Neurology (I-IV) Txs Flashcards
maybe some DDxs too
How do you Tx meningococcal meningitis?
IV PCN G q 4hr x 5-7 d
How do you Tx coma?
1) Support
2) Correct any of the abnormalities found during assessment.
3) Thiamine, dextrose, or naloxone can be given IV without awaiting lab results
What do you need to repeat when a pt is in a coma?
Neurological checks
What 3 things can you do to Tx coma before labs get back?
Thiamine, dextrose, or naloxone
How do you Tx subdural hematomas?
Admit to hospital and neurosurgery consult
How do you Tx minimally conscious pts?
1) Underlying cause – if able
2) Amantadine
How to Tx cluster headaches?
High flow O2 via non-rebreather mask
How to Tx migraines?
acute – early use of high dose NSAIDs (though must weigh risks/benefits)
Triptans** preferred nasal sprays or injections can be used in patients with n/v
CONTRAINDICATED in CAD and cerebrovascular disease
Combo therapy highest yield *NSAIDs + triptans) can also add metoclopramide or Compazine in pts with n/v as well
Goal of migraine Tx?
goal – eliminate pain and assoc symptoms without increasing disability. (ex/ avoid sedation;) early intervention; avoid known triggers
How to Tx tension headaches?
NSAIDs, nonpharmacologic interventions (acupuncture, massage, trigger point injections, PT)
* Note, Botox does not work here*
Dizziness:
1) How do you Tx?
2) What are last resort Txs?
1) Treat any underlying disorders, vestibular suppressant (meclizine), antiemetics, vestibular rehab
2) Intratympanic injections, surgery
How do you Tx vertigo?
Tx underlying cause
How do you Tx CN palsies?
Decompression surgery, B vitamins 6, 12, correct underlying cause if able
How to Tx bells palsy?
60% spontaneously resolve
1) Prednisone 60 mg PO QD x 5d followed by 5d taper increases the chance of complete recovery by 1 yr
2) Acyclovir or Valacyclovir if presence of herpetic vesicles in EACs
3) Lubricating eye drops
How to Tx bulbar palsy?
1) Treat underlying disorder
2) Refer to neurology
3) Riluzole PO BID, Edaravone > meds not on exam
Encephalitis (viral) Tx?
1) HSV = IV acyclovir
2) West Nile = supportive
Tx for concussion?
ABCs, Supplemental O2, tight BP control, repeat neuro checks, rest
What do you need to avoid when treating concussions?
1) Avoid NSAIDs for 2-3 days (can worsen symptoms)
2) Avoid sedatives
How long is concussion management?
Most adults fully recover by 2 weeks and kids within 4 weeks
Describe how to Tx TBIs
1) ABCs, eval and stabilize C spine, fluids, GCS (intubate <8)
2) ?Supplemental O2, strict control of BP, frequent neuro checks, assess for other sites of trauma, reduce ICP,? CSF leak? (Halo sign,) pupils? CT/MRI, reverse any comorbid factors as able (ex/ coagulopathy,) monitor for infections, seizures, PTSD
Describe how to Tx TBIs based on risk
1) Low/Moderate : GCS = >15 (alert, fully oriented and following commands) and CT neg - may d/c home with close observation
2) Mod: + - GCS 9-14, CT findings do not require surgery; admit to ICU for close observation/neuro checks and repeat CT in 24 hrs
3) High: GCS <=8 serious head injury admit to ICU for neurosurgical consultation; stabilize patient, intubate; **do not delay surgery as time is brain cells)
How do you Tx ataxia?
Tx underlying cause
How to Tx essential tremor?
Goal: to minimize tremor enough to prevent disruption of ADLs
1) Typically, in primary care, d/c caffeine and any aggravating meds
2) Exclude secondary causes
3) Propranolol or primidone (B Blockers have central depressive effect; primidone works to increase GABA)
4) Refer to neurology if not comfortable treating it
How to Tx Parkinson’s?
Goal: Sx management; can’t cure- Dopaminergic agents
How to Tx Huntington’s disease?
Symptomatic, cannot be cured or halted:
1) Tetrabenzine can help treat dyskinesia
2) Dopamine blockers.
3) Genetic testing of offspring should be offered with counseling
**ALL HD patients should be referred to neurology
Tx for Tourette’s?
Treat underlying conditions (psych) as able, goal is for “normal” life:
Symptomatic, behavioral therapy (habit reversal training)
Clonidine
dopamine antagonists
choose treatment with best SE profile for specific patient
Haloperidol
Tetrabenzine
Treat any underlying comorbidities (ex/ ADHD, OCD)
Botox if tics limited to a small area
What Tx is contraindicated for Tourette’s?
Stimulants
What are some treatments for restless leg syndrome (RLS)?
Dopaminergic agonists (ropinirole,) gabapentin, clonazepam, treat underlying cause (IDA,) optimize sleeping habits, stretching, or massage.
-A lifelong disorder but can typically be controlled.
Tardive Dyskinesia
1) Tx?
2) How long can it last?
1) Early recognition; immediate gradual removal of offensive agent
2) Can be permanent provider needs to educate patient on symptoms to watch for.
Low rate of spontaneous remission, often causes permanent disability
Treatments for Alzheimer’s disease?
1) Cholinesterase inhibitors
2) Donepezil (but major GI and psych SE)
3) Rivastigmine patch (less GI SE,)
4) Memantine (less SE)
Meningococcal meningitis Tx?
IV PCN G q 4hr x 5-7 d
Encephalitis:
1) Tx if HSV?
2) Tx if West Nile
3) What must be reported?
1) IV acyclovir
2) Supportive
3) Tick-born infections must be reported to local health dept or CDC
What is CNS neoplasm Tx regimen based on?
Tumor type, location, malignant potential, and patients age and physical condition
Primary intracranial tumors; what are the Txs for:
1) Gliomas (usually cancer) and glioblastoma
2) Meningiomas
3) Symptoms due to obstructive hydrocephalus
1) Surgical resection with adjuvant chemotherapy
2) Surgical resection
3) Surgical shunting can provide significant benefits
List 5 brain tumor treatments
1) Shunting (for hydrocephalus)
2) Radiation and/or chemotherapy
3) Corticosteroids (for cerebral edema)
4) Anticonvulsants
5) Intramedullary cord lesions
Describe the Tx of Primary intracranial tumors; what does it depend on and what are the 3 options?
Depends on type and site of tumor:
1) Radiation therapy and chemotherapy: long-term cognitive deficits may complicate radiation therapy and chemotherapy
2) Corticosteroids to reduce edema/increased IC pressure, often started prior to other therapy
3) Seizures: phenytoin
What are 4 Txs for metastatic intracranial tumors?
1) Surgical resection if limited number and surgically accessible is standard of therapy for mets
2) Radiation
3) Steroids for swelling
4) Phenytoin for seizures
MS (multiple sclerosis) Txs?
No cure, symptom management is goal
1) Refer to neurology
2) Glucocorticoids, Interferon beta, MABs, immunosuppressants, anti-inflammatories
1) How to Tx acute MS attacks?
2) What abt disease modifying Tx?
1) Acute attacks: 1 gm IV methylprednisolone daily x 5 days
2) Referral to MS specialty clinics: Interferon IM/SQ + Monoclonal antibodies
In MS, at 10 years, 2/3 are still ambulatory, and treatment can preserve function; ________ has best prognosis
RRMS
Alcohol Nutritional Neuropathy Tx?
Alcohol abstinence, thiamine supplements
Myasthenia Gravis (MG) Txs?
1) Make sure UTD on all vaccines
2) Cholinesterase inhibitors (increase concentration of acetylcholine,)
3) Immunosuppressants
4) Corticosteroids
5) Thymectomy
Txs for CRPS (Complex Reginal Pain Syndrome)?
Early, NSAIDs (Naproxen,) Prednisone, pain management for PT, nortriptyline qhs, gabapentin, nerve blocks
List 4 aspects of CP (cerebral palsy) Tx
1) CP specialty clinic
2) Family support
3) PT/OT/speech therapy
4) Ortho – assist with MSK issues (contraction/spasticity)
List 4 specific treatments for CP
1) Intramuscular Botox
2) Systemic and intrathecal muscle relaxants – baclofen and valium
3) Selective dorsal rhizotomy
4) PT/OT
With CP (cerebral palsy), what should there be adulthood symptomatic management of?
1) Seizures
2) Pressure ulcers
3) Osteoporosis
4) Behavior and emotional issues
5) Speech and hearing impairment
Peripheral neuropathy: How do you treat? What abt f/u + education?
Focus on treating underlying etiology
1) Gabapentinoids (GABA, Neurontin, Lyrica)
2) Antidepressants (TCA, SNRI) can help alleviate neuropathic pain
-Screen with monofilament test – at least annually if not every visit
-Patient education about foot care
Mainstay of Tx for diabetic neuropathy is?
Optimal control of DM
1) Seizure tests should include what? (5 things)
2) What should be added for the first seizure?
1) Electrolytes (CMP), Glucose, HCG, ECG, EEG
2) Neuroimaging: MRI + contrast
Generalized Seizures:
1) Txs?
2) Epidemiology?
1) Ethosuximide, valproic acid, topiramate, carbamazepine
2) M>F; 5 mil new dx/yr globally 3.5 mil/yr US
-0.6% children, 8% adults
Generalized nonmotor seizures: Tx?
Valproic acid (Depakote)
+
Ethosuximide
List 6 treatments for generalized motor seizures
1) Carbamazepine (Carbatrol)
2) Phenytoin (Dilantin)
3) Valproic acid (Depakote)
4) Phenobarbital (Luminal)
5) Lamotrigine (Lamictal)
6) Gabapentin (GABA)
How to Tx Status Epilepticus?
1) ABCs
2) (benzos) lorazepam 4 mg IV bolus (2 mg/min) repeat x 1 in 10 min if needed
3) Then may add phenytoin to maintain control
4) Phenobarbital if no response to benzos
Differentiate between provoked and unprovoked single seizure Txs
1) Provoked: ID and treat underlying condition (ex/drug abuse, brain tumor, stroke, fever)
2) Unprovoked single seizure: often not treated unless recurs, i.e., first single seizure not treated with anti-seizure Rx
Epilepsy:
1) Treated patients should be seizure free for ____ years on Rx prior to consideration of medication withdrawal in appropriate patients.
2) Does withdrawal work?
1) ~ 2 years
2) Depends on epileptic syndrome; some persist for life and will have seizure after Rx withdrawn
Epilepsy:
1) Risk of recurring seizure remains ___________ even in good candidates.
2) Surgical resection may be an option for what pts?
1) high (20-70%)
2) Refractory (to Rx) focal epilepsies
How do you Tx Transient Ischemic Attack (TIA)?
Treat underlying disorder (DM, HTN, hematologic disorders.):
1) CEA, statin or anticoagulation if appropriate
2) d/c smoking, weight reduction
3) Echo, urgent neuro consult
What medication is best to reduce risk of recurrent stroke after mild stroke or TIA?
ASA + Clopidogrel (short term use)
-i.e. dual therapy with aspirin and an antiplatelet
What is TIA routine management?
Guideline directed medical management
1) HTN
2) Dyslipidemia
3) DM
4) Smoking/lifestyle modifications
5) Antiplatelet (ASA + clopidogrel)
6) Anticoagulation if appropriate – AF, valvular disease
What is the goal of stroke (CVA) Tx?
1) minimize disability, 2) prevent recurrent stroke; treat underlying cause if known
What gives some improvement of disability at 90 days after a stroke? When must it be given?
IV thrombolytics (tPA-tissue plasminogen activator); must be given within 3 hours
Ischemic stroke Tx?
1) Embolectomy
2) Neuro consult, admit to stroke unit, tight BP control (esp first 72 hrs)
3) Early rehab
4) +/- decompressive hemi-craniotomy
5) Antiplatelet and anticoagulants
How do you Tx a hemorrhagic stroke?
1) ABCs
2) Neurosurgery consult -admit to ICU/stroke unit
3) Lower sBP 140-180 mmHg IV labetalol or nicardipine
4) Treat underlying cause if any
5) d/c any anticoagulation and reverse any coagulopathies
6) ventricular drainage or hematoma evacuation
Review: What are the maintenance recommendations for secondary prevention of ischemic stroke? (2 options)
1) ASA: daily monotherapy
OR
2) ASA + Clopidogrel (Plavix) daily monotherapy
Cerebral Aneurysm Rupture Tx?
1) ABCs, emergent brain imaging, neurosurgery consult (clip or coil, but not stent)
2) Once stable, CTA = many pts have > 1 aneurysm (mirror aneurysm)
3) sBP < 130 (avoid any vasodilators that could worsen ICP)
4) shunt for hydrocephalus
5) frequent neuro checks
6) prophylactic anticonvulsant meds
7) Nimodipine 60mg q4hr (improves outcomes and decreases vasospasms.)
8) Maintain euvolemia + monitor for hyponatremia
Intracranial Hemorrhage: What is the Tx?
Neurosurgery consult; prevent rebleed:
1) Admit to ICU/stroke center
2) ABCs, prevent neurological complications, pain management, BP control, monitor ICP, fluids to euvolemia
3) Many patients with SAH develop hydrocephalus; drain with intraventricular catheter
How do you Tx syncope?
Counterpressure maneuvers (Valsalva: squat, bear down, abdominal contraction)
-Treat underlying cause
