Treatments 1 Flashcards
Bacterial meningitis <1 month
Ampicillin (Listeria) + cefotaxime/gentamicin (E. coli, GBS)
Bacterial meningitis (1 month-60 yrs)
Cefotaxime/Ceftriaxone (S. pneumo, N. meningitidis), Vancomycin (MRSA), Dexamethasone
Bacterial meningitis > 60 yrs
Ampicillin (Listeria), Cefotaxime/Ceftriaxone (S. pneumo, N. meningitidis), Vancomycin (MRSA), Dexamethasone
Prophylaxis, meningococcal/HiB meningitis
Rifampin or Ciprofloxican
Fungal meningitis
Amphotericin B intrathecally
TB active infection (meningitis, pulmonary)
Rifampin, Isoniazid, Pyrazinamide, Ethambutol
Viral meningitis
Supportive, empiric abx until bacterial meningitis excluded, Acyclovir if suspected HSV
Reye syndrome
Supportive
Viral encephalitis
Supportive, maintain normal ICP, Acyclovir until HSV r/o
Brain abscess empiric abx for comorbid oral, sinus, ear infx
Metronidazole + 3rd gen ceph (ceftriaxone)
Brain abscess empiric abx for hematologous spread, neurosurgery
Ceftriaxone + vancomycin (MRSA)
Brain abscess
Empiric abx, corticosteroids for mass effect (to decrease swelling), usu need neurosurgical drainage
Rabies
Clean wound thoroughly, Rabies IG + vaccine
Tension HA
NSAIDs, can use triptans, dihydroergotamine
Cluster HA
100% O2 (>6 L/min on non-rebreather for >15-20 min)
Can use triptans, dihydroergotamine
Migraine HA
Triptans (sumatriptan) or Dihydroergotamine (vasoconstrictors), NSAIDs, anti-emetics (chlorpromazine, prochlorperazine, metoclopramide) in varying combos
Pseudotumor cerebri
Acetazolamide (first line, start low and increase)
Discontinue inciting agents (vit A, Accutane, long term tetracyclines for acne, corticosteroid withdrawal), weight loss if obese
Invasive - serial LPs, optic nerve sheath decompression, lumboperitoneal shunting
Trigeminal neuralgia
Carbamazepine (first line), Baclofen (alone or combo), Anticonvulsants, Surgical decompression
First TIA
ASA + statin if LDL >100
TIA/stroke due to AF
Warfarin + statin if LDL >100
TIA/stroke + CAD
Clopidogrel + statin if LDL >100
Repeat TIA/stroke while on ASA
Clopidogrel or Aggrenox + statin if LDL >100
CAD surgical indications
Carotid endarterectomy:
Symptomatic patients w/ narrowing 70-99%
Symptomatic men w/ narrowing 50-69%
Asymptomatic patients w/ narrowing 80-99% if life expectancy >5 yrs
CAD nonsurgical treatments
HTN 35, TG <7%
Smoking cessation, exercise, red wine (avoid heavy drinking), ASA/Aggrenox/Clopidogrel
Ischemic stroke
Thrombolysis w/i 3-4.5 hrs, 6 hrs if direct catheter to brain and no C/I (hemorrhagic - look at CT/MRI, recent surgery/bleed, current AC, BP >185/100)
Antiplatelet started w/i 48 hrs (ASA/Clopidogrel/Aggrenox, Warfarin)
Statin started w/i 3 days
BP control if >220/120 or if CAD (wait for BP control in ischemic, may decrease perfusion)
PT, treat underlying disorders
Hemorrhagic stroke
Reverse AC (restart 2 wks after stable) Control BP Control ICP Surgical decompression w/ shunt if blood collection Usu need neurosurgery consult PT, treat underlying disorders
Control increased ICP
Mannitol (lasts 4-5 hrs)
Hyperventilation
Anesthesia
Head of bed to 30 degrees
Parenchymal hemorrhage
Supportive, control ICP
Seizure prophylaxis w/ anticonvulsants
Surgical decompression if large
AVM or aneurysm repair if needed
SAH
Reverse and d/c AC
Systolic BP <150 if cognitive fxn intact (Labetalol, avoid nitroprusside and nitroglycerine - can +ICP)
Nimodipine (CCB) to prevent vasospasm
Good brain environment (avoid hypoxia, hypoglycemia; maintain normal pH, euvolemia, normothermia)
Ventriculostomy to monitor ICP in some patients
Surgical clipping/coiling if aneurysm
Epidural hematoma
Control ICP, good brain environment Drain blood (surgical burr hole, drain w/ radiographic guidance)
Subdural hematoma
Supportive monitoring if no neural deficits
Surgical drainage if needed
Normal pressure hydrocephalus
Ventricoperitoneal shunt
Grand-mal (tonic-clonic) seizures
Valproate, Carbamazepine, Phenytoin, Lamotrigine, Topiramate
Partial seizures
Carbamazepine, Lamotrigine, Phenytoin > Valproate, Topiramate
Absence seizures
Ethosuximide (Valproate second line)
Myoclonic seizures
Valproate
Non-medical treatment for recurrent seizures
Surgery (especially partial)
Vagal nerve stimulator (refractory)
Status epilepticus
ABC IV benzos immediately Phenytoin to prevent recurrence Phenobarbital for refractory (last resort) Treat underlying disorder
Eclampsia - seizures
IV magnesium sulfate (first line)
Deliver baby
Benzos (last resort)
Depression
SSRI/SNRI (first line)
TCA (second line)
MAOI (third line)
ECT (refractory, psychotic, canβt wait, catatonic stupor)
Atypical depression
MAOI > TCA (SSRI also work)
Depression w/ seasonal pattern
Phototherapy (first line)
SSRI/Bupropion (second line)
Serotonin syndrome
D/c serotonergic agents
Supportive care
Sedation w/ benzos (or cyproheptadine, serotonin antagonist if refractory)
Sedation, paralysis and ET tube for temp >41.1
NMS
Dantrolene
Nephrogenic DI caused by lithium toxicity
HCTZ + amiloride (closes Na channels in CT where lithium acts)
Bipolar disorder
Mood stabilizer (first line)
Atypical antipsychotic (first/second line)
AD (not first line)
ECT
Cyclothymia
Mood stabilizer
Psychotherapy
Anxiety disorders (in general)
SSRI/SNRI (first line)
TCA (much less), MAOI (rarely)
Buspirone
Benzos
GAD
SSRI/SNRI (Venlafaxine)
Buspirone
Beta blocker
CBT
Panic disorder
CBT
SSRI
Benzo (acute)
Relaxation training
Specific phobia
Systematic desensitization
Social anxiety disorder
CBT Beta blockers SSRI (severe) MAOI (refractory) Benzo (acute)
PTSD
Psychotherapy (behavioral/exposure, CBT)
SSRI (first line med)
TCA/MAOI
Mood stabilizers (carbamazepine/valproate) for impulsive behavior, arousal, flashbacks
Alpha-blockers (prazosin) for nightmares/sleep problems
Atypical antipsychotics (refractory)
Benzodiazepine OD
Flumazenil
Schizophrenia
Atypical antipsychotics (first line), Typical antipsychotics (second line), Clonazapine (third line)
Acute dystonia (typical AP side effect)
Anticholinergic (benztropine or diphenhydramine)
Tardive dyskinesia
Stop offending medication and start one with less movement AE
Parkinsonβs
1st line: Levodopa-Carbidopa (Sinemet) 2nd line: DA agonists (bromocriptine, etc.) Selegiline (MAOI), early disease COMT inhibitors (potentiate LD) Anticholinergics (tremor) Amantadine (increases DA release)
ALS
Riluzole
Huntington disease
DA antagonists (antipsychotics, tetrabenazine)
Alzheimerβs disease
Donepezil, Rivastigmine, Galantamine (ACHase inhibitors)
Memantine (MNDA receptor blocker)
MS
Corticosteroids (very high dose; acute attacks), IFN-B (maintenance)
Methotrexate, Glatiramer (maintenance), Natalizumab
Syringomyelia
Surgical decompression, shunting for recurrence
Nephrogenic DI
HCTZ
Benign essential tremor
Beta blockers (propranolol) Self medicated w/ alcohol Benzodiazepines Primidone Thalamotomy/DBS (refractory)
Chorea
Treat underlying disorder (hyperthyroidism, Huntington, SLE, rheumatic fever, levodopa use)
Athetosis
Treat underlying disorder (cerebral palsy, encephalopathy, Huntington, Wilson)