3-1113

Just a useful chart

Ligand-gated
ion channel

GPCR

Ach

nAchR

mAchR

GABA

GABAA

GABAB

Glutamate

NMDA

Metabotropic

Serotonin

5HT3

5HT1, 5HT2

Cannabinoids

TRPV1/TRPA1

CB1, CB2

30 yo female p/w agitation,

confusion, aphasia, fever.
CSF: high lymphocytes, high
protein, normal glc, xanthochromia
WHAT BUG?!
HSV-1: likes to infect temporal lobes and
produce rbcs in CSF (xanthochromia is
breakdown of rbcs)
WHERE DOES THIS ORGANISM PROBABLY
LIVE AND WHAT HAPPENED TO CAUSE
THIS?
Reactivation of latent HSV-1 in trigeminal
ganglion
TREATMENT?
Acyclovir

What receptor do
barbiturates act
on? What type of
effect do they
have?

Barbs
PHENOBARBITAL,

PENTOBARBITAL, THIOPENTAL
Acts GABAA ligand gated chloride channel

Opens Cl channel and allows inward mvt of Cl > inhibits

neurotransmission
PROLONGED DURATION of opening time
(barbiDURATes)
INCREASED POTENCY of GABA

latency

to sleep onset, duration/episodes of REM,

stage 3+4 sleep, stage 2 sleep

Can have rebound insomnia

Respiratory

depression in dose-dependent manner

Stimulates P450 enzymes in liver
CI: acute intermittent porphyria
TOLERANCE TO RESPIRATORY DEPRESSANT
EFFECT DOES NOT INCREASE

How are benzos

similar/different
to that
mechanism?

Remember that accumulation of thiopental and other related

lipid soluble barbs in brain is followed by rapid
REDISTRIBUTION into skel mm and adipose tissue
-Waking up is redistribution, not metbolism

Benzos

Long-acting: DIAZEPAM,
CHLORDIAZEPOXIDE, CLONAZEPAM
Medium-acting: LORAZEPAM
Short-acting: OXAZEPAM,
ALPRAZOLAM, MIDAZOLAM
GABAA receptor

INCREASED FREQUENCY of CHLORIDE

CHANNEL OPENING
Benzo, frenzo

You are on neuro and called to the ED. Patient

has been witnessed seizing for at least 15-30
minutes. What is the drug of choice?

Lorazepam

(ATIVAN)
You would also load them
with phenytoin

Which benzo is great for conscious

sedation and outpatient procedures (like
a quick endoscopy)?

Midazolam

Name the benzodiazepine

antagonist.
Flumazenil

What type of drug is

Zolpidem ?
Aka Ambien

Non-benzo benzo

BZ1 receptors

Short half-life
For insomnia, rapid onset, less potential for
tolerance and addiction, less withdrawal

Man with confusion, agitation, and

hallucinations. He was reportedly
seen foaming at the mouth by a
friend. He is a local college
student who likes spelunking.
BUG?!
Rabies.

Restlessness, agitaiton, dysphagia. Can

progress to coma. Also note the exposure to caves.
HOW DOES IT ENTER THE BODY AND PROPAGATE?
Wound > travels retrograde via peripheral nerves to
dorsal root ganglion and then to brain. Massive
replication in CNS
BRAIN BIOPSY SHOWS ______________?
Negri bodies (cytoplasmic inclusion in cells infected

Teacher calls home because young boy typically zones

out during class and seems to not pay attentionhe is
fine for the rest of the day but seems to not remember
zoning out

ETHOSUXIMIDE

(2nd choice: Valproic

acid)
Blocks T-type Ca channels
Absence seizures: 3 Hz spike and wave
Risk of Stevens-Johnson

Patient develops this after

starting new antiepileptic.

PHENYTOIN
Inhibit sodium channels
Adverse effects

Gingival hyperplasia
Hirsutism
LAD
Folate deficiency (interferes with
metabolism)
Hyperglycemia
Fetal hyantoin syndrome

Side effect of Lamotrigine

Steven-Johnsons

rash

Which antiepileptic occasionally causes

pancreatitis? And neural tube defects.

Weight

VALPROIC ACID

gain

HA
GI

upset
Hair loss
Hepatotoxicity (elevated LFTs)
Pancreatitis
Thrombocytopenia
Neural tube defects

What are the endocrine

side effects of Lithium?
Nephrogenic

diabetes
insipidus
Hypothyroidism

Other lithium side effects

TREMOR
Hair

loss
EBSTEINS HEART ANOMALY
Li

inhibits regeneration of phosphatidylinositol in membrane

Use for bipolar disorder
Tx for OD can be hemodialysis

WHICH CLASS?
Fluoxetine
Paroxetine
Sertraline
Citalopram
SSRIs
First

line for depression / anxiety

Hydrocephalus, intracranial
calcifications, chorioretinitis
Classic

triad of congenital toxoplasmosis

Transmitted transplacentally > fetus
affected only if mom infected in first 6
months

Drug for smoking

cessation?
Bupropion
NDRI
No

signficant sexual dysfunction either

Contraindicated with seizure disorders
and eating disorders

Buproprion vs. Buspirone

Buspirone:

Selective agonist of 5HT1AR

GAD
Anti-anxiety, reduced potential for abuse,
no muscle relaxant/anticonvulsant
properties

A man presents with tremor that

worsens when he tries to do things
like hold a cup. He reports that he
has been drinking more than usual
because it seems to help.
WHAT TYPE OF TREMOR?
Intention/action tremor >> essential / postural tremor
Autosomal dominant, often with positive family history
Will often see that alcohol IMPROVES tremor in question stem
HOW IS THIS TREMOR DIFFERENT THAN WITH PARKINSONS?
Parkinsons is resting tremor that improves with intentional movement
TREATMENT?
BB

Patient complains of sudden

lightning-like pain near her jaw. Tx?

Trigeminal

neuralgia
Carbamazepine

Side effects with

carbamazepine?
Anticholinergic

(dry eyes, blurred vision,

nausea, vomiting, clumsiness, delayed
urination)
APLASTIC ANEMIA
Hepatitis/hepatotoxicity
HYPONATREMIA

Non-depolarizing
Tubocurarine, pancuronium
Compete with Ach for postjunctional receptors (just
blocking endogenous agonist) > competitive anatonist
Large margin of safety because 75% Rs must be
blocked before inhibition
Not metabolized by cholinesterases
Readily antagonized and reversed by
anticholinesterase agents (neostigmine,
physostigmine, edrophonium)
Give atropine before (mAchR inhibitor) because
increased Ach would give PS sxs (salivation,
lacrimation, defection, emesis)

Depolarizing agents
Decamethonium,

succinylcholine
NAchR agonists that initially depolarize
muscle but prevent repolarization
Anticholinesterases of no benefit in
reversing (may even prolong it)

Side effects of
succinylcholine?
Increased

intraocular pressure
Muscle soreness
Hyperkalemia (possible arrhythmias)
Contraindicated in burn injury, massive
trauma, severe infection

Eyes will look

*towards* stroke
and
*away* from
seizure.
Think

about the frontal eye fields

Dissociative anesthesia
Conscious

but unable to really respond

to sensory input
KETAMINE!!! NDMA R antagonist

PCP derivative

Increase

BP & HR

Definition of MAC?
Partial

pressure that gives ED50

% of anesthetic that prevents muscular

response to standard painful stimulus in
50% of people

Inversely

agent

related to lipid solubility of

What can cause increased or

decreased MAC?
INCREASED MAC (less
sensitive)

DECREASED MAC (more

sensitive)

Hyperthermia

Hypothermia

Chronic etOH

Acute etOH

Redheads

Age

Drugs that increase CNS

catecholamines

Pregnancy
Sepsis
Alpha2 agonists (clonidine)
Opioids, benzos, barbs,
propofol, local anesthetics,
N2O

Whats unique about etomidate

as an induction agent?
Will

not decrease SVR with minimal

change in BP/HR/CO/contractility
STABILITY OF CV effects so good for
those with heart disease

Risk of priapism?
TRAZODONE

(trazabone)
Blocks 5HT2a; 5HT1a partial agonist;
blocks 5HT reuptake

Which 2 inhalational anesthetics are

good for mask induction (less noxious)?

Sevoflurane
Nitrous

oxide

Nitrous oxide can inhibit enzymes

that are vitamin ____ dependent?
Vit

B12 dependent
Neuropathy
Muscle weakness
Ataxia
Megaloblastic anemia
Others:

increased risk of spontaneous abortion

Why is 100% O2 administered after

finishing use of nitrous oxide?
Once

N2O is stopped and patient

breaths room air, N2O will diffuse into
alveoli from blood and tissues
Dilutes O2 breaths

Major side effect of

halothane?
Hepatotoxicity
Immune

response to proteins that are

trifuoroacetylated

Which inhalational anesthetic has

NO hepatic or renal toxicity?
Isoflurane

Do you remember how to differentiate between

an UMN and LMN lesion with the facial nerve?

Central lesion of the facial nucleus will lead to only paralysis

of the lower face (forehead wrinkles intact) > upper face
receives bilateral UMN innervation
Peripheral lesion will lead to facial paralysis (can not wrinkle
forehead)

Best depression drug for

patient with bulimia?
FLUOXETINE
WHAT

SHOULD YOU NOT GIVE?!

Bupropion

What is the only treatment for

ALS currently?
Riluzole
Extends

survival for a few months or

might delay time until tracheostomy

What would be a good long-term choice

for a girl with cerebral palsy who has
very high spasticity?
Baclofen
Can

use intrathecal pump which is

placed by neurosurgery
GABAB agonist
Can have abrupt withdrawal

Patient returns from surgery and is

noted to develop a very high fever,
muscle rigidity, tachycardia. UA is
positive for blood but has 0 rbcs. CK
very high.
Malignant

hyperthermia related to inhalational anesthetic (esp

halothane) and muscle relaxant succinylcholine
Abnormal ryanodine receptors release large amounts of calcium
after exposure to anesthetic
Rhabdomyolysis: hyperkalemia, high CK
Hyperthermia
Tachy, HTN, myoglobinuria
Can give DANTROLENE: acts on ryanodine R and prevents
further release of Ca > dissociates E-C coupling
Potentially fatal, possible arrhythmias

Why is carbidopa
administered with L-dopa?
Carbidopa reduces peripheral metabolism
of L-dopa and improves brain delivery
Another note: vit B6 supplementation
should not be taken with levodopa
because increases peripheral metabolism
and decreases effectiveness

Which anti-viral is sometimes used

for treatment of Parkinsons disease?
Amantadine
Inhibits

re-uptake of dopamine and may

even enhance its release

What drug might you recommend for a

patient that has combined absence
seizures and tonic-clonic seizures.
VALPROIC

ACID
Because ethosuximide is only going to
be effective against absence
Remember that VPA is a 2nd line for
absence!

What type of drug is

selegeline?
MAO-B

inhibitor
Prevents de-amination of dopamine
(prevents breakdown)
MAO-B preferentially metabolizes DA
over NE/5HT

WHICH CLASS?
Amitriptyline
Imipramine
Desipramine
TCAs

MAJOR MAJOR SIDE EFFECT

OF TCAs
Quinidine like effects on heart > prolongs
myocardial repolarization time
Can cause arrhythmias
Imipramine in particular associated
specifically with sudden cardiac death in
kiddos

Which TCA might you select for

depression if patient has fibromyalgia
(/insomnia/neuropathic pain)?
Amitriptyline

Drug of choice for

myoclonic seizures.
Valproic

acid

WHICH CLASS?
Phenelzine
Tranylcypromine
Selegeline
MAO

inhibitor
NE/5HT accumulate in presynaptic
stores

Depressed patient at a wineand-cheese party develops HTN

Tyramine

crisis
Indirect pressor amine tyramine (found
in beer/cheese/wine/etc) can precipitate
severe HTN with used with MAO-I

Confusion, agitation, MYOCLONUS,

HYPERreflexia, tremor, HTN seen
in depressed patient who just had
some cough syrup
Serotonin

syndrome
TCAs + SSRIs + dextromethorphan +
meperidine [IN COMBO WITH ] MAO-I

What secondary complication do

you worry about with
subarachnoid hemorrhage? How
would it appear on CT scan?
Secondary

arterial vasospasm in vessels

surrounded/irritated by the ruptured aneurysm
blood
Causes vertebral ischemia AGAIN and may
present as new onset confusion and a focal
deficit
Wont show up on CT
Can give Nifedapine (selective CCB)

Definitely be comfortable with the

adverse effects of typical antipsychotics
Lets

say you have a guy who was

recently seen in IOP and was started on
a medication. He now reports that he
now just feels like he cant stand still
or be seated.

Akathisia
Movement

disorder characterized by
inner restlessness and inability to
sit/stand
Sometimes it is missed because the
movement/restlessness if
misinterpreted as worsening psychotic
behaviorthen a doc increases the dose
and exacerbates symptoms
Treat with BB

Involuntary perioral movement (biting,

chewing, grimacing, tongue protrusions)
Tardive

dyskinesia
Often irreversible

Other effects
EPS

(nigrostriatal pathway)

Dystonia
Parkinsonism
Akathesia
TD

Endocrine

Galactorrhea
Gynecomastia
Sexual dysfunction

NMS

Retinitis pigmentosa
Thioridazine

Corneal deposits
Chlorpromazine

 HIGH

POTENCY

Haloperidol
Fluphenazine
Trifluoperazine

LOW

POTENCY (more sedating,

anticholinergic effects)

Chlorpromazine
Thioridazine

Atypical antipsychotics
MAJOR

RISK WITH
CLOZAPINE?

Agranulocytosis

>> need weeklly CBC

Also risk of seizures, hypotension,
weight gain, sialorrhea
Blocks 5HT2a, D2 receptors
So really save for refractory cases

Whats unique about

aripiperazole?
D2

partial agonist (unique mechanism of

action)
High potential for akathesia

T104 F, muscle rigidity, history

of schizophrenia
Neuroleptic

malignant syndrome

Unlike 5HT one, NO myoclonus

Dopamine

agonist (bromocriptine)
and/or direct muscle relaxants
(dantrolene) have been used to
decrease mortality rates
Hyperthermia, extreme generalized
rigidity, autonomic instability, altered
mental status, myoglobinuria

What are the two divisions

of local anesthetics?
ESTERS:

procaine, cocaine, benzocaine,

procainamide
AMIDES: lidocaine, bupivicaine,
ropivacaine

Why does local inflammation decrease

the effectiveness of a local anesthetic?
Concentration

of local anesthetic
necessary for nerve block increases as
pH decreases

Nonionized form necessary for

penetration of nerve sheath

Inflammation

produces DECREASED pH
and therefore decreases effectiveness of
local anesthetics

Give an example reason of why

accidental injections of the local
anesthetics intravascularly is
dangerous
CNS

toxicity first

Talkativeness, sensory (tinnitus, perioral

tingling, slurred speech), drowsiness,
lightheadedness, tremor
Seizures, lethargy

Cardiovascular

Vasodilation (BP drops), except cocaine

causes vasoconstriction
Eventually can progress to arrhythmias

Why do patients with Downs

syndrome develop Alzheimers ?
Beta-amyloid

plays important role

APP is coded by gene on chrom 21

Psammoma bodies. Which brain

tumor?
Meningiomas

Treatment for toxo?

Pyrimethamine

and sulfadiazine

Which antiepileptic causes

nephrolithiasis as adverse
effect?
Topiramate
Side

effect that people commonly like:

weight loss