Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine--->Seizure Disorder
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Question 1#Print Question

A 19-year-old male with known generalized epilepsy was brought to the emergency department for convulsive status epileptics. He has had nausea, emesis, and a low grade fever for the last 5 days and has been unable to take his home antiepileptic drug. He is having ongoing low amplitude, rhythmic clonic movements of his bilateral arms and legs. His vitals are as follows: heart rate 86, blood pressure 106/68, SpO2 100% on 2 L nasal canula, temperature 100.2°C. EMS administered 2 mg of lorazepam and had cessation of clonic movements but still altered and not back to baseline mental state.

What is the next best medication treatment for this patient?

a. Intubate the patient and start propofol
b. Monitor the patients for few hours and order EEG
c. Additional lorazepam to dose of 0.1 mg/kg followed by fosphenytoin with loading dose of 15 mg/kg IV
d. Obtain CT head to further evaluate the etiology and rule out structural abnormalities

Question 2#Print Question

A 74-year-old man presents to the hospital after falling down a flight of stairs. EMS found him on the ground moaning with left-sided weakness but able to answer questions. On arrival to the emergency department he remained neurologically stable. A head CT demonstrated a 5 mm right holohemispheric subdural hemorrhage. Neurosurgery was consulted and recommended initiation of an antiepileptic drug (AED). Valproic acid was started.

Which of the following are concerns related to the use of valproic acid?

a. It has the same early seizure prevention as phenytoin but it associates with improved mortality rate
b. It is an inducer of the CYP system with multiple drug interactions
c. It can result in acute renal injury and possible renal failure
d. It can result in a coagulopathy which potentially could increase the size of the patient’s subdural hemorrhage

Question 3#Print Question

A 56-year-old female is admitted to the intensive care unit for management of a complete right middle cerebral artery ischemic stroke. During her stay within the intensive care unit, she has progressive somnolence over the course of 96 hours with only minor changes on her CT scan and no midline shift. Given her profound stupor, an EEG was ordered and a portion of the recording is shown in the figure below. Her current neurologic examination showed symmetric and reactive pupils at 3 mm, right gaze preference but crosses midline, profound upper motor neuron facial droop on the left, left arm and leg weakness. Patient did not follow commands or open eyes, but she continues to localize with the right arm.

Standard 10 to 20 electrode placement with representation as “double banana” with left over right representation. There is diffuse slowing.

What is the next best step in management for this patient?

a. Continue with supportive care and no change to medications
b. Initiation of antiepileptic medication—levetiracetam 500 mg twice a day
c. Benzodiazepine trial—lorazepam 1 mg IV once
d. Neurosurgery consultation for craniectomy

Question 4#Print Question

A 48-year-old man with subacute progressive headache and confusion was brought in to the emergency department via EMS for convulsive status epileptics. He received a total of 8 mg of IV lorazepam by EMS and was intubated in the field due to respiratory depression. He has continued to have rhythmic clonic movements of his limbs following intubation. He has now had ongoing seizure activity for 30 minutes. He is then treated with IV phenytoin at a dose of 20 mg/kg at a rate of 50 mg/min. During the infusion he has hypotension requiring vasoactive medications to maintain a mean arterial pressure of 65 mm Hg.

What is the underlying cause of hypotension associated with intravenous phenytoin?

a. Loss of vascular sympathetic tone due to voltage-gated sodium channel blockade
b. CNS suppression via voltage-gated sodium channel blockade results in loss of sympathetic tone
c. Ongoing seizure activity has resulted in hypoxia and hemodynamic instability
d. Ongoing seizure activity has resulted in lactic acidosis and hemodynamic instability

Question 5#Print Question

A 43-year-old woman is brought to the emergency department for ongoing convulsive activity. She has a history of traumatic brain injury 5 years ago with residual encephalomalacia in the left parietal lobe, which has resulted in cognitive impairment and partial epilepsy with secondary generalization. She is maintained on levetiracetam, carbamazepine, and clobazam at home. She is admitted to the ICU, and exam reveals an obese female with tachycardia, BP 134/82, and oxygen saturation of 96%. Her labs show a serum sodium of 128.

Which of the following MOST likely is the cause of hyponatremia in this patient?

a. Poor oral intake of solute
b. Medication side effect
c. Cerebral salt wasting secondary to brain trauma
d. Hypothalamic involvement during epileptiform activity
e. Hepatic impairment

Category: Critical Care Medicine--->Seizure Disorder
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