19 Flashcards
Causes of unresponsiveness in children 7
Etiology Discussion
Common causes
Toxic ingestion
Most commonly seen in children between the ages of 9 months and 3 years of age.
Various medications can lead to a state of unresponsiveness.
Some of the more common medications would be opiates, benzodiazepines, and clonidine.
Other considerations would be medications that can cause a metabolic disturbance (e.g., oral diabetic agents causing hypoglycemia.
A careful history must be taken about all medications in the child’s house and other homes where he or she spends time (grandmother’s home, babysitter’s home, etc.).
Seizure
Seizures are common in children.
Best described as paroxysmal neurologic events and have variable forms of presentation, such as generalized or partial seizures.
Seizures can have many causes, from metabolic disturbances (hypoglycemia or hypocalemia) to head trauma resulting in cerebral contusion or intracranial hemorrhage.
Children with developmental abnormalities of the brain or genetic syndromes which involve the brain (e.g., tuberous sclerosis) may also have seizures.
In many children, seizures may be idiopathic.
Some children have only one seizure in their lifetime; others will have recurrent seizures and thus be given the diagnosis of epilepsy (typically classified as two or more unprovoked seizures).
Epilepsy (all forms) has a prevalence of approximately 1% throughout childhood.
Even in the absence of a seizure, other important neurologic causes should be considered in an unresponsive child.
Syncope
Syncope due to breath-holding spells is common in children between the ages of 1 and 3 years.
Breath-holding spells are classified as either cyanotic or pallid type.
In the more common cyanotic type, the key historical feature is a precipitating event that upsets the child, resulting in vigorous crying and hyperventilation, followed by a prolonged expiratory apnea; t ransient hypoxia results in the child turning pale or cyanotic, followed by brief loss of consciousness and limpness.
The episodes quickly self-resolve and there is typically no associated post-ictal state.
Occasionally, a child with a breath holding spell may have a brief generalized seizure, most likely due to hypoxia.
For the most part, parents should be reassured that breath-holding spells are a benign and self-limited condition.
Very rarely, breath-holding spells have been reported to be associated with asystole.
Cardiac syncope:
Cardiac syncope is a bit more unusual in this age patient, but should be considered; it would most likely not be vasovagal type syncope.
However, cardiac causes such as supraventricular arrhythmias (supraventricular tachycardia) or ventricular arrhythmias (in the setting of prolonged QT syndrome) can decrease cerebral blood flow and cause syncope.
Closed head injury
Closed head injury (with or without intracranial injury) may lead to loss of consciousness.
The family or caregiver may not have witnessed the traumatic event.
Should there be indications in the history; inflicted head trauma should also be considered as a possible diagnosis.
Infection
Infectious causes have to be considered in children.
Up to 30-40% of children with meningitis can present with seizure activity.
Fever and irritability may be the only signs seen on exam.
Children with encephalitis will frequently present with fever and seizure.
After the seizure is over, they often do not return to baseline activity and remain impaired.
Enteroviral infections and herpes simplex virus should be considered as possible pathogens for encephalitis.
Less common causes
Intracranial process
Brain tumor can lead to both seizures or more global alterations in mental status.
The patient’s medical history might include a preceding history of headache, behavior change or vomiting.
Brain tumors are the most common solid tumors in childhood (approximately 1,200 cases per year) and usually occur in the posterior fossa.
Intussusception
Intussusception is the telescoping or prolapsing of a portion of the intestine within another immediately adjacent portion of intestine-usually the terminal ileum into the colon.
Repeated episodes of colicky pain are the classic presentation of intussusception.
As the condition becomes more long-standing, lethargy with a near unresponsive state can be seen between the episodes of colicky pain.
In addition, children with intussusception commonly have intravascular volume depletion due to vomiting and third spacing of fluids; this may lead to mental status changes similar to a child who is very dehydrated.
True seizure evidence
A history of alteration of consciousness or loss of consciousness
Incontinence
Deviation of the eyes
Often rhythmic motor movements that cannot be stopped by touching or holding the child
A postictal state.
To address these issues, you may want to ask whether the child was distractible, and if the event could be interrupted. In addition, children who are old enough to verbalize may describe an aura or “premonition” prior to the onset of a seizure, or caregivers may be able to articulate unusual behavior just prior to the event.
Types of seizures 5
Generalized tonic-clonic seizure
This is the most common type seen in children.
This type of seizure event begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes.
Clonic jerks of all extremities follow the tonic phase.
Finally, the child becomes flaccid, and urinary incontinence may occur.
Simple partial seizure
With this type, there are often motor signs in a single extremity or on one side of the body.
However, focal onset seizure activity may spread to become generalized, making it difficult to distinguish from a generalized seizure.
Complex partial seizure
This type of seizure can occur at any age.
Alteration of consciousness is one of the hallmark features.
Signs and symptoms of this type of seizure tend to localize around the eyes (glassy-eyed), the mouth (lip-smacking, drooling, gurgling), and the abdomen (nausea and vomiting).
Automatisms are quasi-purposeful motor or verbal behaviors that are repeated inappropriately and commonly accompany complex partial seizures.
Complex partial seizures often last 30 seconds to 2 minutes and are associated with a post-ictal phase of confusion, sleep, or headache.
Secondary generalization can occur in up to one third of children, so it is important to question witnesses about initial features to help differentiate a complex partial seizure from a generalized seizure
Childhood absence epilepsy (petit mal seizures)
This disorder is seen starting around age 3 years.
Absence seizures are characterized by loss of environmental awareness (“staring off into space”) and automatisms (e.g., eye-fluttering or lip-smacking).
While these are generalized seizures, children usually regain their consciousness more quickly than the post-ictal phase seen in a generalized tonic-clonic seizure.
Absence seizures are not associated with loss of tone or urinary continence.
Absence seizures can be precipitated by hyperventilation or photic stimulation.
Atonic (akinetic) seizure - generalized seizure
Involves loss of motor tone
Determining etiology of seizure 6
The following are all critical to know in determining the etiology of a seizure:
A detailed description of the event
In most cases you will not have the opportunity to observe the child having a seizure, so the event must be reconstructed by obtaining as accurate a history as possible:
Parents, or other observers, may be so upset by this scary event that they may have significant difficulty recalling details of the seizure.
Remember to ask open ended questions.
Ask the parents why they suspected something was wrong; what was the first thing they noticed?
They may mention that the child had a blank stare or that they observed lip smacking or facial twitching.
Then ask about typical movements that one may see in a seizure (e.g., “Did you notice any movements in his arms or legs? How would you describe them?”)
A detailed timeline of events leading up to and through the episode, including how the child recovered from the event (B) can lead you through the differential diagnosis.
Any precipitating events, such as fever
Inquiring about precipitating events such as illness, especially with fever, is essential.
One of most common reasons for seizures in children is febrile seizures, and these are usually generalized seizures.
Febrile seizures occur in 2–4% of children between the ages of 6 months and 5 years.
It’s important to note that not all children who present with a seizure and fever have febrile seizures: The presence of fever may not help to make the distinction between the common, benign condition of febrile seizures and something much more serious such as meningitis or encephalitis.
In febrile seizures, typically a benign and self-limited illness like a viral infection causes fever which can trigger a seizure in a susceptible host (young child, positive family history, etc.).
In a more serious central nervous system infection, such as meningitis or encephalitis, the infection itself causes both fever and seizure; this is because CNS infections directly involve the brain or the meninges surrounding the brain. Prolonged fever prior to the event, especially with irritability or inconsolability, is an indication of a more serious CNS condition causing the seizure.
Occasionally, one might consider whether the fever and the seizure are coincidental; this highlights that, at times, a febrile seizure can be difficult to differentiate from epilepsy. Every child with epilepsy has to have a first seizure at some point and the inciting event may be a mild infection with fever.
In practice, the characteristics of the child’s seizure, the child’s medical and developmental history, as well as whether the seizures recur, will help to more accurately classify the patient.
Possibility of toxic ingestion
Especially worrisome in toddlers is the potential for toxic ingestion, usually from improperly stored medications.
Any history of injury
The possibility of recent history of injury, particularly of the head, should be discussed, since head injuries, either recent or distant, can lead to post-traumatic seizures.
Pertinent medical and family history
A past history of seizures
Developmental delay
Premature birth
Family history of seizure disorders or neurologic problems
Hereditary seizures
Febrile and afebrile seizures can be hereditary
Differential dx of seizure 8
CNS infection (meningitis/encephalitis)
The presence of a tactile fever suggests a viral or bacterial infection; at this point, it’s important to determine if the infection might be causing the seizure directly, such as in a serious infection like meningitis or encephalitis.
Irritability, together with seizure, might suggest a serious underlying neurologic infection.
Approximately 30% of infants with meningitis present with a seizures. However, they typically also have other signs of illness such as vomiting, lethargy or behavior change.
Febrile seizure Alternatively, the fever may be a sign of an infection of little consequence (such as a viral upper respiratory infection) which led to a febrile seizure:
Febrile seizures occur in children ages 6–60 months at a frequency of 2–5% in this age group.
Seizures usually occur on the first day of the febrile illness, often as the first sign to the parents that the child is ill.
Fever > 38 degrees is typically present.
Children with febrile seizures are developmentally normal and often have a positive family history for other first-degree relatives with febrile seizures as children.
Most febrile seizures are generalized.
Head injury/post-traumatic seizure
A seizure related to head injury generally occurs 1–2 hours after the incident.
Even if parents report no history of trauma, it is important to keep non-accidental injury in mind.
Ingestion/poisoning
Even though an insulin overdose has been ruled out, one should always consider an accidental ingestion in a child this age.
Many other poisonings can lead to generalized seizures: Acute alcohol poisoning and more longstanding lead poisoning are two examples.
Fever would be unusual in most ingestions and argues against this diagnosis for Ian.
Idiopathic seizure/epilepsy
A fever often triggers the first seizure in children with epilepsy.
Although some children with epilepsy also have developmental delay due to genetic, congenital, or acquired disorders (symptomatic epilepsy), many other children with epilepsy are developmentally normal (idiopathic epilepsy).
In patients with very prolonged seizures, fever may be due to sustained motor activity and possibly the release of inflammatory mediators.
Hypoglycemia
Low blood sugar can be a cause of seizure.
A blood glucose level is a quick and simple way to immediately check if this is a factor.
Brain tumor
Seizure resulting from a brain tumor or other intracranial mass lesion would most likely begin as a partial seizure.
Breath-holding spell
Breath-holding spells can be complicated by hypoxic seizures.
These are generally very brief.
Toxic appearing child in pediatrics meaning
In pediatrics, the term “toxic-appearing” implies that the child is seriously ill, including some or all of the following characteristics:
Has poor or absent eye contact.
Fails to recognize caregivers.
Is very irritable and cannot be consoled or distracted.
Has a minimal response to painful procedures, such as an IV placement or blood draw.
Has signs of poor perfusion or respiratory distress.
In general, the term is used most often to distinguish between a febrile child who may be unwell but is clinically stable (i.e., “non-toxic appearing”) and a febrile child who requires immediate diagnostic and therapeutic intervention, usually for a serious bacterial infection such as meningitis or sepsis.
Differential dx for fever in young child 8
Viruses
Many common viral infections (e.g., enterovirus, adenovirus) can cause significant fever in young children without any additional clinical signs or symptoms such as congestion, cough, diarrhea, or rash.
Thus, based on history and physical exam alone, a child with a benign viral syndrome may be indistinguishable from a child with a serious bacterial infection such as occult bacteremia or a urinary tract infection (UTI).
Serious bacterial infection (SBI)
Occult bacteremia, meningitis, and UTI are often referred to as SBIs.
Various studies in the literature have also considered the following infections to be SBIs: bacterial gastroenteritis, pneumonia, septic arthritis, and osteomyelitis.
Occult bacteremia - Occult (hidden) bacteremia is the presence of bacteria in the bloodstream of a child who has a fever but who looks well and has no obvious source of infection
Febrile children ages 3-36 months without a discernible focus of infection may have an “occult” bacteremia, usually caused by Streptococcus pneumoniae.
Since the introduction of the protein-polysaccharide conjugate pneumococcal vaccine (PCV-7) in the year 2000, the rates of invasive pneumococcal infections have declined. A year after the introduction of the vaccine, the rate of invasive disease in children under the age of 2 years dropped by 69% (from 24 cases/100,000 to 17 cases/100,000). The current rate of occult bacteremia due to pneumococcal infections is less than 1% of children age 3-36 months with temperatures > 39 C without an obvious source.
In the past, Haemophilus influenzae type b was a feared pathogen, but this is now uncommon due to universal vaccination in the U.S.
Other than fever, children with occult bacteremia often have no additional signs or symptoms of illness.
Undiagnosed, the child with occult bacteremia is at risk for the development of a more serious bacterial infection such as meningitis or osteomyelitis, through bacterial seeding of these distant sites.
Meningitis
Because clinical signs and symptoms of meningitis can be subtle in young children, a febrile 16-month-old with irritability and a seizure (especially if they have not recovered to normal activity and behavior after a period of observation) should have meningitis included in the differential diagnosis, even when the physical exam does not demonstrate a stiff neck.
Urinary tract infection (UTI)
UTI is a common cause of fever in children.
Because small children cannot complain of dysuria, frequency, or costo-vertebral angle (CVA) tenderness, UTI must often be included on the differential diagnosis until ruled out by laboratory testing.
In children with no prior history or risk factors for UTI, however, circumcised males are less commonly affected than females.
Evidence-based guidelines for obtaining urine cultures are dictated by the age of the child. (See the next card for further discussion of UTI.)
Kawasaki disease
Criteria for the diagnosis of Kawasaki disease are persistent fever for more than five days and a combination of four of the following five findings:
Non-purulent conjunctivitis
Rash
Erythema and cracking of lips, strawberry tongue
Cervical lymphadenopathy (usually unilateral)
Swollen hands and feet
Otitis media
Otitis media is another frequent cause of fever in young children.
The diagnosis can be made by visual inspection of the tympanic membrane and pneumatic otoscopy.
Bone/joint infection
Clues to this diagnosis would include:
A swollen or tender joint
Diminished or painful range of motion
Overlying erythema
Fever without source vs fever of unknown origin
The difference lies in the amount of time that has past since the fever has been identified:
The first two terms (FWS and FWLS) are used at the time of presentation (usually 24-72 hours after the onset of fever) to indicate that a child, after an initial evaluation including history, physical examination, and possibly laboratory studies, does not have a clearly identified source for his or her fever. While most children with FWS/FWLS have a viral etiology for their fever, one must still strongly consider less obvious serious bacterial illnesses such as bacteremia, meningitis, pyelonephritis, osteomyelitis, and appendicitis.
The term “fever of unknown origin (FUO)” is applied to a child whose fever without source or localizing signs/symptoms has persisted beyond a 7- to 10-day period. By this time, the routine workup for common febrile illnesses has usually been undertaken and remains negative. In addition, by this time, most common viral infections should have run their course. Children with a true FUO are more likely to have unusual infections, malignancies, or collagen vascular disorders.
Meningitis and febrile seizures- when to obtain LP
Point of access for needle
Data show that the overall risk of meningitis is low in children who present with a simple febrile seizure. In fact, a retrospective analysis of over 700 children ages 6–18 months who had a first simple febrile seizure demonstrated no cases of bacterial meningitis in the 260 CSF samples obtained.
However, obtaining a lumbar puncture may be recommended nevertheless for a number of reasons:
The younger the child, the more subtle the signs of meningitis may be on examination. Very young infants (< 3-6 months) with bacterial meningitis may not show any signs of nuchal rigidity—even to an expert clinician.
While not a specific finding, persistent irritability may be the only key to a child with a serious illness; in some cases this may be sufficient to warrant obtaining cerebrospinal fluid.
The other reason for a spinal tap is when there is an unclear vaccination history: A recent American Academy of Pediatrics clinical practice guideline on the evaluation of the child with a simple febrile seizure makes a point of more strongly recommending a lumbar puncture for febrile seizure patients who do not have complete immunizations. In this guideline, the recommendation is made specifically for children ages 6–12 months old. This age limit was based on the fact that clinicians “would recognize the signs of meningitis in children older than 12 months.”
In any situation, the clinical judgment of the physician should not be restricted by the clinical practice guideline.
A line connecting the superior portions of the posterior iliac crests passes through the L3-4 or L4-5 interspaces. These are the preferred sites for the LP.
Evaluation of first febrile seizures
Evaluation of first non febrile seizure
Evaluation of First Febrile Seizure
The implicit relationship between fever and seizure activation makes the distinction between febrile seizures and new-onset epilepsy challenging.
Does this child have a simple febrile seizure or is this his first epileptic seizure triggered by a fever?
In general, if the child’s clinical history is consistent with the classic pattern of a simple febrile seizure and if his past medical history and physical examination are normal, then he likely has a febrile seizure and no further workup is necessary.
Evaluation of First Non-Febrile Seizure
Additional neurological investigation is often done in a child presenting with a first afebrile seizure:
Electroencephalogram (EEG)
The EEG is a useful adjunct to the history and physical examination in establishing the diagnosis of epilepsy, but a routine interictal (between seizures) EEG will show an epileptiform abnormality in only approximately 60% of infants and children; less in adolescents and adults.
EEGs may be useful to identify epilepsy syndromes based on both the patient’s history and EEG pattern (e.g., absence seizures and infantile spasms have characteristic EEG findings such as 3-Hz spike-and-wave pattern and hypsarrhythmia, respectively); identification of these syndromes can lead to effective treatment and prognosis.
Magnetic Resonance Imaging (MRI)
MRI is frequently performed in the evaluation of epilepsy.
Brain MRI is much more likely to be abnormal in children with focal seizures than in generalized or febrile seizures.
With better resolution than CT scanning, MRI is able to identify brain parenchymal malformations, vascular malformations and temporal sclerosis.
Computed Tomography (CT)
In general, CT is of little use in the evaluation of a child with suspected epilepsy as it provides little useful information for clinical management.
Exceptions include trauma and the investigation of calcifications, such as in cytomegalovirus (CMV) infections or tuberous sclerosis.
Bacterial meningitis Etiology Symptoms Tx Complications
Bacterial meningitis is one of the most potentially serious infections in infants and children. While it is becoming an increasingly uncommon disease due to immunization (and herd immunity), it is potentially devastating and should therefore be included in the differential diagnosis of all febrile children with altered mental status (such as lethargy, irritability, or seizure).
Etiology
Bacterial meningitis in immunized children 2 months to 12 years of age is usually due to S. pneumoniae or N. meningitidis, although, as stated above, the incidence of invasive pneumococcal disease is diminishing with routine vaccination.
In younger infants, gram negatives such as E. coli and organisms like Group B Streptococcus (Strep agalactiae) need to be considered.
Presentation
Meningitis may present with increasing lethargy and irritability, as well as signs of meningeal irritation (often referred to as nuchal rigidity or meningismus).
Alternatively, non-specific findings may predominate, including:
Fever (in 90-95% of cases) Anorexia and poor feeding Symptoms of an upper respiratory infection Myalgias Tachycardia. Treatment
Treatment includes high-dose intravenous antibiotics directed at the most likely organisms, usually starting with a third-generation cephalosporin and vancomycin, and then tailoring antibiotics based on sensitivities, for a total of 7-14 days.
In cases in which meningitis is highly suspected, antibiotics are generally given empirically as soon as the CSF culture is obtained (in severe cases, even beforehand).
Complications
Complications of bacterial meningitis include:
Stroke
Subdural effusions
Syndrome of inappropriate anti-diuretic hormone (SIADH) secretion.
While it is unusual for treated meningitis to be fatal, morbidity such as developmental delays, seizures, and hearing loss are known complications.
Csf findings in bacterial meningitis
5
Measuring true degree of CSF cells in the event of traumatic spinal tap
Bacterial meningitis results in CSF hypoglycoracchia:
Decreased CSF glucose resulting in
Decreased CSF glucose/blood glucose ratio
You would also find:
Elevated protein and
Increase in WBCs with
Predominance (increased number) of polymorphonuclear cells
The gram stain may demonstrate organisms in the CSF.
A number of methods exist to estimate the true degree of CSF pleocytosis (presence of more cells than normal, often denoting leukocytosis and especially lymphocytosis or round cell infiltration; originally applied to the lymphocytosis of the cerebrospinal fluid present in syphilis of the central nervous system).
Often a RBC/WBC ratio of approximately 250:1 is used. This can be generated by looking at the patient’s CBC and dividing the RBC count (in millions/microliter) by WBC (in thousands/microliter).
This is a very rough estimate and should only be used in the presence of experienced clinical judgment.
Csf in viral meningitis 4
Glucose normal
Glucose/blood sugar ratio normal
Protein normal
WBC count elevated
Febrile seizures
2 types simple vs complex
Risk of recurrence
Risk of epilepsy
Incidence
More common - simple
Less common - complex
Duration
< 15 minutes - s
> 15 minutes -c
Frequency
Once in a 24-hour period -s
More than once in a 24-hour period - c
Type
Generalized - s
Focal - c
Risk of Recurrence
If a child has his first febrile seizure before age 12 months, the recurrence risk for a second febrile seizure is about 50%.
If a child has his first febrile seizure after age 12 months, the recurrence risk is about 30%.
While seizure events are very scary for families, parents should be reassured that recurrent, simple febrile seizures have no long-term effects in terms of child development.
Risk of Epilepsy
In a child who has a febrile seizure, the risk of developing epilepsy is slightly increased above the 0.5-1% baseline population risk.
However, not all febrile seizure patients are alike.
Epilepsy is more common among those children with early, recurrent febrile seizures, especially if there is a family history of epilepsy.
This is to be compared to essentially the same risk as the normal population in a child with one or two simple febrile seizures and no other features.
Children with complex febrile seizures, and those with abnormal development, are at increased risk of epilepsy.
