Neurology Final - Emergency

Front 1

Recurrent seizures

Back 1

50ml D40W + 100mg thiamine
Phenytoin intra-ictally (15-20microg/ml) or 10-20mg diazepam IV

Front 2

Status epilepticus 0-5miN

Back 2

O2, protect airway, monitor, IV, glucose level, toxicology, etc

Front 3

Status 6-9min

Back 3

100mg + 100ml D20W (kids 1mg/kg D40W).
If hypogly or glucose level unknown

Front 4

Status 10-20min

Back 4

Diazepam 0.2mg/kg at 5mg/min IV (10-20mg), may be repeated in 5min.
If does not work try Clonazepam 2mg bolus at 0.5mg/min and then 2mg/h or Lorazepam at 0.1mg/kg

Front 5

Status 21-60min

Back 5

15-20mg/kg Phenytoin via different canula at 50mg/min. Maximal daily phenytion 1-1.5g

Front 6

Absence status? focal status?

Back 6

Absence - clonazepam, focal status - clonazepam and later phenytoin 125mg

Front 7

Status >60min?

Back 7

give extra phenytoin to level of 30mg/kg then phenobarbital 15-20mg/kg slowly, then thiopental (100-200mg IV) and propofol and artifical vent

Front 8

Eclampsia?

Back 8

5g Mg-sulfate in 200ml saline, 20min infusion. Check level every 60min, check patellar reflex

Front 9

DD of sudden lose of tone?

Back 9

Drop attack (VB TIA), Cataplexy, Parkinson, Asterixis, Tonic falls (BS origin),

Front 10

How do you categorize syncope?

Back 10

Cardiac origin (with arrhythmia, w/o), extracardiac origin with reduced CO (vasovagal, carotid sinus sens., tussive, micturition), orthostatic disturbances

Front 11

DW-MRI, PW-MRI, how do you use?

Back 11

Reversible damage - decreaesd perfusion with normal diffusion. Irreversible damage - decreased perfusion & decreased diffusion

Front 12

Head injuries CT scale:?

Back 12

1. Negative CT
2. no shift, hyperdense or mixed lesions <25ml
3. shift 0-5mm, lesions <25ml
4. lesions >25ml, shift >5mm

Front 13

Definition of concussion? contusion?

Back 13

Concussion - blunt impact,, short period of LOC, transient amnesia, no focal sign
Contusion - blunt impact, brain tissue damage + focal signs

Front 14

Sx of contusion?. Rx for depressed skull fx?

Back 14

coup/contracoup, edema, focal signs (eye-field, aphasia, etc), seizures, skull base fracture, LOC. If brainstem - impact at craniocervical area may be fatal.
Depressed skull fx - if depth > width --> surgery

Front 15

Traumatic intracerebral hemorrhage - when is the bleeding?

Back 15

80% within 48h, 20% DITCH- delayed intracerebral traumatic hematoma - days 2-6

Front 16

Types of subdural hematoma? Rx?

Back 16

Acute - <72h hyperdense crescent lesion + focal signs, seizures, IICP
Subacute - 3-15days - ~isodense, leading sx IICP
Chronic - >20days mainly in old, alcohol, epilepsy. hypodense -- sx imbalance, headache, slowly progressing focal signs, behavior changes.
Rx - acute/subacute - immediate evacuation. mortality 40%!. Chronic - may be postponed

Front 17

Sx of epidrual hematoma? rx?

Back 17

Temporal region, altered LOC, focal signs , IICP, LUCID INTERVAL only in 10%!

Front 18

Midazolam / fentanyl dosage for sedation ?

Back 18

Midazolam 0.09 mg/kg/h, Fentanyl 0.0012mg/kg/h

Front 19

Types of cerebral edema?

Back 19

Cytotoxic (48h, ischemia/hypoxia), vasogenic (tumors, BBB, white matter, finger like)

Front 20

General rx of IICP

Back 20

Hyperventilate, 20% mannitol 200-250ml, Dexamethasone (tumors), stabilize BP at 160, sedate with thiopental 200mg)

Front 21

IICP - treatment, not emergency

Back 21

elevate head of bed, hypervent to 28-35 CO2, If tumor 40mg dexamethasone IV then 6mg q6h.
Osmotic therapy - 0.35mg/kg mannitol over 10min IV (be careful rebound effect, reduce dose when SeOSM >320, stop when >340, do not give in HF). 40% sorbitol 0.5g/kg x6/d also possible

Front 22

Dosages in IICP

Back 22

Dexamethasone 40mg IV then 4-6mg q6h.
Mannitol 0.35mg/kg, 40% sorbitol 0.5g/kg q4h, Glycerine 0% IV 500ml over 5 hours.
Thiopental 5mg/kg IV bolus then 4mg/kg/h, Phenobarbital 5mg/kg q4h)

Front 23

Antiplatelet drugs- dosages

Back 23

Aspirin: 325mg post stroke, 75-100 prophylaxis
Dipyridamole - 400mg/d
ticlopidine - 250mgx2
Clopidogrel - 75mg

Front 24

Asymptomatic ICA stenosis CEA indications

Back 24

>60%, M/M < 3%, no serious heart disease, good condition, male

Front 25

Warfarin after TIA

Back 25

CHADS2, give for 3 months, then switch to Aspirin UNLESS obvious cardiogenic emboli source then continue Warfarin

Front 26

CEA after recurrent TIA, minor stroke

Back 26

If >70% stenosis and m/m <5-6%

Front 27

CEA after recurrent TIA, minor stroke - C/I

Back 27

With intracranial stenosis, ICA occlusion, post stroke/MI, unstable severe HTN, pulmonary diseases, focal neurological signs, unstable angina

Front 28

Progressive stroke (in evolution) rx

Back 28

Treat IICP if present. Heparinization at 5000U bolus IV + 1000U/h later. PTT x2-3, after 1-2 weeks transition to warfarin for 3 months

Front 29

When should a stroke patient be admitted to ICU?

Back 29

Stupor/coma, ventilation req., IICP, CV, renal, metabolic complications and sepsis

Front 30

When do you decrease HTN in case of thrombotic stroke?

Back 30

If >220mmHg - and then only 15% in first 24h

Front 31

When is edema maximal post stroke?

Back 31

evident within a few hours but maximal 2-4d post

Front 32

Whats the bes drugs for quick decrease of HTN (>220) in stroke ischemic stroke patients?

Back 32

Nitroprussid 0.25-10microg/kg (t1/2 minutes), Labetalol 20-80mg IV (t1/2 hours)

Front 33

dosage of rTPA, indications

Back 33

0.9mg/kg (max 90mg), 10% as bolus rest in an hour. Indications(Csiba)- <4.5h, Basilar <12h, MCA 6h (IA!!). C/I - stupor/coma, INR>1.7, mild, fast remission, BP >185, >1/3 MCA infarct, Plt<100,000, History of IC hem

Front 34

Locations of HTN parenchymal bleeding

Back 34

B.G(50%), thalamus, cerebellum, pons, hemisphere (in that order)

Front 35

recurrent hemorrhage in hemorrhagic stroke (risk %, when). Other 2nd complications

Back 35

15% risk, esp in first 6h, other - seizures, edema,m hydrocephalus

Front 36

How to treat HTN in hemorrhagic stroke

Back 36

stabilize BP at 180. Urapidil 25mg IV bolus then 2mg/min. Nifedipine 10-20mg SL. Metoprolol 5-10mg IV. Nitroprusside final choice at 0.3microg/kg)

Front 37

Osmotic thearpy in hemorrhagic stroke

Back 37

200ml 20% mannitol IV bolus or 250ml 10% glycerin x4d

Front 38

Surgical rx for IC hem - C/I, Indications

Back 38

C/I - brainstem, thalamus, coma, coagulopathy - NO SURGICAL RX
Indications - putamen >30ml, cortical >50ml, altered LOC, brainstem herniation, midline shift

Front 39

Surgical rx for cerebellar hemorrhage- indications

Back 39

Hematoma >20ml and GCS <13

Front 40

What are the dosages for reversal of anticoagulant therapy upon IC hem?

Back 40

Vit. K 5-25mg or 2-3 units of FFP for warfarin,
30mg Protamine sulfate IV for Heparin
4-6 bags of Cryopercipitate for thrombolysis

Front 41

5 clinical symptoms of cerebral vein/sinus thrombosis

Back 41

Headache, seizures, vomiting, IICP, altered LOC

Front 42

Sinus/venous thrombosis - what do you see on LP? on CT? on DSA?

Back 42

LP - xantochromatia
CT - empty delta sign (SSS) + edema...
DSA - missing enhancement, cork-screw veins

Front 43

Rx for sinus/venous thrombosis? if in PP?

Back 43

Heparin (5000 bolus, 1000/h), oral anti coagulant after that. In Postpartum - STEROIDS 60-80mg

Front 44

Hunt-Hess grading for SAH?

Back 44

I - asymp or minimal headache
II - moderate/severe HA, nuchal rgidity, CN palsy
III - drowsiness, confusion, mild focal deficits
IV -stupor, hemiparesis
V - coma,decerebrate.
If I-III - operation possible <3 or >14 days. If IV-V postpone

Front 45

Medical rx for SAH

Back 45

NO aspirin.
Sedation with Propofol 0.4mg/kg/h, BP at 160
Nimodipine for vasospasm prophy

Front 46

Vasospasm after SAH prophy and rx

Back 46

Prophy -nimodipine 30microg/kg/h for 10 days then oral 60m q6h for 7 days. Rx - 30microg/kg/h for 2 weeks than same orally.
ALSO - 3H therapy --> hypertension (160-180 with dobutamine), hypervolemia (albumin 250ml x3d for CVP of 12) hemodilution(Hct 30%)

Front 47

What is the difference between a conus and a conus-cauda syndrome?

Back 47

Conus only - NO paresis (only perianal hypoasthesia and loss of reflexes)

Front 48

What's the difference in continence with lesions above or below T12?

Back 48

Above - reflex bladder will develop after some time
Below - atonic bladder, will not empty

Front 49

GBS - 3 signs, 4 DD

Back 49

signs- ascending distal limb weakness, fatigue, facial palsy (NO sensory deficit or very mild). Also don't forget Albumin-cytologic dissoc.
DD - PN, borreliosis, lead intox, porphyria

Front 50

Differences between GBS and CDIP

Back 50

in CDIP - much slower progression, old age, gloves/stockings sensory deficits and distal muscles atrophy

Front 51

Rx for GBS? R

Back 51

Plasmapheresis 50ml/kg x 5 days, if after 2-3 weeks still no imporvement - 7S IVIg 0.4/kg x 5 times

Front 52

Rx for CIDP?

Back 52

Plasmapheresis 50ml/kg x 5 times or Methylprednisolone 250-500mg/d for 5d IV(try 2 weeks) or IVIG 0.4g/kg x 5 times.
for relapse prevention - steroids, azatihoprin, cyclosporn (100mg bid)

Front 53

Signs for imminent mysathenic crisis?

Back 53

progressing dysarthria, supf. breathing, difficulty raising head, loss of weight

Front 54

Rx for cholinergic crisis in MG?

Back 54

stop AchE-inh, give 1-2mg Atropine, ICU

Front 55

Pyridostigmine dosage? Neostigmine?

Back 55

Pyrido- 60-300mg q4h
Neo - 15-30mg q4h

Front 56

Scheme for PE for MG? C/I?

Back 56

Scheme- 8 exchanges, 2 liters each. 1-2-3 daily, 4-5-6 every other daily, 7 4 days after 6, 8 8 days after 7
C/I - HF, coagulopathies, allergy.
HAS to be combined with immunosuppression as decrease in Ab concentration will result in increased synthesis

Front 57

Whats the immune suppression options for concurrent therapy of MG with PE?

Back 57

Prednisolone 100mg after each PE

Front 58

Steroids regimen for MG?

Back 58

30mg/day perdnisolone up to 100mg/d then for 10 days and reduce gradually over months to 7.5mg/d. (not sx may worsen initially with steroids)

Front 59

Immunosuppresion options for MG other than steroids?

Back 59

Azazthioprine 2.5mg/kg/d - hepatotoxic. Cyclophosphamide 2.5mg/kg/d - alopecia, hepatotoxic, BM suppression
Cyclosporin - 5mg/kg/d - nephrotoxic, no BM suppression

Front 60

Drugs that may worsen MG sx?

Back 60

Aminoglycosides, lidocaine/phenytoin, diazepam, b-blockers, acetozolamide, lithium.
If muscle relaxant needed - Atracurium 1/10 of dose

Front 61

Steroids therapy for acute MS exacerbation?

Back 61

1-5d 500-1000mg methylprednisolone IV then day 6-7 80mg PO, then reduce 20mg every other day.
If ineffective try ACTH or second course.
IF life threatening - cyclophosphamide 50mg/kg for 2 days

Front 62

% of people that have chronic tension headache? % of migraine?

Back 62

Tension - 3% chronic, Migraine - 10% women 5% men

Front 63

Abortive rx for migraine

Back 63

Metoclopramide 10mg po, DHEA 0.5mg intranasally, Sumatriptan 25-100mg po, 6mg SC (aspirin 500mg po or ibuprofen 300mg po or paracetamol 500mg po also)

Front 64

migraine prophy

Back 64

Metoprolol 100mg, verapamil 80mg q8h, flunarizine 5-10mg, naproxen 500mg q12h

Front 65

Cluster headache - prevalence, acute rx, prevention

Back 65

0.04-0.7%, Acute - O2, local lidocaine, sumatriptan (6mg sc) or DHEA (0.5mg nasal). Prevention - CCB, steroids (prednisolone 50mg) or Lithium 675mg. For prevention of episodic (not chronic) may also use Valproic acid 600mg

Front 66

Trigeminal neuralgia rx?

Back 66

200-400mg carbamazepine, blood levels 5-12micromol/l
Phenytoim 100mg q8h, gabapentin. Baclofen 5mg q8 and valproic also possible

Front 67

In vertigo resulting from extraocular muscle problem - when is the diplopia worst?

Back 67

When patient looks towards affected muscle

Front 68

In Meniere's - which side is it easier for the patient to turn head to?

Back 68

The affected side. Looking at the healthy ear makes sx worse

Front 69

Rx for meniere?

Back 69

During attack - antiemetics, dimenhydrinat rectally 100mg, diazepam 10mg IV. Between attacks- betahistine 16mg q8h

Front 70

Maneuvers for BPPV?

Back 70

Diagnosis - Dix-Hallpike, Rx- Epley

Front 71

Steroids for temporal arteritis?

Back 71

120-500mg methylprednisolone IV first day, then 120mg/d until ESR normalizes.

Front 72

3 local and 3 systemic complications of meningitis

Back 72

local - edema, abscess, subdural empyema
systemic - septic shock, waterhouse-friedrichsen, pneumonia

Front 73

Dx of HSV encephalitis

Back 73

CT - hypodense from 3rd-4th day, EEG - spike+slow wave activity may evolve to rhythmic triphasic activity. CSF - mononuclear pleocytosis, elevated protein, increased CSF/serum albumin ratio, serology, PCR

Front 74

Rx of HSV encephalitis

Back 74

Acyclovir 10mg/kg q8 IV for 2 weeks. Give prophy carbamazepine 200mg q12h

Front 75

Management of anxiety in dementia

Back 75

Tiaprid 200-300mg/d, if paranoid give haloperidol 2mg/d. If BDZ - chose short ones (midazolam) as t1/2 can be prolonged in elderly

Front 76

If treating depression in dementia, what to avoid?

Back 76

avoid drugs with significant anit-cholinergic effect as the dementia process already depleted the Ach

Front 77

Rx for Delerium Tremens

Back 77

If with cardio-pulmonary compromise - Diazepam 10mg/h until sx disappear then 20mg/q6h.
If no compromise- give Clomethiazole 400-800mg max 1000mg in first 2h. Maintanance 1-2 capsules q2h.
Others - Haloperidol 5mg IV q6h, Dexamethasone 3mg q12h

Front 78

S/E of Carbamazapine intox?

Back 78

AV block, CNS agitations leading to coma, seizures, depressed ventilation. Treat with 20mg diazepam

Front 79

S/E of phenytoin intox

Back 79

heart blocks, hypergly, altered LOC, nystagmus, seizures

Front 80

S/E of valproic acid intox

Back 80

confusion, hallucinations, absent DTR, coma, elevated ammonia level. If given with Barbiturates (CAVE!) even normal levels can develop valproate-encephalopathy (if so give Flumazenil), else give Naloxone

Front 81

S/E of methyl-dopa

Back 81

hypotension, N/V, hallucinations, hyperkinesis

Front 82

S/E baclofen intox

Back 82

depressed ventilation, altered LOC, seizures, decreased muscle tone

Front 83

S/E of bDZ intox

Back 83

dysarthria, ataxia, resp depression, reduced tone, reflexes - give flumazenil 1ml IV up to 5ml IV(effect only 30min). If severely intox withdrawal will lead to seizures!

Front 84

Naloxone dosage?

Back 84

0.001mg/kg IV can repeat 3 times every 5 min

Front 85

AED causing ataxia? causing nv?

Back 85

Ataxia- PC (pheny,carba), NV-pcv

Front 86

AED causing diplopia, headace

Back 86

Diplopia- PC, headache- Ethosuximd

Front 87

AED causing sedation? tremor?

Back 87

sedation-PCP, tremor-V

Front 88

AED causing weight gain? alopecia?

Back 88

weight gain - CV, alopica-V

Front 89

AED causing hirsutism? gingival hyperplasia?

Back 89

hirsutism+gingival - phenytoin

Front 90

drugs causing sensory PN

Back 90

Chloramphenicol, Cisplatin

Front 91

Drugs causing mainly sensory PN

Back 91

Hydralazine, metronidazole

Front 92

Drugs causing motor PN

Back 92

Dapsone, some sulfa

Front 93

drugs causing mixed PN

Back 93

amiodarone, disulfiram, vincristine