Altered level of consciousness Flashcards
Febrile convulsion
Defined - brief, generalised seizures associated with a febrile illness, in the absence of any CNS infection or past hx of febrile seizure
Occurs in 3-4% of children from 6 m to 5yrs
Recurs in 1/3
In otherwise health children, FC are not accompanied by an increase risk of intellectual disability, cerebral palsy, other neurological disorder or death.
Modest increase in risk of epilepsy.
Types of febrile convulsion
Simple - brief generalised tonic clonic and single one per illness
Complex - Either focal, greater then 15 min, or multiple in a 24 HR period. Incomplete recovery within an hour or recurrence in same illness
Mx for Febrile convulsions
Underlying cause
- Search for cause of fever - commonest is viral
- General temperature control eg remove excess clothing. Only paracetamol if child is uncomfortable.
Seizure - If duration greater than 10 mins. IV or rectal diazepam 0.2-0.4mg/Kg.
Reassurance - only 3% go on to develop epilepsy compared to 0.5%.
Education - low risk of neurological complication and excellent prognosis for eventual remission. 1:3 risk of recurrence. She will outgrow them. Advise on how to mx.
Management of Seizure at home: lay on side, don’t force her month open, remove any danger, call an ambulance, undo tight clothing around neck, time the seizure, stay with patient and try to reassure.
Follow up visit to help explain things afterwards.
What are the risk factors that make the development of epilepsy in a child with febrile convulsion more likely.
Previous abnormal neurological development
A hx of epilepsy in first degree relatives.
Prolonged Febrile convulsion greater then 10min
Focal features present during or after the febrile convulsion
Multiple convulsions during a single febrile episode
DDX for fits
Non paradoxall?
Syncope
TICS
Breath holding spells
Types of breath bonding spell
Cyanosis - cry and then turn blue
Pallor - sml bump makes then pass out vagal vagus.
Triad of hypoglycaemia
Lethargy - coma
Confusion and agitation
Seizure
Triad of hyperglycaemia
Polyuria
Polydipsia
Blurred vision
Driving restrictions for diabetic
HbA1c less than 9 Knows how to recognise high and low Test regularly If BSL higher than 15 or lower then 4 Stop, treat, wait 2 hrs and retest.
Resus of a child
Airway - check secretions or strider, foreign body or unprotected airway
Breathing - RR, Recession and accessory muscle use, O2 stats, auscultation
Circulation - colour, HR, CRT peripheral and central, temp of hands and feet and BP
Disability - Pupils, limb tone and movement, AVPU and GCS
ENT assessment
Temperature assessment
Tummy assessment
Blood glucose assessment
Cause of ALOC
V - aneurysm or AV malformation, embolus I - Meningitis, Encephilitis, abscess, Malaria, Rabies T - trauma A M - metabolic, dehydration, glucose, Na, Ca, Liver failure I - Drug N - primary tutor C O - Seizure
Tx for raised Intracranial pressure
Raised head of bed Fluid balance - avoid over hydration Manitol if serum is less than 325mOsm/L BP maintained in range Maintain PCO2 May need dexamethasone IDC Maintain glucose and temp NGT to prevent aspiration SKID to avoid bed sores
Triad of hypoglycaemia
Lethargy - coma
Confusion and agitation
Seizure
Triad of hyperglycaemia
Polyuria
Polydipsia
Blurred vision
Driving restrictions for diabetic
HbA1c less than 9 Knows how to recognise high and low Test regularly If BSL higher than 15 or lower then 4 Stop, treat, wait 2 hrs and retest.
Resus of a child
Airway - check secretions or strider, foreign body or unprotected airway
Breathing - RR, Recession and accessory muscle use, O2 stats, auscultation
Circulation - colour, HR, CRT peripheral and central, temp of hands and feet and BP
Disability - Pupils, limb tone and movement, AVPU and GCS
ENT assessment
Temperature assessment
Tummy assessment
Blood glucose assessment
Cause of ALOC
V - aneurysm or AV malformation, embolus I - Meningitis, Encephilitis, abscess, Malaria, Rabies T - trauma A M - metabolic, dehydration, glucose, Na, Ca, Liver failure I - Drug N - primary tutor C O - Seizure
Tx for raised Intracranial pressure
Raised head of bed Fluid balance - avoid over hydration Manitol if serum is less than 325mOsm/L BP maintained in range Maintain PCO2 May need dexamethasone IDC Maintain glucose and temp NGT to prevent aspiration SKID to avoid bed sores
Hx Q to ask for suspected febrile convulsion
I'd if seizure or rigor Febrile vs a febrile CNS infect Simple vs complex ID cause Hx fever
Ex for febrile convulsion
Neurological exam
Check for source of fever
Ix for febrile convulsion
Only if complex seizure
Paediatric GCS
For less then 4yr Eyes - spontaneous 4 - verbal 3 - pain 2 - None 1 Verbal - Appropriate words or social smile, fixes, follows 5 - Cries but consolable; less than usual words 4 - Persistently irritable 3 - Moans to pain 2 - none 1 Motor - Spontaneous or obeys verbal command 6 - Localises to stimuli 5 - withdraws to stimuli 4 - Abnormal flex ion to pain - decorticate - 3 - Abnormal extension to pain - decerebrate - 2 - None 1
AVPU
Alert
V - response to voice
P - response to pain - purposefully or not (withdrawal/flexor response or extensor you response) same at GCS 8 needs to protect airways by intubation to prevent aspiration.
U - unresponsive
Assess pupil size, equality and reactivity.
Causes of coma
head injury Meningitis/encephalitis Seizure Toxin ingestion Cerebrovascular accident Major organ failure Metabolic causes Anaphylaxis Shock
Causes of fits, faints, funny turns
Infants and toddlers - Apnoea and acute life threatening event - Febrile convulsion - Breathing hold spells - Reflex anoxic spells - Infantile spasm - Hypoglycaemia and metabolic conditions School aged children - Seizure/Epilepsy - Syncope - Hyperventilation - Cardiac arrhythmia - Hypoglycaemia
Hx Q for a child in a coma
Possible drug ingestion
Prodromal illness or so tact with serious illness
Possibility of non accidentally injury
Hx of convulsion and details about them
Child neurodevelopmental Hx normal prior.
Ex of a child in a coma
Vital signs
- bradycardia in raised ICP
- tachyarrythmia - drug ingestion
- Deep, sighing (Kussmaul) - DKA Ketones on breath
Focus of infection - check rashes, neck stiffness, pneumonia and UTI
Check pupils - symmetrical and constrict?
Check for abnormal posture eg decorticate or decerebrate
Assess LOC with GSC or AVPU
Blood pressure
Ix for a child in a coma.
Blood glucose - hypo-hyperglucaemia
FBC - infection or blood loss
Blood culture - infective
U and E - urea if dehydrated. Na high or low
Blood gases - Metabolic or Resp acidosis
CXR - infection or cardia failure, trauma eg rib fracture
CT or MRI - focal pathology - tumour, haemorrhage, abscess
LP - infection (meningitis, encephalitis) or bleeding (SAH)
Metabolic screen - ammonia in urea cycle defect or Reye’s syndrome. need to exclude raise ICP
LFT - hepatic encephalopathy
URine - toxicology screen for poisoning or overdose. Ketones and culture.
Meningitis
Cause
Viral - Mumps virus - Coxsackie virus - Echovirus - Herpes simplex - Poliomyelitis Bacterial - Neisseria meningitis - Streptococcus pneumoniae - Haemophilus influenza epidemic type B - Group B streptococcus - newborn - Escherichia coli and listeria - newborn
Symptoms and signs of viral meningitis vs bacterial
Viral Preceded by pharyngitis or GI upset Develops fever, headache, neck stiffness Bacteria Drowsy and may be vacant Irritability is common High pitched cry Convulsion Examination Ill child with stiff neck and positive Kernig's sign (pain on extending leg). Bulging fontanelle. Petechiae or purpuric rash. DDX - tonsillitis and otitis media and mimic neck stiffness
Ix of meningitis
Confirmed by LP showing leucocytosis, high protein count, low glucose and may show organism. Appears cloudy.
Tx of meningitis
?
Causes of encephalitis
Herpes simplex virus
Mycoplasma pneumoniae
Symptoms and signs and IX of encephalitis
Onset is mor insidious then meningitis
Personality may change
Confused or clumsy before coma
LP - lymphocytesis, culture and PCR for virus
Tx of encephalitis
Acyclovir Erythromycin Cefotaxime Used until organism is known EEG and MRI show temporal lobe involvement.
Metabolic causes of coma
Hypoglycaemia - due to reduced carbohydrate intake or excess insulin in children with DM or inborn error of metabolism or adrenal insufficiency
Hyperglycaemia - uncontrolled diabetes can lead to DKA and coma. Onset is gradual.
Severe uraemia from renal failure
High ammonia from inborn errors of metabolism such as urea cycle
Sever hypernatraemia or hypo atresia
Severe dehydration
Reye’s syndrome
Preceded by viral illness eg influenza or chickenpox
Commoner in winter
Triggered by aspirin during viral illness
Symptoms - initial phase of vomiting, and lethargy followed by a non inflammatory encephalopathy illness with personality changes, irritability and then coma with ICP
Fatty changes n liver may lead to acute hepatic failure
Tx - mainly supportive aggressive intensive care Tx to trest ICP.
Non accidentally injury
CT brain scan and skeletal survey
Retinal haemorrhages
Urine toxicology screen
Drugs that affect CNS - opiate analgesics, alcohol and antidepressents
Acute asphyxiation event
Birth asphyxia
Near miss cot death
Post cardiac arrest
Shock
Capillary refill greater then 2 sec
Cool, mottled peripheries
Thready pulse
Encephalitis
Fever
Hx of changes in personality or ability
Raised intracranial pressure
Symptoms
Headache, vomiting and visual disturbances
Depressed consciousness
Photophobia
Tinnitus
retrobulbar pain
Papilloedema
decreased visual acuity
Extra ocular movement problems
Diplopia
relative afferent pupillary defect
Signs
Cushing’s triad: Hypertension, bradycardia, Irregular breathing
Signs of Herniation
Subfalcine = common: Headache, contralateral leg weakness
Transtentorial - central: Small but reactive pupil, drowsiness
Transtentorial - temporal uncle: CN III - ipsilateral dilated pupil
Tonsillar: Obtundation, decerebrate posture
Cardiorespiratory arrest.
Head injury DDX
Subdural haematoma
Extramural haematoma
Diffuse axonal injury
Non accidentally injury
Cerebrovascular accident DDX
Vasculitis disorder
HTN
Thrombotic disorder
malformation
Metabolic disorders DDX
Hypoglycaemia DKA Inborn errors of metabolism Renal failure - uraemia Liver failure - hepatic encephalopathy Reye's syndrome
Convulsion
Status epileptic us
Hx of epilepsy
Breath holding spells
Primarily in babies and toddlers
Resolves by 18m
Symptoms - crying due to pain or temper. Cries once or twice and then takes a deep breath become deeply cyanosis and limbs extend. May loose consciousness and have convulsive Jerks. After becoming limp resumes breathing and after a few seconds become alert. 1 min in total.
Dx clinically due to Hx and no postictal.
Tx educating the parent and reassureiing them to treat the child as normal.
Reflex anoxic seizure/Breath holding attacks
White breath holding attacks
Peak at in 6m to 2 yr
Occur after a bump on the head or other minor injury which trigger a excessive vagal reflex results in bradycardia, and circulatory impairment.
May or may not cry, turns pale and collapses.
Transient apnoea and lumpiness followed by recovery after 30-60mins
May have eye rolling and incontinence and sometime clonic stiffening of the limbs but no tongue bitting.
Afterwards may be tired and emotional
DDX for epilepsy by Hx and absence of postictal drowsiness.
Tx
Educate that they are benign and disappear before school.
In episodes : put child in recovery position and await recovery.
Reassurance.
Infantile spasm
Form of generalised myoclonus epilepsy
Onset in infancy, peaking between 4-8m
Symptoms - sudden tonic flexor spasm of the head and trunk causing the child to bend forward
Relaxation after a few seconds and episode may occur in cluster up to 10 to 20 times, Common on awakening, or just before sleep.
Sometime extensor spasm
Dx EEG - Chaotic hips arrhythmia pattern
Ass with tuberous sclerosis so examine with a Wood’s light
MX
Vigabatrin may be beneficial
Ass with severe learning disability.
Syncope
Cause - Hypotension and decrease cerebral perfusion
Particularly - Teenage girl reacting to painful or emotional stimuli or prolonged standing.
Symptoms - blurred vision, light headedness, sweating and nausea precede loss of consciousness. Regain consciousness after lying flat.
In childhood it is rarely a symptom of cardiac arrhythmia a or poor cardiac output in childhood.
Mx
- cardiovascular examination
- standing and lying BP
- ECG if cause is doubted
- Tilt table test in unusually severe cases.
Cardiac arrhythmias
If clear Hx of palpitations or FmHx of cardiac tachyarrythmia said or sudden death.
Cause
- Hypertrophic cardiomyopathy - autosomal dominant condition. Due to episodes ventricular tachycardia with syncope.
- Wolff- Parkinson White syndrome - SVT - recently rhythms and Characteristics ECG wth short PR, Delta wave upstroke to R wave, markedly increase QT interval on ECG
Need 24hr ECG recording.
Hyperventilation
causes
- excitement in teenagers leads to hyperventilation and LOC particularly in teenage girls
- Hypervention - drop in CO2 - triggering apnoea
Dx based on Hx of breathing excessive and deep and tetany may occur.
Tx - rebreathe into a paper bag to allow CO2
- if recurrent episode then psychological therapy is needed.
Hypoglycaemia and other metabolic conditions
Cause LOC with seizures of ALOC Suspect underlying metabolic problem if following as present - developmental delay - Dysmorphism - Hepatosplenomegaly - Micro or macrocephaly
