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Things with benzos Flashcards

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USMLE® Step 1 flashcards
1
Q

Two main groups of seizures

A

Generalized and partial

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2
Q

Generalized seizure

A

Loss of consciousness, may be only sign (thought to be from near simultaneous activity of entire cerebral cortex

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3
Q

Types of generalized seizures

A

Tonic-clonic

Absence (petit mal)

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4
Q

Absence seizures

A

Typically a few seconds. Appear altered without change in postural tone. Appear confused, detached or withdrawn.
May stare, twitch eyelids, lose continence, not respond. No postictal period.
Can happen 100X a day.
More likely in children, if in adults more likely to be minor complex partial (different cause and tx)

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5
Q

Partial (focal seizures)

A

Likely to be secondary to structural lesion
Discharge begins as localized area of cerebral cortex
Simple and complex

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6
Q

Simple partial

A

Remains localized, consciousness not affected;
Symptoms can help guess where seizure started.
Olfactory, gustatory - medial temporal lobe

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7
Q

Complex partial

A

Focal but consciousness is affected. Often caused by focal discharge in temporal lobe, sometimes referred to as temporal lobe seizure.
Can be diagnosed as psych problems as symptoms are so bizarre, including automatisms(Lip smacking, fiddling with clothing, repeating short phrases), visceral symptoms(butterflies from epigastric), hallucinations, memory issues, distorted perception and affective disorders.
Can produce time distortion, fear, paranoia, depression, elation, ectasy (used to be called psychomotor)

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8
Q

Important questions

A

Aura, abrupt or gradual onset, progression of motor activity, incontinence, presence of oral injury, local or generalized activity.

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9
Q

Common precipitating factors

A

Missed dose, med changes, dose changes, conversion from brand name drug, sleep deprivation, strenuous activity, infection, electrolyte disturbances, ETOH/drug use/discontinuation

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10
Q

If no previous hx of seizures ask

A

Recent injuries, nocturnal tongue biting, enuresis (bed wetting) hx of head injury, similar episodes missed as seizures, headache, preggo, metabolic disorders (lyets, hypoxia, systemic illness) coagulopathy or anticoagulation meds, toxins, drugs, ETOH

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11
Q

Physical injuries to look for

A 
Vitals, BGL
Head/neck injuries
Posterior shoulder dislocation is easy to miss
Tongue/mouth lacs
Pulmonary aspiration
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12
Q

Todd’s paralysis

A

Transient focal deficit (usually unilateral), should resolve within 48 hours

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13
Q

Causes of seizures

A 
Trauma (recent or remote)
Anything CNS - bleed/lesion/mass/neuro diseases
Congenital
Metabolic
Sugars, salts, hyperosmolar states
Uremia, liver failure
Toxins/drugs/ETOH
Eclampsia (up to 8 weeks postpartum) 
Hypertensive
Cardiac arrest, anything anoxic/ischemic
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14
Q

Psuedoseizures

A

Associated with conversion disorder(neurological symptoms which cannot be explained), panic disorder, psychosis, impulse control, Munchausen
Suspect if occur in response to emotional upset, or only with witnesses present.

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15
Q

Cellular changes 5 minutes of seizing

A

Decreased expression of GABA receptors, and increased expression of both glutamine and N-methyl-D-aspartate receptors
Blood brain barrier compromised, potassium and albumin leak in which are hyperexcitatory

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16
Q

20 minutes into seizure

A

Hypotension, hypoxia, acidosis, hyperthermia, hypoglycemia.

Possibly cardiac dysrhythmias, rhabdo, pulmonary edema

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17
Q

2 hours into seizure

A

Neurotoxic amino acids and calcium, leading to permanent neuronal necrosis and apoptosis

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18
Q

Dilantin

A

Not compatible with glucose-containing solutions

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19
Q

Status tx

A

Benzo (loraz 2mg or 0.1mg/kg)
Diazepam (10-20mg) +
Phenytoin 20mg/kg at 50mg/min
or Levetiracetam 2000-4000mg

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20
Q

Refractory status tx

A

IV midaz 0..2mg/kg
IV propofol 1mg/kg then 1-10mg/kg/h or ketamine 5mg/kg/hr
Or phenobarb 20mg/kg at 50-75mg/min

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21
Q

Fosphenytoin

A

Water soluble prodrug of phenytoin. Similar onset, effectiveness, and cardiac sides.
Fewer infusion site reactions (no propylene glycol and ethanol as diluents) and can therefore be infused quickly., making it preferred over phenytoin dose is PE (phenytoin equivalent)
Load at 20PE/kg at 150PE/min over 10-15 minutes
Can be given IM

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22
Q

Phenytoin dose

A

50mg/kg (usually need in excess of 1000mg)
25mg/min up to 50 if in status epi
Not too fast as propylene glycol depresses myocardium

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23
Q

Valproic acid

A

20mg/kg IV

Hepatic failure and pancreatitis mean US FDA has issued black box warning

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24
Q

Levetiracetam

A

May inhibit voltage-dependent calcium channels and facilitate GABA transmission
20mg/kg IV

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25
Q

Lacosamide

A

200mg IV over 15 minutes

Potential alternative for status epi

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26
Q

Refractory status epi definition

A

Persistent seizure activity despite IV admin of two adequately dosed antiepi agents, and usually exceeds 60 minutes.

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27
Q

Propofol for status epi

A

started at 2-10mg/kg/h titrated to effect

>40mg/kg starts to risk hypotension and propofol infusion syndrome

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28
Q

Midaz dose for status epi

A

0.05-0.4mg/kg/hr

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29
Q

Ketamine for status epi

A

0.5-4.5mg/kg or infusion of up to 5mg/kg/hr

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30
Q

Causes of psychomotor agitation

A

Psychosis, mania, withdrawal, drugs, delirium, depression/anxiety, meds, pain, worsening of chronic underlying illness

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31
Q

QTc prolonged at

A

450 in men
460 in women
500 from meds is considered highly significant

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32
Q

Chlorpromazine

A

Antipsychotics compared to this, as low, intermediate or high potency
Low potency are more sedating, associated with hypotension, dizziness and anti chol symptoms
High potency are less sedating but more likely to give EPS

33
Q

Neuroleptic malignant syndrome

A

Rare. Potentially lethal.

Altered LOC, hyperthermia, muscular rigidity, autonomic instability, elevated creatinine phosphokinase.

34
Q

Benztropine

A

Antichol for acute dystonia, 2mg

35
Q

Droperidol

A

No longer FDA approved because of QTc prolongation even at low dose and with no cardiac hx

36
Q

Haloperidol

A

QT prolongation (<35mg/d or 20mg at once)

37
Q

AHS doses for combative

A

IM midaz 10 Q 15 max 20

Halo 5mg q 15 max 10

38
Q

Fluphenazine

A

Equivalent to halo. 1.25-10mg dosing

39
Q

Quetiapine

A

Atypical antipsychotic, doses range from 12.5-200mg BID

Somnolence, hypotension.

40
Q

Antihistamines

A

Tx of anxiety in peds and adolesecents, effective if symptoms are anxiety driven

41
Q

A2 agonists

A

Clonidine and dexmedetomidine. Thought that some antipsycho second gen benefits come from A2 agonism

42
Q

Elderly sedation

A

Try reorientation, offering food water and bathroom, hearing aids and glasses.
More susceptible to EPS
Benzos can cause paradoxical disinhibition and increased agitation

43
Q

AHS seizure

A

10 IM

If refractory 5IV max 10

44
Q

AEIUOTIPS

A 
Alchohol
Epilepsy
Infection
Overdose
Uremia (fluid, lytes, hormones)
Trauma
Insulin
Psychosis
Stroke
45
Q

Primary headaches

A

Migraine or cluster

46
Q

Secondary headaches

A

Tumor, menigitis, subarachnoid hemorrhage

47
Q

Thunderclap headache causes

A

Intracranial hemorrhage, aneurysmal hemorrhage, spontaneous intracerebral hemorrhage
Carotid dissection
Reversible cerebral vasoconstrcition
Cerebral venous thrombosis

48
Q

Headache red flags

A

Onset - sudden, trauma, exertion
Symptoms - ALOC, seizure, fever, neuro symptoms, visual disturbances
Meds - anticoagulatons/antiplatelets, immunosuppressants
Neck stiffness

49
Q

Tension headaches

A

Scalp/neck muscles
Stress induced
Pain is bilat, non-pulsing, not worsened by exertion, no N/V give NSAIDS simple analgesics

50
Q

Cluster headaches

A

Rare, short lived, trigeminal nerve origin, 5HT agonists is tx
Severe, unilateral, supraorbital, temporal 15-180minutes duration
Distinguishing - pacing and restless
Cluster - occur for more than 1 week, stop for 4 weeks

51
Q

Migraines

A

4-72hours
Episodic or chronic
Pain unilateral and pulsating, worsened by physical activity, photophobia, phonophobia, n/v onset childhood peaks at age 40

52
Q

Organic headaches

A

Tumor, meningitis, sinus infection etc

53
Q

Coital headache

A

Thunderclap headache occurs at orgasm. Benign with no specific tx

54
Q

Pain tx

A

Vascular headaches tx with maxeran. Dop antagonism decrease both pain and nausea
Fluid often helps

55
Q

Vascular headache presentation

A

N/V/ sweating, photosensitivity, throbbing

56
Q

Vascular headache tx

A

O2, NS 1000mL, metoclopramide 10mg IV in 50mL over 15
Ketorolac 30mg IV/IM
Fentanyl 1mcg/kg or morph 2.5mg

57
Q

Kernigs sign

A

Inability to straighten leg when flex 90 degrees

58
Q

Brudzinskis

A

Feet flex with neck

59
Q

Encephalitis

A

Usually viral (herpes west nile)
Hard to differentiate from west nile
Look for same S&S and confusion, drowsiness, fatigue, seizures, tremors, hallucinations, memory problems

60
Q

Lams

A

Droop 0 or 1
Arms 0 1 2 (palm down 45 degrees if lying 90 if sitting)
Grips 0 1 2

61
Q

Tonic phase

A

Is the tightening, clonic is jerking. Last 1-3 minutes (whole seizure)

62
Q

Dysthmia

A

Persistent form of mild depression

63
Q

Acute dystonia

A

Continuous muscle spasms and contractions

64
Q

Parkinsonism

A

Muscle rigidity

65
Q

Akasthisa

A

Feeling of needing to be in constant motion

66
Q

Tardive dyskinesia

A

Irregular, jerky movements

67
Q

Bipolar drugs

A

Lithium, carbamazepine, valproic acid, TCAs

68
Q

ETOH seizures

A

as early as 6 hours, 90% in first 48 hours

May be brief without postictal period

69
Q

ETOH withdrawal hallucinatins

A

12-48 hours after, can last months

70
Q

Wernicke korsakoff

A

B1 thiamine deficiency
Korsakoffs is chronic wernickes
Confusion, ataxia, tremors, nystagmus

71
Q

Lorazepam

A

for etoh withdrawal 1mg SL q5 max 4mg

72
Q

Subarachnoid hemorrhage

A

Intracranial hemorrhage most common cause. 75% are rupture aneurysm
Classic presentation is thunderclap headache

73
Q

SAH stats

A

10-15% die before reaching hospital

40% die within first week

74
Q

SAH description

A 
Worst headache of life
Nuchal rigidity
Photophobia
N/V seizures and decreasing LOC
Similar to meningitis
75
Q

Grades of SAH

A 
I mild headache 
II severe headache 
III mild alteration in neuro exam
IV Obviously depresses LOC
V posturing or comatose
76
Q

Subdural hematoma

A

Collection of blood on surface of brain, most frequently results of a head injury. Among the most lethal

77
Q

Subdural hematoma patho

A

Sudden decel of brain parenchyma with tearing of bridging dural veins, forms a hematoma b/w dura and arachnoid layer.
Usually venous

78
Q

Timing of subdural hematoma

A

Acute phase begins 3-7 days after injury (up to 14 days)

Chronic phase 2-3 weeks after acute injruy

79
Q

Saccular aneurysms

A

Characteristic rounded shape and are majority (that little bugger bulging off)

Advanced medical (24 decks)

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