1. Sedative & hypnotics
   1. CLASSIFICATION
      1. Benzodiazepines
         1. Diazepam
         2. oxazepam
         3. lorazepam
         4. flurazepam, nitrazepam, clonazepam triazolam, midazolam
      2. . Barbiturates:
         1. Long acting
            1. Phenobarbitone
            2. mephobarbitone
         2. Short acting
            1. Pentobarbitone,
            2. secobarbitone
         3. Ultra-short acting.
            1. Thiopentone
            2. methohexitone
      3. 3. Non-benzodiazepine hypnotics:
         1. Zolpidem,
         2. zopiclone,
         3. zaleplon
         4. eszopiclone
      4. 4. Miscellaneous:
         1. chloral hydrate
         2. promethazine
         3. neuroleptics,
         4. opioids
   2. BENZODIAZEPINES
      1. MECHANISM OF ACTION
      2. uses
         1. Sedation and hypnosis:
            1. Benzodiazepines decrease time required to fall asleep (sleep latency).
         2. Anticonvulsants
            1. control life-threatening seizures in status epilepticus, tetanus, drug-induced convulsions
         3. Diagnostic (endoscopies) and minor operative procedures
         4. Preanaesthetic medication
            1. Subtopic 1because of their sedative amnesic and anxiolytic effects
         5. Antianxiety (anxiolytic) effect
      3. ADVERSE effects
         1. drowsiness, confusion, blurred vision,
         2. amnesia, disorientation, tolerance and drug dependence.
         3. Withdrawal after chronic use causes symptoms like tremor, insomnia, restlessness, nervousness and loss of appetite.
         4. Use of BZDs during labour may cause respiratory depression and hypotonia in the newborn (Floppy baby syndrome).
         5. produce paradoxical effects, i.e. convulsions and anxiety.
   3. Barbiturates
      1. USES
         1. Sedation and hypnosis: Barbiturates were used in the treatment of insomnia They decrease sleep latency, duration of REM sleep, stage 3 and 4 of NREM sleep
         2. General anaesthesia (GA): Ultra-short-acting barbiturates (thiopentone and methohexitone) are used for the induction of GA
         3. Anticonvulsant: Phenobarbitone has anticonvulsant effect and is used in the treatment of status
         4. epilepticus and generalized tonic-clonic seizures (GTCS).
      2. Adverse effects
         1. common side effects are drowsiness, confusion, headache, ataxia, hypotension and respiratory
         2. depression.
         3. 2. Hypersensitivity reactions like skin rashes, itching and swelling of face may occur. 3. Tolerance develops to their sedative and hypnotic actions on repeated use. 4. Physical and psychological dependence develops on repeated use.
         4. 5. Prolonged use of phenobarbitone may cause megaloblastic anaemia by interfering with absorption of folic acid from the gut.
         5. 6. They may precipitate attacks of acute intermittent porphyria; hence barbiturates are contraindicated in porphyria.
         6. 7. In case of acute barbiturate poisoning, the signs and symptoms are drowsiness
      3. acute barbiturate poisoning
         1. Maintain airway, breathing and circulation
         2. Maintain electrolyte balance.
         3. Gastric lavage:
            1. After stomach wash, administer activated charcoal that may enhance the elimination of phenobarbitone.
            2. Endotracheal intubation is performed before gastric lavage to the airway in unconscious patients.
         4. Alkaline diuresis
            1. There is no specific antidote for barbiturates; main treatment is alkaline diuretiss. Intravenous sodium bicarbonate alkalinizes urine.
2. COnsious sedation
   1. Conscious sedation is a level of CNS depression where a patient does not lose consciousness but is able to communicate and cooperate during the procedure/treatment
   2. INDICATION
      1. Uncooperative patients.
      2. Anxious patients.
      3. Emotionally compromised patients.
   3. CONTRAINDICATION
      1. Chronic obstructive pulmonary disease
      2. Pregnancy
      3. Prolonged surgery.
      4. phycosis
   4. Drugs used
      1. BENZODIAZEPINES
         1. Diazepam is the most commonly used drug for conscious sedation.
         2. Small doses (1-2 mg) of diazepam is administered intravenously slowly.
         3. It can also be administered orally.
      2. Midazolam is a short-acting benzodiazepine given intravenously
      3. Nitrous oxide + Oxygen: Nitrous oxide is given by inhalational route along with 100% oxygen.
      4. Chloral hydrate (orally), propofol (i.v. infusion), fentanyl (i.v.), etc. can also be used for conscious sedation.
   5. precaution
      1. Conscious sedation should be administered by trained personnel. Constant monitoring of the vital signs should be done during and after the procedure.
      2. The procedure should be documented. Postoperative instructions should be in written form.
      3. Equipment and emergency drugs should be kept ready to tackle any emergency.
      4. Patient should be escorted by an attendant
3. ANTI EPILEPTIC DRUGS
   1. GENERALISED SEIZURES
      1. Generalized tonic-clonic seizures (GTCS, grand mal epilepsy)
         1. symptoms: Aura-epileptic cry-loss of consciousness-fall to the ground-tonic phase-clonic phase-period of relaxation-postepileptic automatism with confusional states.
      2. 2. Absence seizures (petit mal epilepsy):
         1. Sudden onset of staring, unresponsiveness with momentary loss of consciousness.
      3. Myoclonic seizures
         1. It consists of single or multiple sudden, brief, shock-like contractions.
   2. PARTIAL SEIZURES
      1. Simple partial seizures (SPS)
         1. The manifestations depend on the region of cortex involved.
         2. There may be convulsions (focal motor symptoms) or paraesthesia (sensory symptoms) without loss of consciousness.
      2. 2. Complex partial seizures (CPS, temporal lobe epilepsy, psychomotor epilepsy):
         1. charaterized by aura amnesia abnormal behaviour and automatism with impaired consciousness.
   3. CLASSIFICATION
      1. Hydantoins:
         1. Phenytoin, fosphenytoin.
      2. 2. Barbiturate: .
         1. Phenobarbitone
      3. 3. Iminostilbenes:
         1. Carbamazepine
         2. oxcarbazepine
      4. 4. Succinimide
         1. Subtopic 1Ethosuximide
      5. 5. Benzodiazepines:
         1. Diazepam,
         2. lorazepam,
         3. clonazepam,
         4. clobazam
      6. 6. Carboxylic acid derivative:
         1. Valproic acid (sodium valproate).
      7. 7. Others:
         1. Vigabatrin
         2. lamotrigine
         3. acetazolamide
         4. gabapentin
         5. pregabalin
         6. topiramate
         7. zonisamide
   4. MECHANISM OF ACTION
   5. PHENYTOIN
      1. Uses
         1. Generalized tonic-clonic seizures (grand mal epilepsy).
         2. 2. Partial seizures.
         3. 3. Trigeminal and other neuralgias.
         4. 4. Status epilepticus:
            1. Phenytoin is administered intravenously in normal saline
      2. ADVERSE EFFECTS
         1. 1. Hypertrophy and Hyperplasia of gums
            1. Seen on chronic therapy
         2. 2. Hypersensitivity reactions
            1. include skin rashes, neutropaenia and rarely Hepatic necrosis.
         3. Hirsutism:
            1. Due to increased androgen secretion.
         4. 4. Hyperglycaemia:
            1. Due to decreased insulin release.
         5. 5. Megaloblastic anaemia:
            1. Due to folate deficiency.
         6. 6. Osteomalacia
            1. Due to increased metabolism of vitamin D.
         7. 7. Hypocalcaemia:
            1. Due to decreased absorption of Ca from the gut.
         8. 8. Foetal Hydantoin syndrome:
            1. Cleft lip, cleft palate, digital Hypoplasia,
   6. CARBAMAZEPINE
      1. USES
         1. Carbamazepine is one of the most commonly used antiepileptic drug.
         2. It is the drug of choice in GTCS and partial (SPS and CPS) seizures.
         3. 2. Carbamazepine is the drug of choice in the treatment of trigeminal and other neuralgias
         4. useful in other neuropathic disorders
         5. 3. Carbamazepine is used in the treatment of acute mania and bipolar disorder
      2. Adverse effects
         1. sedation, drowsiness, vertigo, ataxia,
         2. diplopia, blurred vision, nausea, vomiting and confusion.
         3. Hypersensitivity reactions are skin rashes, eosinophilia, lymphadenopathy and hepatitis.
         4. Rarely, it causes bone marrow depression with neutropenia, aplastic anaemia and agranulocytosis.
         5. On chronic therapy, it may cause water retention due to the release of antidiuretic hormone (ADH)
   7. PHENOBARBITONE
      1. uses
         1. effective in GTCS and partial seizures. It is the cheapest antiepileptic drug.
         2. useful in the prophylactic treatment of febrile convulsions.
         3. In status epilepticus, phenobarbitone is injected intravenously when the convulsions are not controlled with diazepam and phenytoin
      2. Adverse effects
         1. nystagmus, ataxia, confusion
         2. megaloblastic anaemia and skin rashes.
         3. On chronic therapy, it may cause behavioural disturbances with impairment of memory in children
4. Status EPILEPTICus
   1. it is a medical emergency and should be treated immediately.
   2. It is characterized by recurrent attacks of tonic-clonic seizures without the recovery of consciousness in between or a single episode lasts longer than 30 minutes.
   3. TREATMENT
      1. Hospitalize the patient.
      2. 2. Maintain airway and establish a proper i.v. line. 3. Administer oxygen.
      3. 4. Collect blood for estimation of glucose, calcium, electrolytes and urea.
      4. 5. Maintain fluid and electrolyte balance.
   4. steps
      1. Step 1
         1. Diazepam 10 mg i.v. slowly; repeat after 10 min if necessary
            1. Watch for hypotension and respiratory depression
         2. Fosphenytoin 20 mg/kg i.v.
            1. Monitor cardiac rhythm and BP
      2. If seizure continues
      3. Step 2
         1. Phenobarbitone 10-15 mg/kg i.v. infusion 100 mg/min
            1. respiratory depression
      4. If seizure continues
      5. Step 3
         1. General anaesthesia with i.v. midazolam or propofol
            1. Maintain airway and BP