Neuro Lecture 4 Flashcards
What medicines do you use controlled substance contract for?
any controlled substance
ex- benzos, opioids, sedatives, stimulants
what can you do to make sure people are following a controlled substance contract?
random drug screens (know metabolite list)
If they break a controlled substance contract what can you do?
- terminate services
2. offer rehab/ counseling
what is the primary reasons for a controlled medication agreement?
Patient education
What is a chronic inflammatory disorder of the CNS that is immune mediated?
Multiple sclerosis
MS is damage caused by the _____ immune system.
innate
Is MS auto-immune?
No, it is immune mediated
What is the pathology of MS
Inflammation disrupts BBB
T-cells and macrophages cause damage around the blood vessel involved
Is MS a white matter disease?
Not specifically, also affects grey matter
What imaging should you use for MS
Brain MRI with contrast
allows you to see inflammatory lesions
What will the lumbar puncture look like with a majority of MS patients?
oligocloncal bands of non-specific IgG
What is the most common cause of inflammation of the optic nerve (optic neuritis)
MS
is cognitive impairment typically a white or grey matter issue
grey matter
what are sign of MS
any neurologic sign
can be anywhere
how do diagnose MS?
History
MRI may not show smaller lesions
to be diagnosed with MS what must have happened
Basically, two or more attacks (demonstrated clinically or by MRI) disseminated in space and time
(ex- inability to use arm that got better then numbness in leg that then got better)
or one year of progressive symptoms and MRI show lesions disseminated by space
Diagnosis for patients who have had only one (monofocal) attack, or two or more (multifocal) attacks simultaneously.
Clinically isolated syndrome (CIS) means there is a high risk of developing MS
will treat them like they have MS
what are the 4 types of MS?
relapsing-remitting
progressive-relapsing
secondary - progressive
primary-progressive
What does the lesion normally follow in MS?
the artery. Usually perpendicular to the ventricles (because they follow a blood vessel
What does “benign MS” mean
Like relapsing remitting, but you return to baseline after every episode
What type of MS starts out as relapsing-remitting but converts into a progressive form
secondary progressive MS
what can help relieve acute symptoms of MS?
High-dose IV corticosteroids
Plasmapheresis may help some patients who don’t respond to steroid therapy
what are MS disease modifying treatments?
Interferon β-1a,
Interferon β-1b
Glatiramer acetate
reduces relapses by about 1/3
doesn’t work as well with people who get continuously worse
what are Natalizumab and mitoxantrone used for?
Second line agents for MS disease-modifying treatment.
Have severe side effects
Is there any effect pharmacologic treatment for progressive MS?
No
What can help MS patients after an episode to get them back to a functioning level?
Neurorehabilitation
When is MS commonly diagnosed and in whom?
20-50
more common in girl than women but equal once over 50
Is MS considered an inherited disorder?
No, but there are identifiable genes that make you more risk for developing it
Does MS affect life expectancy?
No, not significantly (only 5-10 years)
what is a prolonged, deep state of unconsciousness that lasts longer than 6 hours?
Coma
What causes a coma?
Dysfunction of the cortex or the reticular activating system
what are the three components of the Glasgow Coma Scale?
Eye
Verbal
Motor
how many points for eye
1-4
how many point for verbal?
1-5
How many points are for motor?
1-6
What’s the highest score for glasgow coma scale?
15
what is considered a severe brain injury on GCW?
3-8
What’s a normal range for GCS?
13-15
How do you record the GCS?
Total score then score for each and time
Causes of coma?
Intoxication
OD, Misdose
Stroke/ herniation of brain
head trauma, brain loss
what’s the most common cause of coma?
Drugs
Is hypothermia used to treat a coma or is it a cause?
Both
How do you diagnose coma?
Rule out locked-in state (can move eyes but nothing else)
Rule out psychogenic unresponsiveness (caloric stimulation)
What tests should you get one someone with a coma?
Toxin screen
glucose, BMP
brain imaging
What do all coma patients get put on for seizure prophylaxis?
levitoraceatam
Posture where patient is flexed. Cortex is usually involved
Decorticate posturing
Posture where patient is extended. Usually brainstem is cause of coma
Decerebrate (extensor) posturing
If pupils are equal and reactive is the person probably in a coma?
No
If a person have pinpoint pupils that are reactive what is the likely cause?
Opioid OD
If both pupils are dilated and don’t react what is probably the case?
Not really alive
coudl really ahve hypothermia, severe hypoxia, stimulant OD, too much cocaine
If one eye is dilated and unreactive with coma where is it probably
Ipsilateral side
What is status epilepticus w/o physical signs
Subclinical status epilepticus
What imaging tests should you do for coma?
MRI/ CT
EEG
battery of neuro tests
why do you put coma patients in a hypothermic state.
saves brain tissue, less damage
What can tetracycline and minocycline cause neurologically?
Pseudotumor cerebri (increased ICP)
what can lidocaine cause?
Garrulousness (talking your ear off)
psychosis
used in cardio
What is amiodarone used for and what is the common main problem of it.
anti arrythmic agent
tremor is the main problem
what is a big problem calcium channel blocker cause?
tardive dykinesia (over time, usually around mouth)
What can statins cause?
muscle pain and weakness
What can dopamin-receptor blockers cause (enti-emetics)
Parkinsonian syndrome
Lots of Tums or pills high in magnesium and aluminium what can they cause?
Imbalanced electrolytes
what can salicylates (aspirin) cause?
seizures
what can NSAIDs cause?
medication overuse headaches
what is nicotine?
a powerful stimulant
What do oral hormone replacements cause?
Stroke
What does caffeine decrease?
blood flow in the brain
can cause enhanced physiologic tremor
what is the most common reason for seeking medical care?
pain
what are 4 types of pain
nociceptive pain (visceral, somatic)
neuropathic pain
psychogenic pain
idiopathic pain
pain that is is often poorly localized but intense. Pain is found in ligaments, joints, blood vessels. Opiates are often used for this type pain
deep somatic pain
pain is relatively well-defined and easy to locate
superficial
what type pain indicates that the CNS and PNS and functioning correctly
nociceptive pain
where does lung pain refer?
Shoulder
Where does testicular pain refer?
Up towards kidneys
pain due to the PNS malfunctioning due to injury or disease.
Neuropathic pain
3 pain cuases of neuropathic pain
diabetic peripheral neuropathy
postherpetic neuraliga
cancer
Press lightly on skin and it feels a lot harder (over sensitive to feelings in that area)
hyperalgesia
Where connections aren’t made correctly. (ex- do a needle prick and they feel pain)
Allodynia
pain that is more commonly caused by grief, social rejection, emotions often found in headache, abdominal pain, muscle aches, lower back.
psychogenic pain
type of pain where no physical or psychosocial cause is identified
idiopathic pain
what type pain is fibromyalgia?
idiopathic pain
pain that extends beyond the period of healing as the result of an abnormality of the central nervous system (CNS not working correctly)
chronic pain
is chronic pain nociceptive pain?
No, because CNS isn’t working correctly
is the goal of therapy for chronic pain to get rid of the pain?
No goal is is to build a life that you can enjoy and be proud of.
what type pain are opiate analgesics effective for?
Acute
Sharp
Moderate/severe
Visceral/deep-somatic pain
what 2 conditions are there no indication for the benefit of long term opiate treatment?
chronic headache
osteoarthritis
what is a NSAID drug that can be given for pain exacerbations
Ketorolac IM (give in the gluteus)
it will burn (acidic), give it slow
for an 8/10 or more
when can’t you ketorolac?
When they are bleeding (ex- on period)
what can you give when you suspect muscle spasm is the pain?
muscle relaxants
what are some seadating tricyclic antidepressants?
amitriptyline, nortriptyline, (& trazodone- SARI)
What are some SNRIs that are good with depression and daytime pain?
Duloxetine, venlafaxine, desvenlafaxine
Name alpha adrenegeric agonists that are used so signal of pain doesn’t go into brain. Believed to stimulate inhibitory interneurons, useful for pain and muscle spasm.
Clonidine, tizanidine
what drugs helps with the “gateway” theory? overload the pain stimuli
Capsaicin (don’t give with zoster)
menthol
what are some other topical agents for pain?
Lidocaine
Ibuprofen, gabapentin
what are some injected local anesthetics for pain
lidocaine
marcaine
Stimulates nerves under skin
TENS (Transcutaneous electrical neurostimulation)
interferential current therapy (IFC)
who normally develop an opiate addiction?
history of substance use disorder
psychiatric comorbidity
hx of pre-adolescent sexual abuse
A physiological state characterized by a decrease in the effects of a drug (e.g., analgæsia, nausea or sedation) with chronic administration.
Need to increase dose for same effect
Tolerance (anyone on opiates will experience this)
Physiological adaptation to the presence of a medication. The development of withdrawal symptoms when it is discontinued, when the dose is reduced abruptly or when an antagonist is administered.
Dependence
Compulsive use of the medication for nonmedical reasons. Involves dysfnctional behaviors
Addiction
Involves pain-relief seeking behavior. Iatrogenic condition, best treated by education
Pseudo-addiction
who is pseudo-addiction the fault of?
The provider
A chronic pain condition most often affecting one of the extremities (arm, leg, hands, or feet)
complex regional pain syndrome
Type of CRPS that Usually occurs after an injury or trauma to that limb (usually has nerve damage)
CRPS-I
Type of CRPS that can occur w/ no injury
CRPS-II
who does CRPS not affect
children under 5, rarely under 10
who does CRPS typically affect?
Women, mean age is 52 smoke tobacco (68% of patient do)
what are some symptoms of CRPS?
disproportionate to inciting event may involve whole extremity edema (neurogenic) elevation in skin temp (good sign, easier to treat) abnormal sweating pattern
what type osteoporosis is common w/ CRPS
patchy osteoporosis
how do you diagnose CRPS?
history and physical exam
basically rule out a bunch of other things
EMG (show difference b/w type I and II)
Some patients with CRPS have ___________ mediated pain that can be decreased by a nerve block.
sympathetic
is amputation of a limb effective at controlling CRPS?
Not really, only helps 50%
