CNS

• Bipolar I


  Episode of mania or hypomania for at least 7 consecutive days
• Bipolar II


  Hypermania for more than 4 days with one depressive episode
• Diagnosis


  • DSM-5
  • ICD-10
• DSM-5


  Differentiates between bipolar I and II
• Treatment for mania


  • Anti-psychotics
  • Quetiapine
  • Risperidone
  • Haloperidol
  • Olanzapine
  • Lithium
• Lithium


  • Small univalent cation
  • Enters via Na+ channels
  • 0.5-1.5mmol/L therapeutic range
  • Toxicity seen over 1.5mmol/L
  • Teratogenic- contraception
  • Salt free diet contraindicated
  • Interactions- NSAIDs, diuretics (thiazide worse than loop), ACEi
• Sodium valproate


  Used to treat mania
• DO NOT give lamotrigine for mania
• Treatment for depression


  • Fluoxetine with or without olanzapine
  • Quetiapine
  • Lamotrigine
• Schizophrenia


  Increased dopamine
• Diagnosis of schizophrenia


  • DSM-5
  • ICD-10
  • Symptoms= PANSS
  • 2 symptoms for most of the month
• Symptoms of schizophrenia


  • Positive (added- hallucinations, delusions)
  • Negative (taken away, apathy, self neglect)
• Typical antipsychotics


  • Olanzapine
  • Chlorpromazine
• Typical antipsychotics


  • Positive symptoms
  • More EPSEs
  • Block D2 receptors in mesolimbic pathway (antagonist)
• Atypical antipsychotics


  • Risperidone
  • Haloperidol
  • Quetiapine
  • Clozapine
  • Aripiprazole
  • Amisulfide
• Atypical antipsychotics


  • Low affinity for D2 receptor, high affinity for the 5HT2A receptor
  • Clozapine used for treatment resistant schizophrenia
• EPSEs (extra-pyramidal side effects)


  • Seen with typical antipsychotics
  • Parkinsonism/dystonia- anti-cholinergic
  • Tardive dyskinesia- switch to atypical
• Parkinson's


  Decreased dopamine in mesolimbic system
• Treatment for motor symptoms of Parkinson's


  • Levodopa (precursor to dopamine) used in combination with carbidopa or benserizide
  • Dopamine agonists- pramipexole, ropinirole
  • Monoamine MAOB inhibitors- selegiline, rasagiline
• DO NOT offer ergot-derived dopamine agonist first line- bromocriptine
• Adjuvant therapy for Parkinson's


  • COMT inhibitors= entacapone (with levodopa), tolcapone (monitor LFTs)
  • Amantadine- advanced Parkinson's
• Advanced Parkinson's treatments


  • Amantadine
  • Apomorphine hydrochloride (strong so give with domperidone)
  • Levodopa with carbidopa intestinal gel
  • Deep brain stimulation
• Non-motor symptom treatments for Parkinson's


  • Postural hypotension= fludrocortisone, midodrine hydrochloride
  • Parkinson's dementia= acetylcholesterase inhibitor
  • Nocturnal akinesia= levodopa with dopamine agonist, rotigotine
  • REM sleep disorder= melatonin, clonazepam
  • Drooling= glycopyrronium bromide
  • Daytime sleepiness= modafil
  • Psychosis= quetiapine, clozapine
• Focal onset epilepsy


  • Focal and bilateral meaning it has an epi-centre then spreads to both sides
  • Tonic-clonic seizures
  • Warnings prior- motor (lip smacking), non-motor (Deja vu)
• Treatment for focal onset epilepsy


  • 1st line= Levetiracetam
  • 2nd line= lamotrigine
• Generalised onset epilepsy


  • Motor- Tonic, Tonic-clonic (convulsive), A-tonic (drop seizures)
  • Non-motor- Absence (children)
• 1st line treatment for generalised onset epilepsy


  • Tonic= sodium valproate
  • Tonic-clonic= sodium valproate
  • A-tonic= sodium valproate
  • Absence= ethosuximide
• 2nd line treatment for generalised onset epilepsy

  • Tonic= lamotrigine
  • Tonic-clonic= levetiracetam
  • A-tonic= lamotrigine
  • Absence= sodium valproate
• 3rd line treatment for generalised onset epilepsy


  • Tonic-clonic= lamotrigine
  • Absence= levetiracetam
• 4th line treatment for generalised onset epilepsy


  • Absence= lamotrigine
• Myoclonic epilepsy


  Common in the morning, clusters
• Treatment for myoclonic epilepsy


  • 1st line= sodium valproate
  • 2nd line= levetiracetam
• Status epilepticus


  • More than 5 minutes
  • TONIC CLONIC = EMERGANCY
• Treatment for status epilepticus


  • Community- Rectal diazepam, Buccal midazolam
  • Hospital- I.V. lorazepam, I.V. phenytoin, I.V. levetiracetam, I.V. sodium valproate, 3rd line= phenobarbital or general anaesthesia
• Hirsutism common with phenytoin
• Local anaesthesia


  Block Na+ channels, prevents axonal depolarisation and production of action potential
• Local anaesthetic types


  • Esters- Cocaine, Procaine, Tetracaine
  • Amides- Lidocaine, Mepivacaine
• Inhaled general anaesthesia


  • Gases- N2O, xenon
  • Volatile liquids- Halothane, Isothane, Desfluthane
• IV general anaesthesia


  • Benzodiazepine and painkillers
  • Ketamine
  • Propofol
  • Sodium thiopental
• Ketamine


  • NMDA antagonist
  • PCP derivative
  • Increases HR and BP, hallucinations post-op very common