis-1 and cause
scoliosis, epilepsy, eye problems. From chromosome 17
Cause of NF-2
merlin/NF2 proteins on chromosome 22
Sx of NF
cafe au lait spots, axillary freckling, neurofribromas in 2nd/3rd decade
Sturge Weber sx
port wine stain on face, cerebral calcification, seizures. Can see trolley track lines in occipital lobe
Tuberous sclerosis triad
mental retardation, adenoma sebaceum, and epilepsy
Cause of tuberous sclerosis
hamartin and tuberin genes on chromosomes 9 and 16
Sx of maple syrup urine disease
seizures, hypoglycemia, hypertonia, delicious urine
Sx of homocystinuria
multiple thromboembolic events, ectopia lentis, seizures
Dx of Niemann Pick Disease
bone marrow x with decreased sphingomyelinase in leukocytes
Wilson disease sx
degeneration of basal nuclei, cirrohosis of liver, Kaysier Fleischer rings, onset 11-25 yrs
Aminoesters and their metabolism
Cocaine, procaine, tetracaine. Via pseudocholinesterase in plasma/tissues
Aminoamides and their metabolism
lidocaine, bupivacaine, prilocaine, articaine, ropivacaine, levobupivacaine. Via CYP450 in liver, excreted via urine
When to use mepivacaine
with kids, causes little vasodilation so no epi needed
When to use bupivacaine
long procedures
What can epi cause with local anesthetics?
epi-indued hypoxia from vasoconstriction
Serious side effect of bupivacaine
cardiotoxicity
Risk of procaine (and aminoesters)
allergic rxn from PABA (metabolite)
Extra effect of lidocaine
1b anti-arrhythmi drug for atrial fibrillation
Use of prilocaine
for pts who cannot use epi (cardio pts), because it causes vasoconstriction
Atricaine metabolism uniqueness
metabolized in liver and plasma
Major toxicity of local anesthetics
decreased cardio conduction velocity and contractility
Propofol use and side effects
For inducing anesthesia, but causes cardio/respiratory depression
Contraindication for barbiturates and metabolism
porphyria. metabolized in liver
Antidote for benzodiazepines
flumazenil
Ketamine MOA, use and perk
NMDA inhibitor used for profound analgesia (only) with sympathetic stimulation. Causes minimal respiratory depression
Etomidate use and perk
for anesthesia (no analgesia), alternate to propofol cause it causes not cardio contraction problems
Dexmedetomidate MOA, use and side effects
alpha2 agonist, for short term sedation (intubation), and causes heart block/bradycardia
N2O use and side effects
For analgesia/sedation, causes pneumothorax and B12 deficiency sx
Halothane use and side effects (has lots)
For induction of children and maintenance of adult anesthesia. Causes malignant hyperthermia, hepatotoxicity, sensitization of catecholamines (arrhythmias)
Enflurane use and side effects
for anesthesia maintenance and causes increased isoniazid metabolism, m. relaxation, seizures
Isoflurane perk, side effects, and contraindication
Has no proconvulsive properties, causes airway irritation, cannot use with coronary artery disease
Desflurane use and side effects
for maintenace of anesthesia, caueses airway irritation and bronchospasm
Sevoflurane use and perk
For outpt anesthesia, causes no airway irritation
Thiopental + inhaled anesthetics perk
skip stage 1 and 2 of anesthesia
Use of trimethaphan
dissecting aortic aneurysm/HTN emergency
Use of mecamylamine
adjunct to nicotine patch or electroconvulsive therapy
Drugs interacting with NMJ nondepolarizing blockers
inhaled anesthetics, aminoglycosides, tetracyclins, Ca2+ channel blockers
Metabolism of NMJ nondepolarizing blockers (+2 special cases)
Excreted via urine/bile. Atracurium via plasma esterase, and cisatracurium via Hoffmann degradation
Nondepolarizing NMJ blocker to use with liver/renal failure
cisatracurium
Atracurium side effect/cause
cardio/respiratory involvement from histamine release
Long acting NMJ nondepolarizing blockers
doxacurium and pancuronium
Contraindication of succinylcholine
Muscle injury
Anticholinesterase effects on NMJ blockers
nondepolarizing effects are reversed, depolarizing effects are enhanced
Drug addiction pathway
Mesolimbic (ventral tegmental area to nucleus accumbens)
MOA of reward system for opioids
disinhibition (resulting in excitation at nucleus accumbens with DA release)
Tx for alcohol addiction
Benzodiazepine taper for withdrawal
Areas involved in cocaine/amhpetamine addiction
Nucleus accumbens and locus ceruleus
Marijuana addiction MOA
feed forward enhances VTA stimulation
Phencyclidine MOA
blocks NMDA Glut receptors
MDMA MOA
increases 5HT release and blocks reuptake and synthesis
Tx for opioid withdrawal
methadone/buprenorphine taper
Tx for barbiturate withdrawal
phenobarbital
What is common among all drug withdrawals?
Sympathetic hyperactivity
MOA of disulfiram
accumulates acetylaldehyde (from EtOH), causes aversion
Naltroxane MOA
opioid antagonist, only prevents “high”
Methadone MOA
long acting opioid agonist, no “high” spike when taken orally
Buprenorphine MOA
u-opioid partial agonist, decreases withdrawal sx and cravings
Suboxane characteristic
buprenorphine and naloxone, if injected naloxone prevents high, but if taken orally get buprenorphine effect
Varenicline MOA
nicotine partial agonist, contraindicated with psych pts
Acamprosate use
Modulation of Glu hyperactivity in EtOH dependence
Bupropion use and side effect
tx for smoking cessation but lowers seizure threshold (is an antidepressant)
Tx for cocaine/amphetamine addiction
antidepressants (desipramine/fluoxetine)
Triad of spasmus nutans
ocular oscillations, head nodding and torticollis
Signs of central vertigo
no habituation, nystagmus may change direction, immediate or delayed nystagmus
Signs of peripheral vertigo
habituation, no vertical nystagmus, delayed nystagmus
Dix-Hillpike with peripheral disorder
onset 2-20s, lasts less than 1 min, fatiguability, one direction
Dix-Hillpike with central disorder
no latent onset, lasts over 1 min, nonfatiguing, may change direction
Sx of benign paroxysmal positional vertigo
rotatory, fatigable, transient nystagmus. from otoliths being displaced
Vertigo sx with Meniere’s disease
severe and spontaneous lasting min to hrs, nausea and vomiting seen
Vestibular neuritis vertigo sx
sudden and severe, lasts days to months
Meds causing vertigo
antihistamines (meclizine, promethazine, dimenhydrinate), anticholinergics (scopolamine), benzo’s (diazepam)
Sx of cardiac syncope
rapid onset, little posture relation, exertion causes it
What causes convulsive syncope?
seizure triggered by decrease in BP
DM mononeuropathy cause
occlusion of vasa nervorum or compressive injury from lack of sensation
EEG seen with Creutzfeldt Jacob
bi or triphasic spike wave complexes
Most common roots affected in DM radiculopathy
Thoracic roots due to sheer number. Resembles herpes zosters without the vesicles
Sx of poylmyositis
elevated serium creatinine and creatine kinase, inflammation of muscles on MRI/ultrasound, ANA + in 1/3
Sx of Lambert-Eaton syndrome
is paraneoplastic. proximal m. weakness that improves with use, no improvement with anticholinesterase, autonomic findings
Sx of pseudotumor cerebri
elevated intracranial pressure (CSF tap over 250 mmH20)
EtOH abuse disorders (4)
subacute combined degeneration (B12 deficiency), Alcoholic polyneuropathy (symmetric and distal), Marchiafava Bignami (demyelination of cc with seizures, dementia), Wernicke Korsakoff (thiamine deficiency impacting memory)
Tx for Wernicke Encephalitis
thiamine before glucose
Stages of Lyme disease
Bull’s eye rash (local), meningitis/carditis/neuropathy (early disseminated), persistent arthritis (late disseminated)
Sx of Myasthenia Gravis
fluctuating m. weakness that is better in the morning, assc with thymoma. Pyridostigmine used to tx
Location of cluster headaches
Supraorbital/temporal region. often occurs at night. Tx with sumatriptan, verapamil, Li+, methylsergide
Tx for MS
solumedrol (steroid) or interferon drugs
Side effect of all drug withdrawals (and tx)
all will cause hyperactivity of sympathetics. use clonidine which is an alpha2 agonist
Contraindication of varenicline
It is for nicotine craving reduction, but cannot be used with psychiatric pts
Side effect of buproprion
It is for smoking cessation but can cause seizures by lowering threshold
Weak side of Lipid Theory
enantiomers of barbiturates, etomidate and steroids do not almost membranes/do not cause anesthesia (stereochemistry is involved somehow)
Preoperative drugs to control emesis
droperidol/ dexamethasone and metoclopramide
Adverse effect of barbiturates (thiopental/methohexital)
extreme vasoconstriction -> gangrene
Use of ketamine
analgesia w/ sympathetic stimulation
Side effect of etomidate
adrenocortical depression
EEG of West syndrome
high amplitude abnormal spikes (hypsarrhythmia)
EEG of Lennox Gastaut Syndrome
slow spike and wave, paroxysmal fast activity
EEG of atonic seizure
low voltage, polyspike wave, electrodecrement
