neuro final + insomnia

transient insomnia

2-3 nights 

short term insomnia

less than 3 months

chronic insomnia

more than 3 months

substance that induces insomnia

caffeine

cigarette

alcohol

what kind of drugs can induce insomnia? 

anticonvulsants 

adrenergic blocker 

diuretics

SSRI 

steroids 

stimulant

difficulty falling asleep

sleep maintenance (difficulty staying asleep)

PK characteristics

rapid onset

long duration

OTC antihistamines

diphenhydramine

doxylamine

what are OTC antihistamines used for?

occasional problems falling asleep

how many days should self medication be limited to for diphenhydramine?

7-10 days

characterisitcs of anticholinergic toxicity

dilated pupils

flushed skin 

hot and dry mucous membranes

ataxic gait 

hyperthermia 

paradoxical excitation

which pt population does this occur in?

nervousness

restlessness

children mostly

TCAs

amitriptyline

doxepin

nortriptyline

low dose doxepin (silenor) 

indication

sleep maintenance

TCA

SE

anticholinergic

adrenergic

cardiac

mirtazapine

SE

day time sedation

weight gain

low dose trazodone

indication

risk of substance abuse 

serotonergic antidepressant at high doses 

suvorexant and leborexant

indication

sleep onset and maintainence

suvorexant and leborexant

contraindications 

individuals with narcolepsy 

ramelteon

tolerance

SE

well tolerated

headache / dizziness

benzodiazepine warnings

complex sleep behavior

• sleep driving

• sleep eating

benzodiazepene properties 

sedative

anxiolytic

muscle relaxant 

anticonvusant activites 

benzodiazepenes 

SE 

psychomotor incoordination 

decreased concentration 

retro amnesia (forgetfulness)

non-benzodiazepene

indication

insomnia

why isn’t zaleplon not useful for sleep maintenance? 

rapid onset

short DOA

non-benzodiazepene

SE

daytime sleepyness

non-Rx products 

valerian

melatonin 

chamomile flower extract 

valerian

SE

day time sedation

AASM guideline

sleep onset

zaleplon

triazolam

ramelton

AASM guideline

for onset and maintenance 

eszopliclone

zolipidem

temazepam

AASM guideline

sleep maintenance 

suvorexant 

doxepin 

what channels do general anesthetics affect?

GABA

glycine

glut

nAch

5-HT3

block Aδ fibers

prevent 1st pain

myelinated

block C fibers

prevent 2nd pain

ester-linked

procaine

tetracaine

cocaine

benzocaine

amide-linked

lidocaine

bupivacaine

levobupivacaine

ropivacaine

prilocaine

what is procaine contraindicated in?

sulfonamide antibiotics

which ester-linked are used topically?

benzocaine

lidocaine, benzocaine, prilocaine contraindications

methemoglobinemia

what is buvacaine used for?

epidural anesthetic

which esters have long duration?

tetracaine

which esters have medium duration?

cocaine

which esters have short duration?

procaine

which esters are surface active?

benzocaine

cocaine

which amides have long duration?

bupivacaine

ropivacaine

which amides have medium duration?

lidocaine

ester-linked hypersensitivity reactions

procaine → PABA

fast induction of general anesthesia

adverse effects

decrease chances of AE

the potency of anesthetic increase as solubility in oil _______

increase

perfusion limited anesthetics

small (blood/gas)

low blood solubility → increase in Palv → fast induction

ventilation-limited anesthetics

large (blood/gas)

high blood solubility → low in Palv → slow induction

what does larger partition coefficient mean for inhaled anesthetics?

more potent

good anesthesia at lower partial pressure

inhaled anesthetics

either

nitrous oxide

halothane

isoflurane / enflurane

desflurane

inhaled anesthetics

High λ (oil/gas) → High potency → Low MAC

ether

halothane

high gas P will want to stay in the blood = slow induction

inhaled anesthetics

Low λ (oil/gas) → Low potency → High MAC

nitrous oxide

sevoflurane use

for kids bc its sweet tasting

isoflurane/enflurane

smaller λ (oil/gas) than halothane → faster

enflurane

AE

renal toxicity

desflurane/sevoflurane

low λ (blood/gas) → fast

high λ (oil/gas) → potent

IV agents

barbituates

propofol

etomidate

dexmedetomidine

ketamine

which IV agents used the most?

propofol

propofol

MOA

GABAaR enhancer + Na+ blocker

cardiac depression

what is thiopental?

short-acting barbiturate for rapid anesthesia

etomidate

MOA

GABAaR

no effect on symp nervous system / no analgesic

dexmedetomidine

MOA

a2 adrenergic agonist

short term ICU setting

ketamine

MOA

NMDAR antagonist

increase HR/BP

no res depress

adjuvant drugs

benzodiazepines

opioids

adjuvant drugs

MOA

nAChR blockers

benzodiazpenes

diazepam

lorazepam

midazolam

flumazenil → BZD antagonist

opioids

morphine

fentanyl/remifentanil

naltrexone → antagonist

what if pt wants analgesic w/o res depress?

ketorolac (NSAID)

neuromuscular blockers

nondepolarizing agents (nAChR antagonists)

depolarzing agents (nAChR agonists)

both given IV

what are neuromuscular used in conjunction with?

general IV

inhaled anesthetics

nondepolarizing agents

isoquinolone

steroid derivatives

isoquinolone derivatives

atracurium

cisatracurium

mivacurium (shortest DOA)

steroid derivatives

pancuronium

rocuronium

vecuronium

neuromuscualr blocker depolarizing agents

succinylcholine

ultrashort DOA

SE: muscle pain

amygdala

fear

PTSD

cortico-striatal-thalamic-cortical circuit

worry

CNS stimulants

amphetamines

caffiene

cocaine

ephedrine

methylphenudate

CNS depressants

EtOH

barbituates

narcotics

anxiety tapering

1 year before tapering

what is generalized anxiety disorder (GAD)

worry/anxiety more than 6+ months

anxiety 1st line treatment

SSRI : setraline

fail → alt SSRI/SNRI

how long do you use anxiety BDZ ?

used for short term

what do you do if a patient has a partial response to an SSRI?

12 weeks after partial response for full response

panic disorder treatment

1st: SSRI / SNRI

2nd: TCA

how long do you cont panic meds for?

min 1 year

panic meds taper

4-6 months

SSRI fluoxetine, fluvoxamine, paroxetine DDI

inhibits

SSRI

key pt counseling points

increase in anxiety

risk of withdrawl

delay in onset of effect

SSRI adverse reaction

sexual dysfunction

hyponatremia

weight gain

SSRI → MAOI

discont

4 weeks

SSRI → other antidepressants

2 weeks

benzo uses

lag time until antidepressants kick in

failure to other therapies

how long is benzos used for?

8 weeks for acute anxiety attacks

benzos AE

rebound anxiety

insomnia

muscle tension

benzos tapering

25% per week until 50% dose is reached → 1/8 every 4-7 days

benzos

commonly abused

lorazepam

xanax

benzos

elderly pt

lorazepam

oxazepam

benzo

less likely to be abused

clonazepam