Test #1 Flashcards
Huntington’s Disease
Cerebral and caudate nucleus atrophy -> GABA and acetylcholine deficiency
Chronic, progressive chorea w/ impulsive and antisocial behavior from dopamine surplus
Dx: MRI (caudate atrophy), PET (caudate metabolic abnormalities), Genetic testing - gold standard
Huntington’s Disease Treatment
Goal: Downregulate dopamine, suppress chorea
Neuroleptic and Tetrabenazine to suppress and breakdown Dopamine
Anticonvulsants: Clonazepam, Valproic Acid
Antipsychotic: Risperidone, Olanzapine
Antidepressants: Fluoxetine, Sertraline, Nortriptyline (TCA)
Huntington’s Treatment Side Effects
Hyper-excitability, fatigue, restlessness
Antipsychotic SE mimic signs of Parkinson’s - dull facies, tardive dyskinesia
Essential Tremor
Most common tremor cause - inherited
Bilateral, occurs w/ action, constant frequency w/ variable amplitude
Have to r/o Parkinson’s - should be only abnormal thing on exam
Relieved by ETOH
Essential Tremor Treatment
Propanolol - 1st line (Atenolol w/ asthma/bronchospasm)
Mysoline/Gabapentin - anticonvulsants
Parkinson’s Disease
Progressive neurodegenerative disorder -> substantia nigra breakdown causes dopamine deficiency
TRAP, fixed facial expressions, Myerson’s sign (repeated tapping of the nose causes blinking), Lewy bodies
Onset usually after 50 years old
Tremor @ rest, disappears during sleep, cog-wheel/rachet-like motions
TRAP
Tremor - resting and postural = unilateral, @ rest
Rigidity = increased resistance to passive movement, unilateral -> bilateral
Akinesia (Bradykinesia) = difficulty/slow initiation movements, get “frozen or stuck” - huge fall risk
Postural instability = late stage, lean forward w/ shuffling gait, prone to falling backwards
- All DTRs intact w/ no weakness
Parkinson’s Therapeutic Treatment
Depression: SSRI
Hallucination: Decrease Sinemet, Zyprexa
Orthostatic HOTN: TED hose, slow rising
Sexual dysfunction: Viagra, Dopamine agonist
Constipation: Cease causative medication; Reglan is CI - Dopamine antagonist
Deep Brain Stimulation
No more effective than highest med dose, no SE
Use in pts w/ drug-induced dyskinesias who lack any complicating med/psych conditions
Pulse generator at the STN and Thalamus - replace every 5 years
Restless Leg Syndrome/Wittmaack-Ekbon’s Syndrome
Uncontrollable urge to move limb to stop uncomfortable/painful/odd sensation - mot common in legs
Often have varicose veins, less common among Asian pop
Always get a CBC to r/o iron deficiency anemia
Causative agents of RLS
Meds: Anti-nausea, H2 Blocker, antihistamines, SSRI/anti-psych
Food: Diet soda/aspartame, ETOH
RLS Treatment
Tx underlying cause, OTC Ibuprofen, baths/massages, warm/cool packs
Pramipexole, Ropinirole, Sinemet, Lyrica (w/ Parkinson’s)
Gabapentin, Opioids
Parkinson’s Treatment
GOAL: Restore dopamine activity, manage SE of therapy
Selegiline (MAO-B) may slow progression w/ early therapy
All other meds replenish Dopamine or block Acetylcholine/GABA
Apomorphine (NMDA) is used only for emergent freezing instances
Levodopa/Carbidopa (Sinemet)
Gold standard, generally 1st line (>70 yo, dementia)
Levodopa = dopamine precursor, Carbidopa = prevent peripheral breakdown
Best for rigidity and slowness, less for tremor/balance/gait
Short acting, high doses cause dyskinesias
Sinemet side effects and contraindications
SE: Vivid dreams, hallucinations, HOTN, Dyskinesia
Wearing off effect - after 4-6 yrs, gets progressively worse
- initial bradykinesia, tremor before next dose
CI: MAOI, psychotics, angle-closure glaucoma, history of melanoma
Use caution w/ cardiac dx, PUD
Monoamine Oxidase-B Inhibitors (MAO-B)
Selegiline/Rasagiline = stop dopamine breakdown, penetrate BBB
May slow progression if given @ early onset in young pt
1st line for mild dx, also to decrease Sinemet wearing off effect
MAO-B side effects and contraindications
SE: Insomnia, Jitteriness, Dyskinesias, Increases Sinemet SE
CI: TCA, SSRI, Demerol
Caution: Liver impairment, cardio/CV dx, seizure, hypothyroidism, DM, psych disorders
Dopamine Agonists
Older, Ergo derivatives: Bromocriptine
Newer, synthetic: Pramipexole, Ropinirole
Stimulate dopamine receptors in substantia nigra
- Improve akinesia, postural instability
1st line in young pts w/ moderate symptoms
Dopamine agonist side effects and contraindications
SE: poorly tolerated - drowsiness/sleepiness, HA, constipation, nightmare/psychosis/dyskinesias
CI: psychotic illnesses, recent MI, PUD
Avoid ergo derivatives in pts w/ PVD
Apomorphine (Apokyn)
Emergent only, NMDA agent
Treats episodes of freezing/hypermobility
Give SQ, expensive
SE: N/V, yawning, dyskinesia, sedation, dizziness
- give w/ antiemetic that is not Zofran/Kytril
Catechol-O-Methyltransferase Inhibitors (COMT-I)
Entacapone (Comtan, Tolcapone (Tasmar)
Inhibit enzyme that metabolizes levodopa in periphery
Only use w/ Sinemet - improves wearing off effect
SE: Happen immediately, poorly tolerated - dyskinesias, confusion/hallucinations, urine discoloration, cramps, N/D, HA, insomnia
Amantidine
Antiviral, MOA unknown, Adjunct only
Use for early mild sx, short-lived
No effect on tremor
SE: sedation, vivid dreams, dry mouth, depression
Caution w/ renal dysfunction
Anticholinergic Acetylcholine-blocking drugs
Trihexyphenidyl, Benzotropine
Target Acetylcholine to prevent dopamine inhibition
Primarily for tremor, helps w/ rigidity - no effect on akinesias
SE: CNS and systemic, SE usually outweigh any benefit
- CV, IOP, AMS
CI: BPH (causes retention), obstructive GI, angle-closure glaucoma
COMT uses
Try to improve on-off syndrome
Take off if not effect in a few weeks due to SE
Epidural hematoma
Most commonly skull fx - high force trauma
Arterial blood from venous sinus or dural artery
Dyperdense biconcave, respects suture lines
Acute presentation
Subdural Hematoma
Venous blood - from venous plexus
Cresent shaped, doesn’t respect suture lines
Low force trauma
Insidious presentation - worsening HA over days
Subarachnoid Hemorrhage
Below arachnoid/Within the brain
Arterial blood from circle of Willis - aneurysm rupture or high-force trauma
Acute presentation - thunderclap HA
Glasgow Coma Scale components
Eye Opening - 4 points
Best Verbal Response - 5 points
Best Motor Response - 6 points
GCS 13-15 = Mild TBI
GCS 9-12 = Moderate TBI
GCS <8 = Severe TBI
GCS 3 = Totally unresponsive, lowest possible score
GCS Eye opening
Spontaneous = 4
Response to verbal command = 3
Response to pain = 2
No eye opening = 1
GCS best verbal response
Oriented = 5
Confused = 4
Inappropriate words = 3
Incomprehensible sounds = 2
No verbal response = 1
GCS best motor response
Obeys commands = 6
Localizing response to pain = 5
Withdrawal response to pain = 4
Flexion to pain = 3
Extension to pain = 2
No motor response = 1
Seizure and Types
Sudden, excessive disorderly discharge of neuronal activity in brain
- Sudden, transient
- Motor/sensory/autonomic/psychic manifestations
- Temporary alteration of systemic arousal
- Often manifests as convulsions; different kinds of seizures
Seizure disorder/Epilepsy
Recurrent seizures without any immediate treatable cause such as hypoglycemia or ETOH withdrawl
Convulsion
Rapid contraction and release of muscle causing an uncontrollable shake
Epilepsy
Occurrence and reoccurrence of seizures without know or correctable cause
Can get strange sensations/emotions/behavior -> convulsions, spasms, LOC
Idiopathic or primary generalized epilepsy usually present by puberty
Seizures after 20 yo -> usually focal process/metabolic derangement
Cancer, stroke, degenerative brain disorders cause seizures later in life
Epilepsy Pathophysiology
A. Complex gene mutations or environmental factors = abnormal connections
B. Hypersensitive neurons have sudden, violent depolarizations
-Temperature, electrolyte imbalances set off
C. Epilectogenic neurons fire more often and intensly w/ greater amplitude than normal
Provoked vs Unprovoked Seizures
Provoked = triggered by provoking factors in healthy brain
- metabolic, ETOH, drugs, high fever
Unprovoked = occur with persistent brain pathology
-repeat seizures may be similar or different, get a complete H&P after initial seizure to r/o other conditions
Sudden unexpected death (SUDEP)
Sudden, nontraumatic, nondrowning death of a person w/ epilepsy
Happens in refractory epilepsy or poorly controlled seizure disorder
Seizure phases
Prodrome (1st phase) = hours/days before seizure
-deja vu, smell/sounds/taste, fear, dizzy, HA, nausea
Aura = 1st seizure sx, beginning of seizure
Middle “ictal phase” = from Aura to end of seizure
- awareness lost, confused/daydreaming, can’t talk/swallow
Ending “postictal” = recovery can be immediate or takes minutes/hours
-sleepy, slow to respond, confused, HA, nausea
Loss of consciousness
Complete/partial unawareness or lack of response to sensory stimuli
Induced by hypoxia, metabolic or chemical depressants, brain pathology, trauma
Focal Seizures
Occur on one side of the brain
Occur w/ and w/out consciousness impairment
w/out: Jacksonian March (motor), Todd’s Paralysis, sensory, autonomic, psychic
w/: pt unresponsive, may evolve from w/out
- most common, arise from temporal lobe - pt appears to be “daydreaming”
- 30 seconds to 1 minutes w/ confusion and tired 15 min postictal
Jacksonian March
Motor focal seizure w/out consciousness impairment
Starts at fingers and works its way up limb
Abnormal activity in primary motor cortex
Also get sudden head & eye movement, tingling, numbness, lip smacking, and muscle spasms
Todd’s Paralysis
Focal seizure w/out impaired consciousness - Postictal state
Temporary (30 min to 36 hours), unilateral paralysis of limb
Have to r/o stroke
Generalized Onset Seizures
Disturbed consciousness, bilateral cerebral cortex malfunction
Absence, Atypical, Myoclonic, Atonic, Febrile, Tonic-Clonic, and Secondary seizure types
Can develop from focal seizures
Absence seizure
“petit mal seizure”
Looks like daydreaming, disturbed consciousness w/o convulsions
Typically in childhood
Abrupt onset and termination w/ brief impairment ~10 seconds
May have mild tonic-clonic, or atonic components; no postictal
Atypical Absence Seizures
Lapse in awareness w/ gradual onset and resolve
Autonomic features and muscle tone lost
Often occurs in mentally impaired kids
Doesn’t respond well to AED therapy
Myoclonic Seizures
Rapid, recurrent muscle spasms
Bilateral or unilateral, synchronous or not
Often terminate into generalized tonic-clonic (grand mal)
Often cluster after waking or while falling asleep
Atonic Seizures
“drop attacks”
Abrupt muscle tone loss, pt just collapses
Often seen in kids w/ diffuse encephalopathies
Febrile Seizures
Most common convulsion cause in kids 6 mo to 5 years
Temp > 38C (100.4 F), simple or complex
Have to r/o brain infection, metabolic issue, hx previous seizure w/o fever
No association/cause from mental impairment, behavioral problems, or poor school performance
Sx: Body stiffens, arm/leg twitch, vomit, foam @ mouth, incontinence
Tonic-clonic Seizures
“Grand mal”
Sudden LOC and involves all extremities
Primary deep brain structure or secondary focal generation
Tonic: <1min, sudden LOC and collapse, respiration arrested
Clonic: 2-3 min, muscle jerking and AMS
May recover, sleep, or go into status epilepticus
Postictal = HA, disorientation, drowsiness, N, muscle soreness
Secondary Generalized Seizure
Focal seizure that becomes generalized - 30% focal episodes
1-3 minutes, longer recovery time
Sx: muscle stiffening, LOC, bite tongue/cheek, tonic/clonic phases
Dx: EEG, MRI
Tx: Carbamazepine
Post-traumatic Epilepsy
Degree of injury matters
Many develop seizures by 1-2 yrs, mostly focal or secondary generalized
Penetrating, cerebral contusions, intracerebral hematoma, unconsciousness, or amnesia >24 hours
Seizure Diagnosis - 3 Objectives
- Determine if pt has epilepsy
- Classify seizure and type
- Identify (if possible) specific underlying cause
PE should be normal between seizures
-Look for lateralized sx, Todd’s, bruits, heart murmur
4 Conditions that mimic seizures
REM behavior disorder = sudden arousal from REM, aggressive behavior
-Dx w/ overnight sleep test
Transient Ischemic Attack = lateralizing weakness/vision loss
Transient Global Amnesia = vascular, >50yo, recurrent short-term amnesia w/o other impairments
Migraine = aura w/ AMS, mimics complex partial seizure, tonic-clonic postictal
Seizure Workup
EEG: Most important, get during active seizure and during sleep
MRI: study of choice, used to identify brain pathology
-get in all kids and in pts >20 w/ suspected neoplasm and seizures
Labs: baseline and to r/o systemic causes
Status Epilepticus
Seizure >30 min, or prolonged series of seizures w/o consciousness recovery between
Life-threatening, caused by drug noncompliance/withdrawal, fever
Tx: Give Thiamine, glucose, Ativan (lorazepam if fever), Fosphenytoin
No response in 20 min = Phenobarbital and Pepacon
Still nothing = General anesthesia w/ vent and neuromuscular junction block
Seizure Treatment Guidelines
Unprovoked - typically don’t treat until 2nd or 3rd seizure
Referral to Neurology for further surgery/treatment/workup
60% controlled w/in 1st year, 15% controlled later
25% have seizures despite treatment
Seizure Medications - 3 MOA
- Affect voltage-dependent Na or Ca Channels
- Na: Effective for tonic-clonic and partial seizures
- T-type Ca: absence seizures - Increase inhibitory neurotransmission (GABA)
- Decrease excitatory neurotransmission (glutamate, aspartate)
1st line for Generalized Tonic-Clonic
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Valproic Acid (Depakote)
2nd line for Generalized Tonic-Clonic
Levetiracetam (Keppra)
Gabapentin (Neurontin)
Phenobarbital
Felbamate (Felbatol)
1st line for Focal seizures
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Valproic Acid (Depakote)
Lamotrigine (Lamictal)
Topiramate (Topramax)
Oxcarbazepine (Trileptal)
2nd line for Focal seizures
Gabapentin (Neurontin)
Phenobarbital
Zonisamide (Zonegram) - Adjunctive tx only for focal w/o consciousness impairment
Felbamate (Felbatol)
Tiagabine (Gabitril)
1st line for Absence Seizures
Lamotrigine (Lamictal)
Ethosuximide (Zarontin)
Seizure drugs Pregnancy category D
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Valproic Acid (Depakote)
Phenobarbital
So all 1st line for Generalized tonic-clonic
Lumbar Puncture Contraindications
Site skin infection
Increased intracerebral pressure - except w/ pseudotumor
Spinal cord mass/intracranial mass lesion
Bleeding/coagulation defect
Spinal column deformities
Spinal epidural abscess
Noncompliant pt
Rule out ICP
Get a CT on pts w/:
Altered mental status
Focal neurologic signs
Papilledema
Seizure w/in 1 week
Impaired cellular immunity
CSF normals:
Pressure
Appearance
Total protein
Glucose
Cell count
Pressure: 70-180
Appearance: clear, colorless
Total protein: 15-45
Glucose: 45-85
Cell count and diff: 0-5 wbc/uL, 0 rbc
Elevated ICP DDx
Meningitis
Intracerebral Hemorrhage (ICH)
Neoplasm
Xanthochromia DDx
Yellow
Orange
Pink
Green
Brown
Occurs w/in 2 hours, lasts 2 weeks
Yellow: Blood lysis, hyperbilirubinemia, protein > 150, rbc >100,000 (hemorrhage)
Orange: rbc lysis, high carotenoid ingestion
Pink: rbc lysis products
Green: Hyperbilirubinemia, purulent CSF
Brown: Meningeal melanomatosis (CNS melanoma)
Protein DDx
One of the most sensitive CNS pathology indicators
150 in newborns, normalizes around 6-12 months
Low: repeat LPs, CSF leak, acute water intoxication
High: Infection, ICH, Guillain-Barre, Neoplasm, endocrine, inflammatory
Can be falsely elevated w/ traumatic tape -> -1 protein/1000 rbc
Glucose DDx
Normal w/ viral
Low w/ bacterial/fungal/neoplasms
High if peripheral glucose is also elevated
Cell count and Differential
Wbc: Meningitis - <1000 = viral, > 1000 = bacterial
-increased post-seizure, ICH, malignancy, inflammation
Rbc: Traumatic tap = #rbc decreases in consecutive tubes
-ICH = no consecutive decrease in #rbc
Cell differential: Normally 70% lymphocytes, 30% monocytes
-Meningitis: neutrophils = bacteria, lymphocytes = viral/fungal/TB, eosinophils = parasites
LP Microscopic DDx
India Ink + = cryptococcus
Wright/Gimesa + = toxoplasmosis
Other LP findings
Latex agglutination and PCR
Latex agglutination = rapid detection of bacterial antigens in meningitis
PCR for viral: HSV, EBV, enterovirus, CMV, TB, acute neurosyphilis
Nerve Fibers
A-alpha
A-delta
C fibers
A-alpha = large, myelinated; touch, vibration, position
A-delta = small, myelinated; cold, pain
C fibers = unmyelinated; warm, pain
Nerve Conduction Velocity
Only studies A-alpha fibers
Can miss polyneropathies in small fibers
Measures quality and speed of the signal sent to peripheral fibers
Used to study demyelinating polyneropathy (Guillain-Barre) or focal demyelination (carpal tunnel)
Nerve Conduction Studies
Test peripheral nerves to diagnose focal or generalized disorder
Can differentiate muscle from nerve disorders depending on whether nerve signal or muscle response is altered or appropriate
Indicated w/ paresthesias/weakness of limbs, or nerve conduction disorders
Electromyography (EMG)
Measures muscle electrical activity @ rest and contraction
Indicated for disease that damage muscle, nerve, or nerve-muscle junction
- herniated disc, amyotrophic lateral sclerosis (ALS), MS
Electroencephalogram (EEG)
Distinguish epileptic seizures from:
-psychogenic spells, syncope, movement disease, migraine variants
Differentiate between organic or psychiatric encephalopathy or delirium
Test for brain death, or for discontinuation of antiepileptic drugs (AED)
EEG waves and amplitude
Delta: 0-4 Hz
Theta: 4-8 Hz
Alpha: 8-12 Hz
Beta: >12 Hz
Increased slow waves (Delta and theta) in awake patients = focal brain lesion/abnormality
A normal EEG does not r/o epilepsy
Head CT: Contrast or no
Contrast: Neoplasm, infection, vascular or inflammatory disease
-contrast lights up the blood vessels
No Contrast: trauma, stroke/hemorrhage r/o, hydrocephalus, dementia, epilepsy, congenital malformations
CT Scan interpretation
Look for
- Fluid
- Mass
- Shift
- Compare both sides for symmetry
Water is dark, skull is white
More dense the tissue, the brighter it is
CT Angiography indications
Atherosclerosis
Thromboembolism
Vascular dissection
Aneurysm
Vascular malformations
Penetrating trauma
Carotid evaluation
MRI T1 and T2 indications
T1: Look at normal brain function
- fat is bright, water is dark
T2: Look for abnormal processes or brain pathology
- water and blood are bright, white matter is dark
Indications: subacute/chronic hemorrhages, stroke f/u, metastasis, intracranial abscesses, MS/demyelination, vasculitis, new onset/refractory seizure
Basilar skull fracture indications
Raccoon eyes
Battle’s Sign
CSF Leak
Hemotympanum
- get an MRI to evaluate
TBI Hospitalization
GCS <15 or deteriorating
Abnormal CT or bleeding parameters
Seizure
Decorticate vs Decerebrate
Decorticate = elbows and fingers flexed w/ UE adduction
-Cerebral cortex or thalamic dysfunction, better prognosis
Decerebrate = UE adduction w/ extension
-Caudal diencephalon, pons, or midbrain injury
LE Extension w/ plantar flexion and inversion occur w/ both
Coma Respiratory Patterns
Cheyne-Strokes
Hyperventilation
Apneustic breathing
Ataxic breathing
Cheyne-Strokes: cyclic hyperpnea and apnea from bilateral hemisphere or diencephalic insult
Hyperventilation: pontine or midbrain tegmentum injury
Apneustic: prolonged pause @ inspiration end from mid and caudal pons lesion
Ataxic: irregular rate and tidal volume from medulla damage
Mini-Mental Status Exam Rankings
24/30 = suggestive of dementia
20-26 = functional dependence
10-20 = moderate, immediate dependence
<10 = severe, total dependence
Neuropathologic Hallmarks of Alzheimer’s Disease
Begin years before symptom onset
Amyloid-rich senile plaques
Neurofibrillary tangles
Neuronal degeneration
Alzheimer’s Disease Diagnosis
Definite: Histopathological evidence (autopsy), course and exam have AD characteristics
Probable: 2 or more cognition deficits, 40-90 yo onset w/ progressive course and no other explanation
Possible: Deficit in 1 cognition area, atypical course, other dementia causes present
Unlikely: Sudden onset, focal signs, early seizures or gait disturbances
Alzheimer’s Disease Clinical Course
Stages 1-4
1: Normal, symptom free but pathology underway
2: Normal forgetfulness with age, concentration difficulty
3: Mild cognitive impairment, subtle deficits noted by close contacts
- repeated questions, cannot master new tasks, performance decline
4: Mild AD - can Dx w/ accuracy, pt less able to manage complex ADLs (finances, cooking)
- Lasts ~2 years
Alzheimer’s Disease Clinical Course
Stages 5-7
5: Moderate AD - independent survival limited, struggle w/ basic ADLs
- cannot recall major events, current life events, lasts ~1.5 yrs
6: Moderately severe AD - cannot do basic ADLs (dress themselves, live alone) - lasts ~2.5 years
7: Severe AD - speech and facial expression lost, cannot ambulate/sit independently, primitive/infantile reflexes restored
- Can last several years
Medications to avoid w/ Alzheimer’s Disease
Benzodiazepines
Antihistamines
Anticholinergics
These all worse symptoms, provide no benefit
Vascular Dementia
Cognitive deficit onset w/ CVA and stepwise deterioration
May be present or a predisposition for AD
Frontotemporal Dementia (FTD)
Focal atrophy of frontal and temporal lobes w/o AD pathology
-Pick’s Disease = subtypes w/ Pick bodies in neocortex and hippocampus
35-75 yo
Insidious onset w/ gradual progression resulting in early decline of emotions, conduct, and insight
Normal-Pressure Hydrocephalus
Pathologically enlarged ventricles w/ normal LP opening pressures
Triad: dementia, gait disturbances, urinary incontinence
-Wacky, wobbly, wet
Reversible w/ ventriculoperitoneal shunt
Dx w/ MRI and Miller Fischer gait test
Dementia with Lewy Bodies (DLB)
Associated w/ Parkinsonisms
Most common dementia syndrome, 2nd most common neurodegenerative dementia after AD
- pronounced variable attention/alertness, recurrent visual hallucinations, spontaneous motor features (Parkinsonisms)
Distinguish from Parkinsons? Dementia is presenting feature of DLB, occurs in the last 1/2 of Parkinson’s clinical course
Progressive Supranuclear Palsy (PSP)
Rare, mimics PD early on
Restricted up and down eye movement - head is either straight or tilted back
Postural instability w/ frequent falls backwards
Distinguish from PD = PD pts lean forward, PSP pts head tilts back
Delirium
Treatable, attention impaired at onset
Consciousness and effect on memory varies
Have attention deficit and psychomotor disturbances
Risk: Post-op, Elderly, AIDS, burns, withdrawal
High indicator for death w/in 6 months, death if hospitalized
Lasts 10-12 days or up to 2 months
Delirium Causes
I WATCH DEATH
Infection
Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia
Deficiency, Endocrinopathies, Acute vascular, Toxins/drugs, Heavy metals
44% have 2 or more pathologies
Agitation Pharmacological management
Haloperidol (neuroleptic), Risperidone (anti psych), Inapsine (sedative)
Haloperidol and Inapsine associated w/ Torsades and prolonged QT - monitor via telemetry
Benzodiazepines TOC for ETOH/benzo withdrawal
- may worsen delirium, cause respiratory depression
- CI w/ hepatic failure
Sleep-promoting and arousal promoting neurotransmitters
Sleep: GABA from VLPO
Arousal: Norepinephrine from LC, Serotonin from Raphe, and Histamine from TMN
Sleep Stages and breathing
1: light sleep, between conscious and asleep
2: Intermediate; HR slows, brain only does simple tasks
Breathing in 1&2 - cyclic waning and waxing of TV and R w/ brief apneic periods (periodic breathing)
3&4: Slow wave sleep; 3- body repairs, 4- temp and BP decrease
Breathing is 3&4 is regular, slower
REM: Eye movements; HR, BP, breathing and temp increase
Breathing is irregular +/- apneic periods, not periodic
Blood gases in sleep
PCO2 increases 2-8
PO2 decreases 5-10
pH decreases 0.03 - 0.05
Insomnia medications - Trouble falling asleep
Zolpidem (Ambien) - 1st line
Zaleplon (Sonata)
MOA: Interact w/ GABA-benzodiazepine receptor complexes
Insomnia medications - Trouble maintaining sleep
Eszopiclone (Lunesta) - 1st line
Benzodiazepines (Triazolam, Lorezepam, Estazolam)
Melatonin Agonists (Ramelteon)
Orexin receptor Antagonists (Suvorexant, Belsomra)
Hypersomnolence Disorder
Recurrent excessive daytime sleepiness or prolonged nighttime sleep - common in adolescents and young adults
Dx: excessive sleepiness for 1 month (acute) or 3 months (persistent) w/ prolonged sleep or daytime sleepiness at least 3x/week
Tx: Modafinil (Provigil) 1st line, Dextroamphetamine 2nd line
-Dextro has BBW for high abuse potential
Narcolepsy Tetrad and Meds
- Extreme drowsiness w/ sleep attacks - 15 mins, wake up refreshed
- Sleep paralysis = muscle flaccidity between asleep and awake
- Cataplexy - 30 seconds to a few minutes
- Hypnagogic Hallucinations - preceding sleep or during a sleep attack
Tx: Modafinil (Provigil) 1st line, Dextroamphetamine
Non-24 hour sleep-wake phase and treatment
Common in blind
Internal day is longer than 24 hours
Tx: Hetlioz for blind pts
MOA: Binds melatonin to MTI and MT2 receptors
Pregnancy C, SE: HA, abnormal dreams
Non-REM sleep arousal disorders
Sleepwalking
Night terrors
Enuresis (Parasomnias)
REM Sleep Behavior Disorder
Dream enactment during REM w/ sleep atonia loss
Antidepressants, Narcolepsy, Alpha-synuclein neurodegeneration (elderly)
Tx: Melatonin 1st line -prepares body for sleep
Clonazepam 2nd line
RLS treatment
Dopamine agonist (Ropinirole) OR
Alpha-2-delta Ca channel ligand (Gabapentin)
Bruxism
Teeth grinding
Jaw soreness, teeth flattening, radiating AM HA
Tx: Clonazepam, Botox, oral appliances
Periodic Limb Movement Disorder (PLMD)
Unilateral or bilateral involuntary limb movement in sleep
Pt is unaware, may be related to PD or narcolepsy
Tx: Dopamine agonist 1st line
Anticonvulsants, Benzodiazepines
