Neurology 2 Case Questions

KH is a 31yo male who presents to the ED complaining of a severe migraine. He reports pain for 24hr despite two doses of his home sumatriptan (100mg per dose). He reports nausea but denies vomiting and has no other past medical history. His labs and vital signs are all within normal limits.

• The treating provider wants to perform a sphenopalatine ganglion (SPG) block on KH in an attempt to treat his headache. Which of the following is incorrect regarding SPG blocks?

KH is a 31yo male who presents to the ED complaining of a severe migraine. He reports pain for 24hr despite two doses of his home sumatriptan (100mg per dose). He reports nausea but denies vomiting and has no other past medical history. His labs and vital signs are all within normal limits.

• Which of the following agents is most likely to provide benefit as part of a migraine cocktail?

SM is a 62yo female with past medical history of hypertension, atrial fibrillation, and type 2 diabetes. She takes lisinopril 10mg po daily, metoprolol tartrate 25mg po bid, rivaroxaban 20mg po daily, and metformin 500mg po bid and is allergic to heparin (HIT). She presents to the ED as a stroke alert due to left sided weakness and aphasia. Her initial blood pressure is 206/112 mmHg, heart rate 86, RR 17, O₂ saturation 96% on room air, and blood glucose 186mg/dL. She is taken promptly to CT scan which reveals a right sided intra parenchymal hemorrhage.

• SM’s responsiveness continues to decline, and the physician determines that intubation is necessary to protect her airway. Which of the following sequences of agents is most appropriate for the rapid sequence intubation of SM?

SM is a 62yo female with past medical history of hypertension, atrial fibrillation, and type 2 diabetes. She takes lisinopril 10mg po daily, metoprolol tartrate 25mg po bid, rivaroxaban 20mg po daily, and metformin 500mg po bid and is allergic to heparin (HIT). She presents to the ED as a stroke alert due to left sided weakness and aphasia. Her initial blood pressure is 206/112 mmHg, heart rate 86, RR 17, O₂ saturation 96% on room air, and blood glucose 186mg/dL. She is taken promptly to CT scan which reveals a right sided intra parenchymal hemorrhage.

• The treating provider asks you about if and how her rivaroxaban should be reversed, knowing that you do not have andexanet alfa on formulary. What is the most appropriate recommendation?

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 decision is made to utilize an osmotic agent to treat DG’s increased intracranial pressure. Which is not an appropriate agent to recommend?