Neurology 1. Case Questions

JW is a 24yo female (51kg, 62”) with a known history of seizure disorder for which she takes lacosamide 100mg twice daily. She is also on levonorgestrel/ethinyl estradiol 0.15/0.03mg once daily and sertraline 50mg once daily. Upon arrival to the emergency department, EMS reports that she has been seizing for 15 minutes and that they have been generalized tonic-clonic seizures for the duration. She did not respond to 2mg IM midazolam, leading them to give a second dose of 3mg IM midazolam. Her available labs and vital signs are as follows: HR 130bpm, RR 27, BP 110/64, O₂ saturation 97% on room air, body temperature 98.2°F (temporal), fingerstick blood glucose 107mg/dL.

• The treating physician asks what the next treatment option should be based on the fact that JW did not respond to two doses of benzodiazepines. What do you recommend?

JW is a 24yo female (51kg, 62”) with a known history of seizure disorder. Her home medications include lacosamide 100mg PO twice daily, levonorgestrel/ethinyl estradiol 0.15/0.03mg PO once daily, and sertraline 50mg PO once daily. Upon arrival to the emergency department, EMS reports that she has been seizing for 15 minutes and that they have been generalized tonic-clonic seizures for the  entire 15 minutes. The seizures did not cease after a dose of 2mg IM midazolam. At that time, the EMS crew gave a second dose of 3mg IM midazolam. JW did not respond to the second dose either. Her available labs and vital signs are as follows: HR 130 bpm, RR 27 breaths/minute, BP 110/64 mmHg, O₂ saturation 97% on room air, body temperature 98.2°F (temporal), fingerstick blood glucose 107 mg/dL.

• After receiving adequate doses of benzodiazepine and IV access has been obtained, what would be the most appropriate dosing of levetiracetam in JW?

JW is a 24yo female (51kg, 62”) with a known history of seizure disorder for which she takes lacosamide 100mg twice daily. She is also on levonorgestrel/ethinyl estradiol 0.15/0.03mg once daily and sertraline 50mg once daily. Upon arrival to the emergency department, EMS reports that she has been seizing for 15 minutes and that they have been generalized tonic-clonic seizures for the duration. She did not respond to 2mg IM midazolam, leading them to give a second dose of 3mg IM midazolam. Her available labs and vital signs are as follows: HR 130bpm, RR 27, BP 110/64, O₂ saturation 97% on room air, body temperature 98.2°F (temporal), fingerstick blood glucose 107mg/dL.

• The decision is made to intubate JW after first- and second-line therapies failed. Which of the following agents would be the least appropriate for post-intubation sedation?

DG is a 72yo male (82kg, 68”) with past medical history of hypertension, hyperlipidemia, and type 2 diabetes for which he takes losartan 50mg po daily, atorvastatin 40mg po daily, metformin 1000mg po bid, sitagliptin 50mg po bid, and aspirin 81mg po daily. He is allergic to penicillin (rash). He presents to your emergency department for altered mental status and reports a severe headache. He denies any falls or other recent trauma. Labs and vital signs are as follows: BP 198/104 mmHg, HR 73, RR 18, O₂ saturation 97% on room air, blood glucose 157mg/dL. He is taken to CT scan which reveals an intracerebral hemorrhage. Upon return to the ED, additional labs have resulted, including BMP and CBC which are all within normal limits.

• What is the most appropriate action to take regarding DG’s blood pressure?

DG is a 72yo male (82kg, 68”) with past medical history of hypertension, hyperlipidemia, and type 2 diabetes for which he takes losartan 50mg po daily, atorvastatin 40mg po daily, metformin 1000mg po bid, sitagliptin 50mg po bid, and aspirin 81mg po daily. He is allergic to penicillin (rash). He presents to your emergency department for altered mental status and reports a severe headache. He denies any falls or other recent trauma. Labs and vital signs are as follows: BP 198/104 mmHg, HR 73, RR 18, O₂ saturation 97% on room air, blood glucose 157mg/dL. He is taken to CT scan which reveals an intracerebral hemorrhage. Upon return to the ED, additional labs have resulted, including BMP and CBC which are all within normal limits.

• The treating provider asks you if they should administer platelets to reverse DG’s aspirin. What is the most appropriate response?