Things with benzos Flashcards
Two main groups of seizures
Generalized and partial
Generalized seizure
Loss of consciousness, may be only sign (thought to be from near simultaneous activity of entire cerebral cortex
Types of generalized seizures
Tonic-clonic
Absence (petit mal)
Absence seizures
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 Appear confused, detached or withdrawn.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)
Partial (focal seizures)
Likely to be secondary to structural lesion
Discharge begins as localized area of cerebral cortex
Simple and complex
Simple partial
Remains localized, consciousness not affected;
Symptoms can help guess where seizure started.
Olfactory, gustatory - medial temporal lobe
Complex partial
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)
Important questions
Aura, abrupt or gradual onset, progression of motor activity, incontinence, presence of oral injury, local or generalized activity.
Common precipitating factors
Missed dose, med changes, dose changes, conversion from brand name drug, sleep deprivation, strenuous activity, infection, electrolyte disturbances, ETOH/drug use/discontinuation
If no previous hx of seizures ask
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
Physical injuries to look for
Vitals, BGL Head/neck injuries Posterior shoulder dislocation is easy to miss Tongue/mouth lacs Pulmonary aspiration
Todd’s paralysis
Transient focal deficit (usually unilateral), should resolve within 48 hours
Causes of seizures
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
Psuedoseizures
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.
Cellular changes 5 minutes of seizing
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
20 minutes into seizure
Hypotension, hypoxia, acidosis, hyperthermia, hypoglycemia.
Possibly cardiac dysrhythmias, rhabdo, pulmonary edema
2 hours into seizure
Neurotoxic amino acids and calcium, leading to permanent neuronal necrosis and apoptosis
Dilantin
Not compatible with glucose-containing solutions
Status tx
Benzo (loraz 2mg or 0.1mg/kg)
Diazepam (10-20mg) +
Phenytoin 20mg/kg at 50mg/min
or Levetiracetam 2000-4000mg
Refractory status tx
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
Fosphenytoin
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
Phenytoin dose
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
Valproic acid
20mg/kg IV
Hepatic failure and pancreatitis mean US FDA has issued black box warning
Levetiracetam
May inhibit voltage-dependent calcium channels and facilitate GABA transmission
20mg/kg IV
Lacosamide
200mg IV over 15 minutes
Potential alternative for status epi
Refractory status epi definition
Persistent seizure activity despite IV admin of two adequately dosed antiepi agents, and usually exceeds 60 minutes.
Propofol for status epi
started at 2-10mg/kg/h titrated to effect
>40mg/kg starts to risk hypotension and propofol infusion syndrome
Midaz dose for status epi
0.05-0.4mg/kg/hr
Ketamine for status epi
0.5-4.5mg/kg or infusion of up to 5mg/kg/hr
Causes of psychomotor agitation
Psychosis, mania, withdrawal, drugs, delirium, depression/anxiety, meds, pain, worsening of chronic underlying illness
QTc prolonged at
450 in men
460 in women
500 from meds is considered highly significant
Chlorpromazine
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
Neuroleptic malignant syndrome
Rare. Potentially lethal.
Altered LOC, hyperthermia, muscular rigidity, autonomic instability, elevated creatinine phosphokinase.
Benztropine
Antichol for acute dystonia, 2mg
Droperidol
No longer FDA approved because of QTc prolongation even at low dose and with no cardiac hx
Haloperidol
QT prolongation (<35mg/d or 20mg at once)
AHS doses for combative
IM midaz 10 Q 15 max 20
Halo 5mg q 15 max 10
Fluphenazine
Equivalent to halo. 1.25-10mg dosing
Quetiapine
Atypical antipsychotic, doses range from 12.5-200mg BID
Somnolence, hypotension.
Antihistamines
Tx of anxiety in peds and adolesecents, effective if symptoms are anxiety driven
A2 agonists
Clonidine and dexmedetomidine. Thought that some antipsycho second gen benefits come from A2 agonism
Elderly sedation
Try reorientation, offering food water and bathroom, hearing aids and glasses.
More susceptible to EPS
Benzos can cause paradoxical disinhibition and increased agitation
AHS seizure
10 IM
If refractory 5IV max 10
AEIUOTIPS
Alchohol Epilepsy Infection Overdose Uremia (fluid, lytes, hormones) Trauma Insulin Psychosis Stroke
Primary headaches
Migraine or cluster
Secondary headaches
Tumor, menigitis, subarachnoid hemorrhage
Thunderclap headache causes
Intracranial hemorrhage, aneurysmal hemorrhage, spontaneous intracerebral hemorrhage
Carotid dissection
Reversible cerebral vasoconstrcition
Cerebral venous thrombosis
Headache red flags
Onset - sudden, trauma, exertion
Symptoms - ALOC, seizure, fever, neuro symptoms, visual disturbances
Meds - anticoagulatons/antiplatelets, immunosuppressants
Neck stiffness
Tension headaches
Scalp/neck muscles
Stress induced
Pain is bilat, non-pulsing, not worsened by exertion, no N/V give NSAIDS simple analgesics
Cluster headaches
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
Migraines
4-72hours
Episodic or chronic
Pain unilateral and pulsating, worsened by physical activity, photophobia, phonophobia, n/v onset childhood peaks at age 40
Organic headaches
Tumor, meningitis, sinus infection etc
Coital headache
Thunderclap headache occurs at orgasm. Benign with no specific tx
Pain tx
Vascular headaches tx with maxeran. Dop antagonism decrease both pain and nausea
Fluid often helps
Vascular headache presentation
N/V/ sweating, photosensitivity, throbbing
Vascular headache tx
O2, NS 1000mL, metoclopramide 10mg IV in 50mL over 15
Ketorolac 30mg IV/IM
Fentanyl 1mcg/kg or morph 2.5mg
Kernigs sign
Inability to straighten leg when flex 90 degrees
Brudzinskis
Feet flex with neck
Encephalitis
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
Lams
Droop 0 or 1
Arms 0 1 2 (palm down 45 degrees if lying 90 if sitting)
Grips 0 1 2
Tonic phase
Is the tightening, clonic is jerking. Last 1-3 minutes (whole seizure)
Dysthmia
Persistent form of mild depression
Acute dystonia
Continuous muscle spasms and contractions
Parkinsonism
Muscle rigidity
Akasthisa
Feeling of needing to be in constant motion
Tardive dyskinesia
Irregular, jerky movements
Bipolar drugs
Lithium, carbamazepine, valproic acid, TCAs
ETOH seizures
as early as 6 hours, 90% in first 48 hours
May be brief without postictal period
ETOH withdrawal hallucinatins
12-48 hours after, can last months
Wernicke korsakoff
B1 thiamine deficiency
Korsakoffs is chronic wernickes
Confusion, ataxia, tremors, nystagmus
Lorazepam
for etoh withdrawal 1mg SL q5 max 4mg
Subarachnoid hemorrhage
Intracranial hemorrhage most common cause. 75% are rupture aneurysm
Classic presentation is thunderclap headache
SAH stats
10-15% die before reaching hospital
40% die within first week
SAH description
Worst headache of life Nuchal rigidity Photophobia N/V seizures and decreasing LOC Similar to meningitis
Grades of SAH
I mild headache II severe headache III mild alteration in neuro exam IV Obviously depresses LOC V posturing or comatose
Subdural hematoma
Collection of blood on surface of brain, most frequently results of a head injury. Among the most lethal
Subdural hematoma patho
Sudden decel of brain parenchyma with tearing of bridging dural veins, forms a hematoma b/w dura and arachnoid layer.
Usually venous
Timing of subdural hematoma
Acute phase begins 3-7 days after injury (up to 14 days)
Chronic phase 2-3 weeks after acute injruy
Saccular aneurysms
Characteristic rounded shape and are majority (that little bugger bulging off)
