A film by Robyn Symon

Host a Screening of DO NO HARM

Int J Med Rev Case Rep. Online First

http://mdpub.net/?mno=315

doi: 10.5455/IJMRCR.Opsoclonus-Myoclonus-Chikungunya

Indications for Chest ultrasound include:

1.To differentiate white out of pleural effusion from consolidation

2. Bedside detection of anomalies to avoid transporting critically Ill patient and faster ,dynamic picture

3.Guidance for diagnostic and therapeutic thoracentesis.

 A 3.5 to 5.0 MHz transducer.

Cardiac transducers are particularly effective allowing scanning between rib interspaces.

Typical Position in Critically Ill patient:- Supine with the ipsilateral arm held across the chest towards the opposite side.

Method :-The transducer is oriented to scan between the ribs. The A lines and B lines are shown below:-

A lines:- A lines are horizontal lines that are brightly echogenic and located between the rib shadows when the probe is positioned longitudinally

B lines:- Pleural ultrasound image depicting B lines (“comet tail artifact”), which are seen in acute pulmonary edema and acute respiratory distress syndrome. The presence of B lines would provide an alternate explanation for increased density seen on the chest radiograph, other than pleural fluid.

Lung sliding — The sonographic effect of lung sliding (also known as lung gliding or the lung sliding sign) is created by movement of the lung relative to the chest wall during respiration . The sonographic appearance is that of a thin, bright line moving horizontally along the pleural line with a wave-like pattern located above (towards the chest wall) and a granular pattern below. Lung sliding is an indirect sign indicating adherence of the visceral pleura to the parietal pleura. When air separates the two pleural layers as in a pneumothorax, the movement disappears.

In addition the Blue Protocol can be downloaded from this link https://com-anest.sites.medinfo.ufl.edu/files/2015/06/2015-BLUELung.pdf which can be summarized as below:-

• Predominant A lines + lung sliding = Asthma/COPD
• Multiple predominant B lines anteriorly with lung sliding = Pulmonary Edema
• Normal anterior profile + DVT= PE
• Anterior absent lung sliding + A lines + lung point = Pneumothorax (PTX)
• Anterior alveolar consolidations, anterior diffuse B lines with abolished lung sliding, anterior asymmetric interstitial patterns, posterior consolidations or effusions with out anterior diffuse B lines = Pneumonia

• A lines:
  • Appear as horizontal lines
  • Indicate dry interlobular septa.
  • Predominance of A lines has 90% sensitivity, 67% specificity for pulmonary artery wedge pressure <= 13mm Hg
  • A line predominance suggests that intravenous fluids may be safely given without concern for pulmonary edema
• B lines (“comets”):
  • White lines from the pleura to the bottom of the screen
  • Highly sensitive for pulmonary edema, but can be present at low wedge pressuresThe  hypothesized  physical  and  anatomic  basis  of  echocardiographic  lung  comet  tails.  Reflections  of  the  ultrasound  beam  between  thickened  interlobular  septa  and  the  pleura  generate  a  resonance  signal  over  a  prolonged time.  The  increased  return  over  time  is  interpreted  by  the  ultrasound  machine  as  a  hyperechoic  structure  originating deeper  in  the  tissue  and  is  displayed  as  a  comet-tail  on  the  ultrasound  screen.  (Illustrations  and  images  from  Jambrik et  al.  Usefulness  of  ultrasound  lung  comets  as  a  nonradiologic  sign  of  extravascular  lung  water. 
  • Lung Abscess 

 This video shows a small pleural effusion and adjacent alveolar consolidation of the lung. With each inspiration, aerated lung is interposed into the imaging window with loss of visualization of the underlying structures. This is termed the curtain sign. The 3.5 MHz transducer is in longitudinal orientation and placed perpendicular to the chest wall to scan through the 8th intercostal space in the left mid-axillary line.

Cardiac output (CO) monitoring using oesophageal Doppler monitoring (ODM):

A.Uses frequency shifts in reflected sound waves to estimate flow velocity

B.Will overestimate values of stroke volume (SV) and CO if the probe is poorly positioned

C.Can be used in children

D.Does not measure blood flow to the head or arms

E. Requires measurement or estimation of aortic cross-sectional area.

All are true except B.

An animation illustrating how the Doppler effect causes a car engine or siren to sound higher in pitch when it is approaching than when it is receding. The pink circles represent sound waves.
The Doppler effect (or the Doppler shift) is the change in frequency of a wave (or other periodic event) for an observer moving relative to its source. It is named after the Austrian physicist Christian Doppler, who proposed it in 1842 in Prague.

To understand what happens, consider the following analogy. Someone throws one ball every second at a man. Assume that balls travel with constant velocity. If the thrower is stationary, the man will receive one ball every second. However, if the thrower is moving towards the man, he will receive balls more frequently because the balls will be less spaced out. The inverse is true if the thrower is moving away from the man. So it is actually the wavelength which is affected; as a consequence, the received frequency is also affected. It may also be said that the velocity of the wave remains constant whereas wavelength changes; hence frequency also changes.

When the probe has been placed and focused , blood f low velocity can be calculated based on the Doppler principle. Emitted ultrasound is scattered by erythrocytes travelling in the descending aorta and partially reflected back to the probe.When ultrasound is reflected by a moving object such as erythrocytes, the frequency of reflected ultrasound is higher than the emitted frequency when erythrocytes move towards the probe and lower when they move away from the probe . Erythrocyte velocity is directly proportional to the Doppler frequency shift (Df), i.e. the discrepancy between transmitted frequency (fT) and received frequency. This relationship is described by the Doppler equation : Blood flow velocity (v) can now be calculated from the frequency shift, because other factors that determine velocity are basically known and constant (c is the velocity of ultrasound waves in body tissue, fT the transmitted frequency and θ is the angle between ultrasound beam and blood flow). The angle θ is not precisely known, however, it closely approximates the angle with which the ultrasound transducer is mounted to the central axis of the probe (i.e. 45° with the CardioQ device), because the oesophagus and aorta run nearly parallel at mid-thoracic level.

Technical limitations derive from the blood flow velocity measurement itself as well as the assumptions needed to translate velocity into CO. The intensivist needs to be aware of these limitations, as there are conditions in which TED derived measurements may not necessarily be reliable. The measurement of blood flow velocity assumes that all erythrocytes travel in the same direction and at the same speed. Indeed, in healthy subjects, descending aortic blood flow is usually laminar with a relative uniform velocity profile over the aortic cross section . However, skewed velocity profiles and rotational blood flow in the descending aorta has also been described. Non-laminar f low is likely to occur in patients with pathology of the aorta or aortic valve. Another important aspect in velocity measurement is the angle with which ultrasound is insonated into the aorta, because the cosine of this angle makes part of the Doppler equation. As described earlier this angle is not precisely known .but is assumed to equal the angle with which the ultrasound transducer is mounted to the central axis of the probe. However, this assumption may not hold true in those patients who have an altered relationship between the aorta and oesophagus, e.g. because of previous surgery, tumour mass or severe scoliosis. Due to the non-linear character of the cosine function, deviations in the actual angle from the assumed angle will result in relatively small errors at small degrees but become unacceptably high when the angle of insonation exceeds 60°. With the angle of 45°, which the CardioQ uses, a deviation of 1°, 5° and 10° in the actual from the assumed angle results in measurement errors of approximately 2%, 8% and 16%, respectively. Translation of blood flow velocity into CO requires estimations of the aortic cross sectional area as well as the distribution of blood flow between the descending aorta and supraaortic arteries. However, neither of the above measurements is actually taken. Rather, the CardioQ uses a nomogram and provides a calibration factor to translate descending aortic blood flow velocity to total left ventricular cardiac output over a wide range of patient conditions. However, a nomogram derived from average values in a population does not always accurately predict individual values. Moreover, the nomogram neither accounts for changes in aortic diameter nor in changes of blood f low distribution. Aortic diameter may change due to changes in blood volume and blood pressure.Furthermore, blood f low distribution may also change, e.g. due to changes in vascular tone caused by pharmacologic action, sympathetic blockade, blood loss, sepsis or anaphylaxis.Despite these limitations, trend monitoring should generally be possible if the basic conditions remain constant. However, it is important to realize that changes in the basic condition, e.g. sudden changes of aortic diameter and blood flow distribution due to acute haemorrhage, may lead to inconsistent or even misleading CO readings . Thus, the intensivist needs to be aware of the technical limitations of TED to avoid misinterpretation of displayed data.. If θ is 0, cos θ is 1, but as θ gets progressively closer to 90° the velocity of blood flow becomes more and more underestimated. At 90° cos θ = 0 (velocity is not measured).

Oesophageal Doppler:
a.Utilises the Doppler shift to measure blood velocity.
B.Velocity of blood (m/s) in the descending aorta can be calculated provided the aortic cross-sectional area is known.
C.It is assumed 70% of cardiac output is distributed caudally to the descending aorta.
D. Doppler probes must be removed after 1 week.
E. Is accurate when used with a working epidural.

A & C are True only.

Oesophageal Doppler:
A.Peak velocity is a good estimate of myocardial contractility.
B.By age 70 peak velocity falls to less than 50cm/second.
C. Stroke distance (SD) is the area under the velocity-time curve and provides an estimate of stroke volume.
D .An increase in stroke volume of less than 5-10% with a fluid bolus suggests hypovolaemia.
E. A corrected flow time (FTc) greater than 400ms is due to hypovolaemia.

A & C are true only
Peak velocity declines with age, with normal values of 90-120cm/s at the age of 20, falling to 50-80cm/s by the age of 70.

Concerning corrected flow time (FTc) measured by oesophageal Doppler:

A.An FTc less than 330ms may be due to excessive metaraminol use.
B.An FTc of up to 400ms may be normal in anaesthetised patients.
C.A normal FTc is 230 to 260ms.
D.A low peak velocity and FTc less than 330ms may be due to increased preload.
E.Goal-directed therapy using oesophageal Doppler protocols may improve outcomes for surgical patients.

A,B and E are true
FTc is prolonged by vasodilatation, and therefore an FTc of up to 400ms may be considered normal in anaesthetised patients, in particular, in those with a working epidural in situ, due to the vasodilatation that is encountered.
Increased afterload may result in a low peak velocity and low FTc.

A 74-year-old lady with a history of ischaemic heart disease and severe congestive cardiac failure is admitted to the ICU with hypotension and presumed sepsis. She is sedated and ventilated in pressure support mode. On examination she is confused, BP is 85/35mmHg, HR is 115bpm (sinus tachycardia), Sp02 is 95% on 60% oxygen. Arterial blood gas analysis shows a lactate of 4.3mmol/L (39mg/dL). Which is the BEST guide to the need for further intravenous fluid replacement?

A.Response of oesophageal Doppler to passive leg raising. B.Insertion of a pulmonary artery catheter and pulmonary artery occlusion pressure measurement.
C.Titrate fluid resuscitation against repeated blood lactate measurements.
D.Assess pulse pressure variation.
E.Urine output measurement.

The following assumptions are made when determining stroke volume using an oesophageal Doppler probe:
a. 70% of total cardiac output passes the probe.
B. The ascending aorta runs parallel to the oesophagus.
C.The diameter of the aorta is constant throughout systole.
D.Haematocrit is unchanged between measurements.

A 58-year-old man is ventilated on the ICU following a Whipple’s pancreatoduodenectomy. He is hypotensive (BP 85/65mmHg) and tachycardic (HR 120bpm). Initial oesophageal Doppler measurements include a flow time corrected (FTc) of 290ms, which rises to 310ms following a 250ml fluid challenge. Which statement is TRUE?
a. A low FTc invariably means more fluid is required.
B.This patient has normal cardiac contractility.
C. FTc is a marker of afterload. D. Fluid should be titrated to an FTc of 340ms.
E. Dobutamine should be started at this point.

A 42-year-old woman is admitted to the ICU generally unwell 1 week following abdominal surgery. She is oliguric, hypotensive (BP 80/35mmHg) and tachycardic (HR 130bpm). An oesophageal Doppler probe is sited, showing: flow time (corrected) 380ms, peak velocity 110cm/s, stroke volume 90m1. Which of the following statements is TRUE? a. A fluid challenge should be administered.
B.Cardiac contractility is impaired.
C.A cautious dose of frusemide should be given.
D.The measured (uncorrected) flow time will be greater than 380ms.
E.The data are consistent with massive pulmonary embolism

Which one of the following is the correct sequence
in increasing order of their basal blood supply
(ml/min/100g of tissue) – (ICS 98)
a) Heart, brain, kidney
b) Brain, Kidney, Heart
c) Kidney, heart, brain
d) Brain, Heart, Kidney

Liver has the maximum 02 consumption (51m1
mt)the next organ to have the maximum 0 2
oxygen(ml/mt) is – (AIIMS 85)
a) Heart b) Brain
c) Skeletal muscle d) Kidney

Capillaries with tight junctions allowing the
passage of only small molecules are found in –
a) Brain b) Skin (Delhi 96)
c) Kidney d) Muscle

Most permeable capillaries – (JIPMER 99)
a) Post pituitary b) Liver
c) Kidney d) Small intestine

True about blood flow in various organs –
a) Liver > Kidney > brain > heart (PGI 99)
b) Liver > brain > Kidney > heart
c) Kidney > brain > heart > . liver
d) Liver > heart > brain > kidney

In metabolic acidosis, true about urinary change
is – (UPSC 83, Delhi 84)
a) Increase in ammonia
b) Decrease in ammonia
c) Decrease in lactic acid
d) HCO3

Normal filtration fraction is — (PGI 84)
a) 0.9 b) 0.2
c) 0.6 d) 1.0

Lung volumes and capacity measurements.Top left: A cartoon figure representing lung space divided into lung volumes. Dead space refers to areas where gas exchange does not occur; all other spaces are defined in the accompanying table. Top right: Spirometer recordings are shown with marked lung volumes and capacities. Table at bottom defines individual measurements and values from the top graphs. Note that residual volume, total lung capacity, and function residual capacity cannot be measure with a spirometer.[Widmaier EP, Raff H, Strang KT: Vander’s Human Physiology: The Mechanisms of Body Function, 11th ed. McGraw-Hill, 2008]

Pressure-volume curves of the isolated lung, isolated chest wall, combined respiratory system, inspiratory muscles, and expiratory muscles. FRC, functional residual capacity; RV, residual volume; TLC, total lung capacity

Flow-volume curves in different conditions: O, obstructive disease; R(P), parenchymal restrictive disease; R(E), extraparenchymal restrictive disease with limitation in inspiration and expiration. Forced expiration is plotted in all conditions; forced inspiration is shown only for the normal curve. TLC, total lung capacity; RV, residual volume. By convention, lung volume increases to the left on the abscissa. The arrow alongside the normal curve indicates the direction of expiration from TLC to RV.

Questions:-

Which tends to decrease with increasing
age – (AIIMS 85)
a) Vital capacity b) Systolic B.P.
c) Pulse pressure d) Residiial volume

All of following tend to increase in old age
except – (Delhi 96)
a) Residual volume b) Systolic BP
c) Pulse pressure d) Vital capacity

The hall mark of generalised obstructive lung
disease is- (PGI 80, AIIMS 81)
a) Reduced tidal volume
b) Reduced residual volume
c) Reduced timed vital capacity
d) Reduced vital capacity

For diagnosis of obstructive airway disease which
of the following measurement is usuala)
Vital capacity (PGI 81, UPSC 86)
b) Timed vital capacity
c) Tidal volume
d) Blood gas analysis

The hallmark of generalized obstructive disease
is reduced (PGI 81, Delhi 84)
a) Vital capacity
b) Arterial 02 saturation
c) Timed vital capacity
d) Tidal volume

Spirometry is useful to calculate all the except –
a) Tidal volume b)FEV (AI 97)
c) Residual volume d) Vital capacity

Total vital capacity is decreased but timed vital
capacity is normal in — (JIPMER 80, UJPSC 87)
a) Bronchial Asthma b) Scoliosis
c) Chronic bronchitis d) All of the above

In diffuse pulmonary fibrosis all are decresed excepta)
Vital capacity (AIIMS 97)
b) Diffusion capacity
c) Compliance
d) Alveolar arterial 0 2 gradient

All are seen in emphysema except – (Kerala 95)
a) Decreased vital capacity b) Hyper inflation
c) Rhonchi d) Damage to alveoli

In COPD all are affected except— (A189)
a) FEV b) Ratio of FEV to vital capacity
c) FVC d) None

Lung function test in emphysema reveals -(PGI 01)
a) Increased vital capacity
b) Decreased diffusion capacity for carbon monoxide
c) Increased diffusion capacity for carbon monoxide
d) Decreased total lung capacity
e) FEV, decreased

Which is not characterstic of interstitial lung
diseasea)
Decreased vital capacity
b) Decreased total lung capacity
c) Increased diffusion capacity of carbon
d) All

Vital capacity of the lung is very low in
a) prone b) lithotomy c) trendelenberg d) supine

All of the following differ in males and females except
(a) Tidal volume (b) vital capacity (c) residual volume (d) Expiratory reserve volume

Trendelenberg position produces decrease in all of the following except: AIIMS – 04
a. Vital Capacity b. Functional residual capacity c. Compliance d. Respiratory rate

Which is not increased in pregnancy UP. 96
(a) vital capacity (b) blood volume (c) Extracellular fluid (d) weight

In upper air way obstruction all of the following changes
are seen except :
(A) Decreased Maximum breathing capacity
(B) RV decreased
(C) Decreased FEV
(D) Decreased vital capacity

Tidal volume is calculated by
A. Inspiratory capacity minus the inspiratory reserve .
volume
B. Total lung capacity minus the reserve volume
C. Functional residual capacity minus residual
volume
D. Vital capacity minus expiratory reserve volumes

A patient presents with decreased vital capacity and
total lung volume. What is the most probable
diagnosis ?
A. Bronchiectasis
B. Sarcoidosis
C. Cystic fibrosis
D. Asthma

Volume of air taken into the lungs in normal
respiration is known as – (PGI 88)
a) Vital capacity
b) Timed vital capacity
c) Tidal volume
d) Inspiratory reserve volume

The following are acceptable as normal resultsa)
PO, 100 mm Hg (JIPMER 79, AIIMS 85)
b) V/Q ration 1.0
c) Resting tidal ventilation 5L/min
d) FEVI 60% of vital capacity

All of the following differ in males and females
except – (Assam 95)
a) Tidal volume
b) Vital capacity
c) Residual volume
d) Expiratory reserve volume

Vital capacity is a measure of (Kerala 91)
a) Total volume
b) Inspiratory reserve volume plus expiratory reserve
volume
c) Tidal volume plus inspiratory reserve volume plus
expiratory reserve volume
d) Expiratory reserve volume plus reserve volume

The instrument used for measuring the vital
capacity and FEV is – (JIPMER 78, DNB 90)
a) Wright peak flow meter
b) Vitalograph
c) Carlen’s catheter
d) None of the above

Vital capacity is – (ROHATAK 97)
a) Tidal Volume+Expiratory Reserve Volume
b) Tidal Volume+Inspiratory Reserve Volume
c) I.R.V+E.R.V.
d) T.V.+I.R.V.+E.R.V.
e) Tidal volume

Physiological effects of emphysma may include
all of the following, except – (SGPGI 05)
a) increased vital capacity
b) Irregular ventilation
c) Impaired gas diffuse
d) Pulmonary hypertension

Pulmonary function abnormalities in interstitial
lung diseases include all of the following except –
a) Reduced vital capacity (AIIMS NOV 05)
b) Reduced FEV I/FVC ratio
c) Reduced diffusion capacity
d) Reduced total lung capacity

A 12 year old girl presents with acute rheumatic
fever and carditis with severe mitral insufficiency.
She is likely to have which of the following functional
disability ? (AIIMS Nov 07)
a) Increased residual volume
b) Increased PEFR
c) Increased TLC
d) Decreased functional residual capacity

In cryptogenic fibrosing alveolitis which is not seena)
Decreased lung capacity- (PGI 89)
b) Decreased diffusing capacity
c) Decreased arteliolar oxygen tension
d) Decreased FEV I/FVC ratio

Most common cause of hypoxemia is- (Kerala 2K)
a) Lowered inspired P0 2
b) Hypoventilation
c) Intracardiac shunting
d) Ventialtion perfusion mismatch
e) Decreased diffusing capacity

Total lung capacity depend on – (Al 98)
a) Size of airway b) Closing tidal volume
c) Lung compliance d) Residual volume

True about interstitial lung disease – (PG1 :June 07)
a) Decreased FVC
b) Decreased FEV,
c) Decreased diffusion capacity
d) Presence of end inspiratory crackles

Which pulmonary function change is not seen in
COPD- (Al 92)
a) Decreased Residual volume
b) Decreased FEV
c) Low mid expiratory flow rate
d) Decreased diffusion capacity

Regarding pectus Excavatum all are true except –
a) Gross CVS dysfunction (PGI 9 7)
b) Depression in chest
c) Cosmetic defromity
d) Decrease in lung capacity

An 18 year old male presents with pectus excavatum.
He denies history of any dyspnoea or chest pain. On
examination there is mild pectus excavatum and
intermittent wheezing on exertion. Surgery in this
patient is indicated if he has – (AIIMSNov 07)
a) FEV i/FVC less than 0.60
b) Limiation of maximum inspiration during exercise
c) Peak physical work capacity 60% of

Which muscle is not punctured during a thoracic
procedure in the mid-axillary line ? (AIIMSNov 07)
a) Internal intercostal
b) External intercostal
c) Transverse thorasis
d) Innermost intercostals

All the following are true about Chronic Obstructive
lung disease except
A. Decreased FeV i
B. Decreased MEFR
C. Increased RV
D. Decreased diffusion capacity

Total lung capacity depends upon :
(A) Size of airway
(B) Closing volume
(C) Lung compliance
(D) Residual volume

Normal functional Residual capacity is – (Al 93)
a) 0.5 Litres b) 1.5 Litres
c) 2.2 Litres d) 4.0 Litres

Nitrogen washout method is used for estimatinga)
Dead space volume (PGI 98)
b) Functional residual capacity
c) Tidal volume
d) Diffusion capacity

Guedels stages of anaesthesia is seen classically with
a) Ether b) Chloroform c) Morphine d) Nitrous oxide e) halothane

The term anasthesia was coined by
a) Guedel b) Morton c) Claude d) Oliver Wendel Holmes.

Intravenous Regional Anaesthesia was described by
a) Macintosh b) Magill c) Guedel d) Bains e) Bier

The first public demonstration of anesthesia was by
a) John snow b) 1. W magill c) Thomas morton d) H.G. Wells

First spinal anaesthesia was given by TN 2001
a) August Bier b) Sicard c) Morton d) Priestly

Ether was invented by
a) Morton b) Priestly c) Wells d) Simpson

Nitrous oxide was discovered by
a) J.B.Priestly b) Humphry Davy c) I4orace wells d) P.C.Barton e) G.Q. cotton

In 1937, Guedel published his classic description of the clinical signs of ether anesthesia. He used clear physical signs involving somatic muscle tone, respiratory patterns, and ocular signs to define four stages.

In the first stage, analgesia, characterized by slow, regular breathing with the diaphragm and intercostal muscles and the presence of the lid reflex, the subject experiences complete amnesia, analgesia, and sedation.

In the second stage (delirium), the subject experiences excitement, unconsciousness, and a dream state with uninhibited activity. Ventilation is irregular and unpredictable. Reflex dilatation of the pupils occurs, the lid reflex is intact, and the risk of clinically important reflex activity (e.g., vomiting, laryngospasm, or arrhythmias) increases.

The third stage (surgical anesthesia) consists of four progressive planes. Plane 1 is characterized by slight somatic relaxation, regular periodic breathing, and active ocular muscles. During plane 2, breathing changes, inhalation becomes briefer than exhalation, and a slight pause separates inhalation and exhalation. The eyes become immobile. In plane 3, the abdominal muscles are completely relaxed, and diaphragmatic breathing is very prominent. The eyelid reflex is absent. In plane 4, the intercostal muscles are completely paralyzed, and paradoxic rib cage movement occurs. Breathing is irregular, and pupils are dilated.

In Guedel’s fourth stage (respiratory paralysis), muscles become flaccid, and eyes widely dilate. Cardiovascular and respiratory arrest occurs, as does cardiovascular collapse.
In 1954, Artusio expanded Guedel’s description of ether analgesia (stage 1) into three planes. In plane 1, the patient has no amnesia or analgesia. In plane 2, the patient has total amnesia and partial analgesia. In plane 3, the patient has complete analgesia and amnesia, but is comfortable and responsive to verbal stimulation; there is little depression of reflexes. Artusio observed that once patients were anesthetized past stage II (delirium) to the deeper anesthesia of stage III, they could be brought back and forth between stage III and plane 3 of stage II without ever exhibiting stage II. The clinical signs of depth of anesthesia defined by Guedel and others had significant practical utility for the administration of ether, cyclopropane, and chloroform anesthesia.

MUSCLE RELAXANTS

Succinyl choline is a muscle relaxant which act by
a) persistent depolarisation b) competitive blockade c) mechanism of action uncertain d) a and b

Muscle relaxant contra indicated in CRF

a) Gallamine b) Succinylcholine c) Tubocurare d) Pancuronium

Muscle relaxant not to be used in liver failure is PGI 88
a) Pancuronium b) DTC c) Suxamethonium d) Decamethonium

Decamethonium (Syncurine) is a depolarizing muscle relaxant or neuromuscular blocking agent

Site of-action of anaesthetic muscle relaxants is PGI 88
a) Myoneural junction b) central c) ascending reticular activating system d) Red nucleus

Muscle relaxant most commonly implicated in malignant hyperpyrexia a) DTC b) Gallamine c) Succinylcholine d) Decamethanium

Decamethonium (Syncurine) is a depolarizing muscle relaxant or neuromuscular blocking agent

The muscle relaxant effect of succinylcholine last for
a) 1 minute b) 2 minutes c) 3 to 5 minutes d) 10 minutes

Shortest acting muscle relaxant is a) Curare b) Pancuronium c) Gallamine d) Succinylcholine

The most effective muscle relaxant is a) Ether b) N20 c) Halothane d) Trilene

Which of the following are antagonists of non depolarising muscle relaxants PG184
a) Neostigmine b) Edrophoium c) Pyridostigmine d) Cyclopyronium

To decrease awareness in general anaesthesia, the following is given PG! 89
a) increase depth of anesthesia b) more muscle relaxant used c) promedicate with morphine d) premedicate with diazepam

Which muscle relaxant does not cross the placental barrier in significant concentrations a) Succinyl choline b) D- tubocurare c) Gallamine d) all

The following are muscle relaxants except
a) Decamethonium b) Suxamethonium c) hexamethonium d) Pancuronium

Hexamethonium is a depolarising ganglionic blocker,^[1] a nicotinic nACh (N_N) receptor antagonist that acts in autonomic ganglia by binding mostly in or on the N_N receptor, and not the acetylcholine binding site itself. It does not have any effect on the muscarinic acetylcholine receptors (mAChR) located on target organs of the parasympathetic nervous system but acts as antagonist at the nicotinic acetylcholine receptors located in sympathetic and parasympathetic ganglia (N_N)

It was formerly used to treat disorders, such as chronic hypertension, of the peripheral nervous system, which is innervated only by the sympathetic nervous system. The non-specificity of this treatment led to discontinuing its use.^[3]

The use of inhaled hexamethonium, an unapproved drug, in a normal volunteer during a medical study is believed to have caused or contributed to her death^[4][5] in light of the presence of abnormal "ground glass opacities" on her chest X-ray

Which is not true of Non depolarising skeletal muscle relaxant
a) causes Histamine release b) Hypothermia
c) fasciculation of muscle d) ganglion blockade

In children, which of the following is preferred for intubation: AIIMS 84, 85, 86
a) Halothane b) Curare c) Muscle relaxant d) None of the above

Muscle relaxant action of scoline is not prolonged by
a) ethylene chloride b) chloroform c) enflurane d) halothane.

Non-depolarising relaxants may be reversed by
a) atropine b) succinyl choline c) neostigmine d) calcium chloride.

Shortest acting muscle relaxant
a) pancuronium b) Atracurium c) Mivacuriun d) Vecuronium

Muscle relaxant in kidney failure
a) atracurium b) pancuronium c) Gallamine d) all of the above

In the immediate post operative period the common cause of respiratory
insufficiency could be because of the following, EXCEPT AIIMS 2003
a) Residual effect of muscle relaxant b) Overdose of narcotic analgesic
c) Mild hypovalemia d) Myocardial infarction

21 years old lady with a history of hypersensitivity to neostigmine is posted for an elective casearean section under anesthesia. The best muscle relaxant of choice in this patient should be AIIMS 04
a) Pancuronium b) Atracurium c) Recuronium d) Vecuronium

Shortest acting on depolarizing muscle relaxant is: SGPGI – 05
a. Acetylcholine b. Succinylcholine c. Mivacurium d. Pancuronium

Muscle relaxant in hepatic failure Manipal 2006
a) Atracurium b) Gallium
c) Tubocurarine d) Scoline

Muscle relaxant in hepatic and renal failure Manipal 2006
a) Atracurium b) Gallium c) Tubocurarine d) Vecuronium

Which drug is contra indicated in myasthenia gravis Al 88
a) Succinyl choline b) Tubocurare c) Neostigmine d) Halothane e) Cyclopropane

Post operative aching of muscles occur with the use of a) succinyl choline b) panc’uronium c) Gallamine d) DTC

Succinylcholine causes all except a) Muscle pain b) Malignant hyperthermia c) Hyperkalemia d) Hypokalerriia

Which drug is totally excreted by the kidney a) Gallamine b) DTC c) Succinyl choline d) alcuronium

Succinylcholine causes intraocular tension TN 90
a) Decreased b) Normal c) Increased cl) Variable

Fasciculations with succinylcholine are first seen over PGI 80, Delhi 86, 93
a) Eyelids b) Limbs c) Neck d) Abdomen

Uterine tetanic contraction is most rapidly treated with: AIIMS 79, BHU 87
a) Spinal anesthesia b) Halothane c) D-tubocurarine d) Succinylcholine e) Surgical incision

Succinyl choline is short acting due to
a) rapid excretion b) poor absorption c) rapid hydrolysi- d) none.

A high potassium level with succinyl choline for intubation occurs with AIIMS 99
a) Renal failure b) Chronic paraplegia c) Fracture femur
d) Myocardial infarction

Psuedocholine esterase is acted upon by J&K 2001
a) Pancuronium b) Succinyl choline c) Choline d) Atracurium

The administration of succinylocholine to a paraplegic patient led to the
appearance of dysarrhythmias, conduction abnormalities and finally cardiac
arrest. The most likely cause is: AIIMS 2003
a) Hypercalcemia b) Hyperkalemia c) Anaphylaxis d) hypermagnesemia

Not used to the patient with penetrating eye injury Orissa 2004
a) Pancuronium b) Succinyl choline c) d IC A:racurium

Aggravation of myasthenia is a feature of all the
following drugs except – (MAHE 98)
a) Gentamic in b) Neomycin
c) Edrophonium d) Succinyl

Drug of choice for myaesthenia gravis – (PGI 99)
a) Gallamine b) Succinylocholine
c) D. tubocurare d) Pyridostigmine

Use of succinylcholine in ECT: PGI 78, AllMS 84
a) Safer than curare b) May cause prolongation of apnoea c) Reduces
possibility of fractures d) All are true

Injection of which is followed by pain Burdwan 2K
a) Succinyl choline b) Neostigmine c)Curare d) Morphine

A young boy undergoes eye surgery under day case
anesthesia with succinyl choline and propofol and
after 8 hours he starts walking and develops muscle
pain. What is the likely cause?
A. Early mobilization
B. Due to the effects of eye surgery
C. Succinyl choline
D. Propofol

Hyperkalemia is a dangerous complication when
succinyl choline is given to patient with –
a) Spinal cord injury (PGMCET 07)
b) Head injury
c) Thoracic trauma
d) Abdominal trauma

True about Pseudocholineesterase
a) Present in neuromuscular junction
b) Level is increased in pregnancy
c) Succinylcholine is metabolized
d) Organophosphorus inhibit it

The enzyme pseudocholinesterase acts on
a) Decamethonium b) Tubocurarine c) Galiamine d) Suxamethonium

5 year old suffering from Duchenne muscular dystrophy has to undergo
tendon lengthening procedure. The most appropriate anaesthetic would be: Al 2003
a) Induction with intravenous thiopentone and N 20; and halothane for maintenance
b) Induction with intravenous suxamethonim and N 20; and oxygen for maintenance
c) Induction with intravenous suxamethonium and N 2 0; and halothane for maintenance
d) Inhalation induction with inhalation halothane and N 2 0; and oxygen for maintenance

During rapid sequence induction of anesthesia: Al 2003
a) Sellick’s maneuver is not required b) Pre — oxygenation is mandatory
c) Suxamethonium is contraindicated
d) Patient is mechanically ventilated before endotracheal intubation

Which of the following anesthetic agents doesn’t trigger malignant hyperthermia? All India 2006
a) Halothane. b) Isoflurane. c) Suxamethonium. d) Thiopentone.
( Ref. : Katzung 9th Edition Page 410)

Which of the following agents is used for the treatment of postoperative shivering? All India 2006
a) Thiopentone. b) Suxamethonium. c) Atropine. d) Pethidine.

Rapid termination of the action of Suxamethonium
is due to – (MAHE 98)
a) Rapid renal elimination
b) Enzymatic degradation by pseudocholinesterase
c) Metabolized by liver to acetyl CoA
d) Redistribution

Key Points for IV anesthetic agents:-

Thiopental:-

Barbiturates are almost water insoluble.

Dose:- 3-5 mg/kg

No analgesic action and may be antanalgesc at low doses.

Neuroprotection.

Transient apnoea is common.Centrlly mediated respiratory depression.Laryngeal reflexes remain intact. Larngeal spasm can occur.

Slow recovery.

Enzyme inducers.

C/Ied in pophyria,status asthmaticus,severe shock,pericardial tamponade and uncompensated myocardial disease.

Etomidate:-

Two Isomers.

S-isomer is anesthetic.

Dose:- 0.3 mg/kg

Doesn’t release histamine.

CBF,CBM,CMRO2 and ICP fall.

Excitatory phenomenon may be seen with induction.Premedicate with Midazolam.

Induction agent of choice for poor risk patients with cardiorespiraory disease.

Etomidate doesn’t blunt the sympathetic response to laryngoscopy and inubation unless combined with a potent opioid analgesic.

The increased mortality in critically ill patients sedated with etomidate infusion due to inhibitory effect on cortisol synthesis even after a single induction dose of etomidate.

Inspite of its side effect profile,etomidate remains a valuable induction drug for specific indications such as patients with severe cardiovascular and cerebrovascular disease.

Etomidate is associated with high incidence of postoperative nausea and emesis when used in combination with opioids for short outpatient procedures.

Propofol:-

Highly Lipid soluble.

1% or 2% emulsion in 10% soyabean oil with 1.2% egg phosphatide as the emulsifying agent.

Dose:- 1-2.5 mg/kg for induction.Lower dose should be used in elderly.

Sedation may be produced with 0.2 mg/kg bolus dose intravenously or infusion of 1 mg/kg/hr.

Co-induction with either an opioid(3ug/kg) or midazolam(1-3 mg) enables the induction dose to be reduced.

Rapidly and extensively metabolized.

Clearance rate exceeds hepatic blodd flow suggesting that an extrahepatic elimination route contributes to its clearance.

Decreases CBF,CM and CMRO2.

Analogous to the barbiturates,Children require higher induction and maintenance doses of propofol on a milligram-per kilogram basis as a result of their larger central distribution volume and higher clearance rate.

Elderly and patients with poor health require lower induction and maintenance doses of propofol.

Antioxidant Potential.Free radical scavenger.Its neuroprotective effect may be partially related to this antioxidant potential of propofol’s phenol ring structure,which may act as a free radical scavenger,decreasing free-radical induced lipid perodixation.

Propofol has been reported to inhibit phagocytosis and killing of bacteria in vitro and to reduce proliferative responses when added to lmphocytes from critically ill.

Anti-Emetic.Nausea and vomiting very uncommon.

Direct Myocardial Depressant.Arterial and Venodilatation without compensatory tachycardia.Arterial hypotension is more pronounced in the hypertensive patient.Alters the baroreflex resulting in smaller increase in heart rate for a given decrease in arterial pressure.? A central anticholinergic response may be responsible for bradycardia.

Green colour of urine due to oxidation to quinol derivative.

PROPOFOL INFUSION SYNDROME:-Identified in pediatric ICU.Metabolic acidosis,acute cardiomyopathy and skeletal myopathy associated with prolonged (>48 hrs) high dose (>5mg/kg/hr) infusion.It appears to be due to failure of FFA metabolism secondary to inhibition of both FFA entry into mitochondia and specific sites in the respiratory chain.

Midazolam:-

*Propofol Half Life in minutes

Dose:- 0.15 – 0.3 mg/kg for induction

Sedation:- Infusion 2-5 ug/kg/min in ICU.Higher maintenance infusion rates and prolonged administration will result in accumulation and prolonged recovery times. Lower infusion rates are sufficient to provide sedation and amnesia during local and regional anesthesia

Because of its high lipophilicity and short half-life, propofol has a rapid onset of action (1 to 2 minutes) and a short duration of action (10 to 15 minutes) compared with other sedative options. For patients receiving propofol infusions for longer than 72 hours, the wake-up time can extend to 30 to 60 minutes.

When infused over days for chronic sedation, the mean elimination half-life of 10 hours may increase to 30 hours as peripheral tissue stores release accumulated midazolam..

Inhibitors of CYP3A4, such as macrolide antibiotics, diltiazem, propofol, and fluconazole, reduce the metabolism of midazolam and prolong its seda-tive actions

Co-induction with a small IV dose (1-3 mg of midazolam) allows a reduction in the dose of propofol required for induction. and adds to the hypnotic and amnesic effects.

Two isomers-Open ring (water soluble)and closed ring(lipid-passage across BB barrier).

Midazolam is a water-soluble benzodiazepine that is available in an acidified (pH 3.5) aqueous formulation that produces minimal local irritation after iv or im injection.25 At physiologic pH, an intramolecular rearrangement changes the physicochemical properties of midazolam such that it becomes more lipid-soluble.

On IV injection a rise in PH changes it to closed ring form.

Amnesic effect greater than Diazepam.

Intranasal Midazolam more effective in terminating seizures than rectal diazepam.

Active Metabolites.

Low clearance.

Short terminal elimination half life.

Low steady state volume of distribution.

Confusional state after prolonged infusion in ICU-COMMON

CVS:- Stable when used in combination with opioid.

Ketamine:-

Dose:- 1-2 mg/kg IV for induction

25-100 ug/kg/min for maintenance of anesthesia.

Analgesic even at subanaesthetic doses.

Dissociative Anaesthesia:- Muscle tone maintained

Spontaneous respiration preserved

Pharyngeal reflexes preserved

Profound Analgesia and amnesia

Eyes open.

Involuntary movement is common

Useful in ASTHMATIC

UNPLEASANT EMERGENCE PHENOMENON RESTRICTS THE USEFULLNESS.

Increases ICP

Increases BP,HR,CO and myocardial oxygen demand.It also sensitizes the heart to small doses of epinephrine and can precipitate arrythmias.

The author wish to acknowledge the excellent guidance of Dr Kapil Chhabra, Consultant, Deptt. of Critical Care Medicine in this topic

Rapid Sequence Intubation

RSI is the cornerstone of modern emergency airway management and is defined as the virtually simultaneous administration of a potent sedative (induction) agent and an NMBA, usually succinylcholine, for the purpose of endotracheal intubation. This approach provides optimal intubating conditions, while minimizing the risk of aspiration of gastric contents.

Administration of 100% oxygen for 3 minutes of normal, tidal volume breathing in a normal, healthy adult results in the establishment of an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs.

FIGURE 1-7 The LEMON airway assessment method

A seizure (from the Latin sacire, "to take possession of") is a paroxysmal event due to abnormal excessive or synchronous neuronal activity in the brain.

The meaning of the term seizure needs to be carefully distinguished from that of epilepsy. Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process. This definition implies that a person with a single seizure, or recurrent seizures due to correctable or avoidable circumstances, does not necessarily have epilepsy. Epilepsy refers to a clinical phenomenon rather than a single disease entity, since there are many forms and causes of epilepsy.

Todds paralysis is seen in – (NIMHANS 88)
a) Head injury
b) Strokes
c) Epilepsy
d) Subarachnoid hemorrhage

Seen in Partial/Focal Motor Seizures.

IMPORTANT:-Focal seizures originate within networks limited to one cerebral hemisphere (note that the term partial seizures is no longer used).

Three additional features of focal motor seizures are worth noting:-

1.First, in some patients the abnormal motor movements may begin in a very restricted region such as the fingers and gradually progress (over seconds to minutes) to include a larger portion of the extremity. This phenomenon, described by Hughlings Jackson and known as a "Jacksonian march," represents the spread of seizure activity over a progressively larger region of motor cortex.

2.Second, patients may experience a localized paresis (Todd’s paralysis) for minutes to many hours in the involved region following the seizure.

3.Third, in rare instances the seizure may continue for hours or days. This condition, termed epilepsia partialis continua, is often refractory to medical therapy.

Tic douloureux is synonymous with- (Kerala 91)
a) Trigeminal neuralgia
b) Temporal lobe epilepsy
c) Glossopharyngeal neuralgia
d) Todds paralysis

The most common physical sign of cerebral
metastasis- (Karnat 98)
a) Epilepsy
b) Focal neurological deficit
c) Papilloedema
d) Visual defects

Bano Begum, 45 year old lady has typical hand and limb movements with abnormal smell sensation. She was not able to recall any of the events afterwards.Her most probable diagnosis? (AI 02)

a) Temporal lobe epilepsy b) Dislocation disorder
c) Fugue d) Conversion reaction

MOST IMPORTANT:-The range of potential clinical behaviors linked to focal seizures is so broad that extreme caution is advised before concluding that stereotypic episodes of bizarre or atypical behavior are not due to seizure activity. In such cases additional, detailed EEG studies may be helpful.

Stereotypical :- Designating behaviour which is repeated without variation irrespective of the particular circumstances.

Simple partial seizure is diagnosed by –
a) EEG b) BEAR (NIMHANS 2K)
c) CT scan d) MRI

Drug of choice for simple partial seizure is -(A197)
a) Sodium Valproate b) Carbamazepine
c) Phenobarbitone , d) Diazepam

Ethosuximide is used in the treatment of:
A. Tonic-clonic seizure
B. Absence seizure
C. Myoclonic seizure
D. Simple partial seizure

The drug carbamazepine is used for all except

a) MDP (AIIMS 97)
b) Partial seizures
c) Trigeminal neuralgia
d) Migraine

Carbamazepine (CBZ) is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia. It is also used off-label for a variety of indications, including attention-deficit hyperactivity disorder (ADHD), schizophrenia, phantom limb syndrome, complex regional pain syndrome, paroxysmal extreme pain disorder, neuromyotonia, intermittent explosive disorder, borderline personality disorder and post-traumatic stress disorder.

It has been seen as safe for pregnant women to use carbamazepine as a mood stabilizer, but, like other anticonvulsants, intrauterine exposure is associated with spina bifida and neurodevelopmental problems.

Ethosuximide is used in the treatment of- (AI 06)
a) Tonic-clonic seizure b) Absence seizure
c) Myoclonic seizure d) Simple partial seizure

Mesial temporal lobe epilepsy. The EEG suggested a right temporal lobe focus. Coronal high-resolution T2-weighted fast spin echo magnetic resonance image obtained through the body of the hippocampus demonstrates abnormal high-signal intensity in the right hippocampus (white arrows; compare with the normal hippocampus on the left, black arrows) consistent with mesial temporal sclerosis.

In status epilepticus the drug of choice is –
a) IV Phenytoin (NIMHANS 88)
b) IV ethosuximide
c) IV Phenobarbitone
d) IV diazepam

The duration of seizure activity sufficient to meet the definition of status epilepticus has traditionally been specified as 15–30 minutes. However, a more practical definition is to consider status epilepticus as a situation in which the duration of seizures prompts the acute use of anticonvulsant therapy. For GCSE, this is typically when seizures last beyond 5 minutes.

Status epilepticus is a medical emergency. Initial management includes maintenance of the airway and 50% dextrose (25–50 mL) intravenously in case hypoglycemia is responsible. If seizures continue, an intravenous bolus of lorazepam, 4 mg, is given and repeated once after 10 minutes if necessary; alternatively, 10 mg of diazepam is given intravenously over the course of 2 minutes, and the dose is repeated after 10 minutes if necessary. This is usually effective in halting seizures for a brief period but occasionally causes respiratory depression.

Regardless of the response to lorazepam or diazepam, phenytoin (18–20 mg/kg) is given intravenously at a rate of 50 mg/min; this provides initiation of long-term seizure control. The drug is best injected directly but can also be given in saline; it precipitates, however, if injected into glucose-containing solutions. Because arrhythmias may develop during rapid administration of phenytoin, electrocardiographic monitoring is prudent. Hypotension may complicate phenytoin administration, especially if diazepam has also been given. In many countries, injectable phenytoin has been replaced by fosphenytoin, which is rapidly and completely converted to phenytoin following intravenous administration. No dosing adjustments are necessary because fosphenytoin is expressed in terms of phenytoin equivalents (PE); fosphenytoin is less likely to cause reactions at the infusion site, can be given with all common intravenous solutions, and may be administered at a faster rate (150 mg PE/min). It is also more expensive.

If seizures continue, phenobarbital is then given in a loading dose of 10–20 mg/kg intravenously by slow or intermittent injection (50 mg/min). Respiratory depression and hypotension are common complications and should be anticipated; they may occur also with diazepam alone, although less commonly. If these measures fail, general anesthesia with ventilatory assistance and neuromuscular junction blockade may be required. Alternatively, intravenous midazolam may provide control of refractory status epilepticus; the suggested loading dose is 0.2 mg/kg, followed by 0.05–0.2 mg/kg/h.

After status epilepticus is controlled, an oral drug program for the long-term management of seizures is started, and investigations into the cause of the disorder are pursued.

Diazepam:-Sufficient cerebral levels are reached within one minute of a standard intravenous injection, and rectal administration produces peak levels at about 20 minutes. Diazepam is rapidly redistributed after acute administration, and thus has a relatively short duration of action. After repeated dosing, diazepam accumulates, resulting in higher peak levels, which persist. This can result in sudden and unexpected CNS depression and cardiorespiratory collapse. Diazepam is metabolised by hepatic microsomal enzymes. Respiratory depression, hypotension, and sedation are the principal side effects. Sudden apnoea can occur, especially after repeated injections or if the injection is administered at too fast a rate.

Bolus intravenous doses of diazepam should be given in an undiluted form at a rate not exceeding 25 mg/minute, using the Diazemuls formulation

Lorazepam:- has a lesser volume of distribution and is less lipid soluble than diazepam. Its pharmacokinetic characteristics result in a slower onset of action, but a longer duration of action. Lorazepam is indicated in the early stage of status epilepticus only, where its lack of accumulation in lipid stores, strong cerebral binding, and long duration of action due to its distribution half-life are very significant advantages over diazepam.

Initial injections of lorazepam are effective for about 12 hours (longer than with diazepam), but repeated doses are much less effective, and the drug has no place as long-term therapy.

Lorazepam is administered by intravenous bolus injection. As distribution is slow, the rate of injection is not critical. In adults, a bolus dose of 0.07 mg/kg (to a maximum of 4 mg) is given, and this can be repeated once after 20 minutes if no effect has been observed. In children under ten years, bolus doses of 0.1 mg/kg are recommended. Long-term infusion of lorazepam should not be used. It is usually available as a 1 ml ampoule containing 4 mg of lorazepam.

The initial infusion of phenytoin takes 2030 minutes in an adult, and the onset of action is slow. It is therefore often administered in conjunction with a short-acting drug with a rapid onset of action, such as diazepam

PHENYTOIN:-It is a highly effective anticonvulsant, with the particular advantage of a long duration of action.The usual phenytoin solutions have a pH of 12 and, if added to bags containing large volumes of fluid at lower than physiological pH (for example, 5% glucose), precipitation may occur in the bag or tubing; use in a solution of 0.9% sodium chloride (normal saline) (5-20 mg/ml) is safer. There is also a serious risk of precipitation if other drugs are added to the infusion solution.

The rate of infusion of phenytoin solution should not exceed 50 mg/minute, and it is prudent to reduce this to 2030 mg/minute in the elderly. The adult dose is 1520 mg/kg; this usually amounts to about 1000 mg and therefore takes at least 20 minutes to administer. Regrettably, a common and potentially serious mistake is to give a lower dose which results in suboptimal cerebral levels.

PHENOBARBITONE:-Phenobarbitone is a drug of choice for the treatment of established status epilepticus. It is highly effective, has a rapid onset of action, and prolonged anticonvulsant effects. It has stable and non-reactive physical properties, as well as convenient pharmacokinetics. Wide experience has been gained of its use in adults and in children, and few drugs are as well tried in the newborn. It has stronger anticonvulsant properties than most other barbiturates, and may be preferentially concentrated in metabolically active epileptic foci. As well as excellent anticonvulsant properties, it may also have cerebral-protective action. Acute tolerance to the antiepileptic effect is unusual, in contrast to the benzodiazepines and, once controlled, seizures do not tend to recur. Indeed, there is evidence to suggest that given with barbiturate anaesthesia, it can reduce the relapse rate with anaesthetic withdrawal.
The main disadvantages of phenobarbitone are its potential to cause sedation, respiratory depression, and hypotension; although in practice these effects seem slight except at high levels or with rapidly rising levels, its safety at even high doses is well established. The well-known chronic side effects of phenobarbitone in long-term therapy are of little relevance in the emergency situation of status epilepticus. The drug is eliminated slowly and, although this is of no importance on initial phenobarbitone loading, on prolonged therapy there is a danger of accumulation and blood level monitoring is essential. In the newborn period dosing is more difficult than in adults, as the pharmacokinetics change rapidly during the first weeks and months of life. The drug has a strong tendency to autoinduction. Phenobarbitone is a stable preparation, which does not easily decompose, and the drug is not absorbed by plastic. It should not be used in a solution containing other drugs (for example, phenytoin), as this may result in precipitation.
The usual recommended adult intravenous loading dose of phenobarbitone is 10 mg/kg (doses of up to 20 mg/kg have been used and recommended), given at a rate of 100 mg/minute (i.e. a total of about 700 mg in seven minutes). This should be followed by daily maintenance doses of 1-4 mg/kg. In neonates, initial phenobarbitone loading doses of between 12 and 20 mg/kg have been recommended to produce therapeutic levels, with subsequent supplementation of 3-4 mg/kg per day, to a maximum dose of 40 mg/kg. In older children, loading doses of between 5 and 20 mg/kg are recommended and maintenance doses of 1-4 mg/kg, although much higher doses have been safely given. After loading, maintenance doses can be given by the oral, intravenous, or intramuscular route. Phenobarbitone is usually presented in 1 ml ampoules containing 200 mg of phenobarbitone sodium.

Which of the following is not an adverse effect of
phenytoin – (AI 90)
a) Gum hyperplasia
b) Osteomalacia
c) Gynecomastia
d) Megaloblastic anaemia

In epilepsy, EEG is – (Kerala 90)
a) Diagnostic
b) Useless in diagnosis
c) Complimentary in diagnosis
d) may or may not be useful

Investigation of choice to diagnose epilepsy is –
a) MRI b) EEG (Kerala 94)
c) CT scan d) Angiogram

EEG with spike and dome pattern is characteristic
of…. Epilepsy – (AIIMS 85)
a) Jacksonian b) Grandmal
c) Petitmal d) Temporal lobe

Drug of choice for psychomotor epilepsy is

a) Valproic acid b) Carbamazepine (AIIMS 87) c) Ethosuximide d) Barbiturate
e) Phenytoin

Temporal lobe epilepsy was first recognized in 1881 by John Hughlings Jackson, who described "uncinate fits" seizures arising from the uncal part of temporal lobe and the "dreamy state."

In the 1940s, Gibbs et al introduced the term psychomotor epilepsy.The international classification of epileptic seizures (1981) replaced the term psychomotor seizures with complex partial seizures. Complex means that there is some alteration of consciouness, versus a simple partial seizure, which means there is no alteration of consciouness. The ILAE classification of the epilepsies uses the term temporal lobe epilepsy and divides the etiologies into cryptogenic (presumed unidentified etiology), idiopathic (genetic), and symptomatic (cause known, eg, tumor).

Carbamazepine (or a related drug, oxcarbazepine), lamotrigine and phenytoin are currently the drugs of choice approved for the initial treatment of focal seizures, including those that evolve into generalized seizures. Overall they have very similar efficacy, but differences in pharmacokinetics and toxicity are the main determinants for use in a given patient. For example, an advantage of carbamazepine (which is also available in an extended-release form) is that its metabolism follows first-order pharmacokinetics, and the relationship between drug dose, serum levels, and toxicity is linear. Carbamazepine can cause leukopenia, aplastic anemia, or hepatotoxicity and would therefore be contraindicated in patients with predispositions to these problems. Oxcarbazepine has the advantage of being metabolized in a way that avoids an intermediate metabolite associated with some of the side effects of carbamazepine. Oxcarbazepine also has fewer drug interactions than carbamazepine. Lamotrigine tends to be well tolerated in terms of side effects. However, patients need to be particularly vigilant about the possibility of a skin rash during the initiation of therapy. This can be extremely severe and lead to Stevens-Johnson syndrome if unrecognized and if the medication is not discontinued immediately. This risk can be reduced by slow introduction and titration.

Psychomotor epilepsy is Temporal lobe epilepsy

True about juvenile mycoclonic epilepsy – (PGI 03)
a) Focal seizure
b) Generalised seizure
c) Myoclonus
d) Responses to Sodium Valproate
e) Spike and waves in EEG

All the following are indications for brain imaging
in epilepsy, except – (J & k 05)
a) Epilepsy starts after the age of 5 years
b) Seizures have focal features clinical
c) EEG shows a focal seizure source
d) Control of seizures is difficult

Gustatory hallucinations are most commonly
associated with – (Corned 08)
a) Temporal lobe epilepsy
b) Grand mal epilepsy
c) Anxiety disorders
d) Tobacco dependence

Cause of death which is common in case of coma –
a) Tongue falling back and obstructing airway
b) Secretions obstructing airway (TN 03)
c) Cardiac arrest
d) Epilepsy

1501. Which vitamin deficiency is most commonly seen in a pregnant mother who is on phenytion
therapy for Epilepsy? All India 2006
a) Vitamin B6 b) Vitamin B12 c) Vitamin A d) Folic Acid

In Petit Mal epilepsy all findings are seen except JIPMER ’98
a) Transient loss of conciousness b) Non specific ECG pattern
c) No tonic-clonic phase d) Ethosuccamide is Drug of choice

A 15 year old boy with epilepsy on treatment with
combination of valproate and phenytoin has good
control of seizures. Levels of both drugs are in the
therapeutic range. All of the following adverse effects
can be attributed to valproate except :
A. Weight gain of 5 kg
B. Serum alanine aminotransaminase 150 IU/L
C. Rise in serum ammonia level by 201.tg/dL
D. Lymphadenopathy

Which of the following statements is incorrect in
relation to pregnant women with epilepsy?
A. The rate of congenital malformation is increased
in the offspring of women with epilepsy.
B. Seizure frequency increases in approximately
70% of women.
C. Breast feeding is safe with most anticonvulsants.
D. Folic acid supplementation may reduce the risk of
neural tube defect

An elderly male on ventilator has received atracurium
infusion for 3 days. He now develops epileptic fits.
Probable cause for his epilepsy is:
A. Allergy to drug
B. Accumulation of Atracurium
C. Accumulation of Laudanosine
D. Ventilator failure

Palatal Myoclonus is seen in – (SGPGI 05)
a) Epilepsy
b) Multiple sclerosis
c) Cerebellar infarction
d) Guillain Barre syndrome

Deja Vu is seen in – (Kerala 94)
a) Normal persons b) Temporal lobe epilepsy
c) Psychosis d) All of the above

Arun, diagnosed to have epilepsy recently and put
on phenytoin. He was previously on
antidepressents. He has developed fatigue and
anorexia. His Hb=8.0; TC=7500 ; ESR=30 in first
hour; SGOT=35; SGPT=35 and B-=0.6. the test
for diagnosis would be – (AIDE 99)
a) Chest x-ray b) Urine culture
•c) MCV d) Blood culture

All are used in treatment of epilepsy excepta)
Ethosuximide b) Reserpine (Kerala 94)
c) Acetazolamide d) Vigabatrine

Carbamazepine is useful in the following
conditions EXCEPT- (Kann 95)
a) Grandmal epilepsy b) Petitmal epilepsy
c) Psychomotor epilepsy d) Trigeminal neuralgia

Which is true regarding febrile seizures- (AI 93)
a) 50% recurrance
b) Long term phenytoin required
c) Interictal EEG normal
d) Status epilepsy is common

Hypsarrythmia in a child is due to

a) Grandmal epilepsy (AIIMS 91, Delhi 93)
b) Petitmal epilepsy
c) Myoclonic epilepsy
d) Reflex epilepsy

All of the following are true of febrile seizures except

a) Most commonly seen between 9 months and 5 years (AP 97)
b) Does not last more than 10 minutes
c) Almost invariably develop into epilepsy
d) Prognosis is good

WhIch of the following has the worst
prognosis – (JIPMER 2001)
a) Rolandic epilepsy b) Versive epilepsy
c) Absence epilepsy d) Infantile spasm

Which one of the following in the characteristic
feature of juvenile myoclonic epilepsy ? (AIIMS 06)
a) Myoclonic seizures frequently occur in morning
b) Complete remission is common
c) Response to anticonvulsants is poor
d) Associated absence seizures are present in
majority of patients

A 18-month old baby presents with recurrent
episodes of excessive crying followed by cyanosis,
uncon sciousness and occassional seizures since 9
months of age. The most likely diagnosis
is – (UPSC 98)
a) Epilepsy b) Anoxic spells
c) Breath holding spells d) Vasovagal attack