Aquifer - Neuro (Part 1) Flashcards
19, 23, 24
DDx - unresponsiveness in children (7)
- Toxic ingestion
- Seizures
- Syncope
- Closed Head Injury
- Infection
Less common:
Intracranial process, intusussception
Most common age of presentation of toxic ingestion in children?
9 months-3 years
List some of the common medications that can lead to unresponsiveness. List some poisons that can lead to generalized seizures.
Opiates, benzodiazepines, and clonidine
Other medications that can cause a metabolic disturbance (e.g., oral diabetic agents causing hypoglycemia) should be considered
Acute alcohol poisoning and lead poisoning
Syncope due to ___ is common in children between what ages? What causes this phenomenon?
Breath-holding spells; 6 months to 6 years
Occurs during expiration and is reflexive in nature - child starts to cry, then suddenly falls silent in the expiratory phase of respiration, which can be followed by a color change
Two types of breath-holding spells?
Cyanotic (more common) or pallid (acyanotic) type
Key features of a cyanotic breath-holding spell? Key features of pallid spells?
Precipitating event that upsets the child resulting in vigorous crying and hyperventilation, followed by a prolonged expiratory apnea
Transient hypoxia results in the child turning pale or cyanotic followed by brief LOC and limpness
Quickly self-resolve, typically no associated post-ictal state
A child with a breath holding spell may have a brief generalized seizure, most likely due to hypoxia
Pallid: typically associated with injury
Prognosis of breath holding spells?
Parents should be reassured that these are a benign and self-limited condition. Very rarely, they have been reported to be associated with asystole.
Cardiac syncope is more unusual in an infant or toddler, but should be considered. It would most likely not be vasovagal type syncope - what can cause it?
Supraventricular arrhythmias (tachycardia) or ventricular arrhythmias (in the settling of prolonged QT syndrome) can decrease cerebral blood flow and cause syncope
Up to 30-40% of children with meningitis can present with seizure activity. What other signs may be seen?
Fever and irritability; post-seizure impairment
How do children with encephalitis present?
Waxing and waning mental status, as well as fever and seizure; post-seizure impairent
What 2 viruses should be considered as possible pathogens for encephalitis?
Enterviral infections and HSV
Medical history in a patient with a brain tumor?
Preceding history of headache, behavior change, vomiting, focal neurologic change, seizure from an intracranial mass lesion would most likely begin as a partial seizure
What are the most common solid tumors in children and where do they occur?
Brain tumors (1200 cases/year), usually in the posterior fossa
What is intussusception?
Telescoping or prolapsing of a portion of the intestine
Why can intussusception lead to a near unresponsive state or mental status changes?
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 commonly have intravascular volume depletion due to vomiting and third spacing of fluids, leading to mental status changes similar to a child who is very dehydrated.
List the 5 types of seizures.
- Generalized tonic-clonic
- Simple partial
- Complex partial
- Petit mal (childhood absence epilepsy)
- Atonic (akinetic)
What is the most common type of seizure in children?
Generalized tonic-clonic
Describe a generalized tonic-clonic seizure.
Begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes. Clonic jerks of all extremities follow the tonic phases. Finally, the child becomes flaccid, and urinary incontinence may occur.
Describe a simple partial seizure.
Motor signs in a single extremity or on one side o the body; may spread to become generalized, making it difficult to distinguish from a generalized seizure
Describe a complex partial seizure.
Altered level of consciousness (hallmark), blank stare, lip-smacking, drooling, gurgling, N/V
Automatisms (quasi-purposeful motor or verbal behaviors that are repeated inappropriately) commonly accompany this type
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 1/3 of children
Age of onset of childhood absence epilepsy?
Around 3 years
Describe absence seizures.
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 in generalized tonic-clonic
No loss of tone or urinary continence
Can be precipitated by hyperventilation or photic stimulation
Describe an atonic (akinetic) seizure.
Loss of motor tone
True seizures result from ___. Many other conditions (e.g., motor tics, myoclonus, gastroesophageal reflux in Sandifer’s syndrome, and pseudoseizures, aka psychogenic non-epileptic seizures) can result in movements or behaviors mimicking a seizure.
Sudden and abnormal electrical activity in the brain
List evidence for a true seizure.
History of alteration or loss of consciousness
Incontinence
Deviation of the eyes
Rhythmic motor movements that cannot be stopped by touching or holding the child
Postictal state
List the steps in determining the etiology of a seizure.
- Detailed description of the event
- Detailed timeline of the events
- Any precipitating events such as fever
- Possibility of toxic ingestion
- Any history of injury
- Medical and family history - past history of seizures, developmental delay, premature birth, family history of seizure disorders or neurologic problems, family members with certain medical conditions which may require certain medications that could have been ingested by the patient.
List prenatal, perinatal, and neonatal events/complications that may be associated with neurologic abnormalities leading to a seizure.
- Intrauterine congenital infections can lead to microcephaly, developmental delay, and seizures
- Teratogens must be considered
- Perinatal complications such as asphyxia
- Premature infants are at risk for intracranial hemorrhages
- Neonatal meningitis, prolonged hypoglycemia, and kernicterus in the newborn period
What is the relationship between developmental maturation and seizures?
Abnormalities in neurodevelopmental maturation could suggest serious underlying disease in a child with seizures. Most children with febrile seizures are developmentally normal. Pre-existing developmental abnormalities are a risk factor for subsequent epilepsy.
DDx - seizure (8)
- CNS infection (meningitis/encephalitis)
- Febrile seizure
- Head injury/post-traumatic seizure
- Ingestion/poisoning
- Idiopathic seizure/epilepsy
- Hypoglycemia
- Brain tumor
- Breath-holding spell
A seizure related to head injury generally occurs ___ (time) after the incident.
1-2 hours
Discuss the presentation of epilepsy in children.
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, what can cause a fever?
Sustained motor activity and release of inflammatory mediators
Diagnosis of epilepsy?
2+ unprovoked seizures
Epilepsy in all forms has a prevalence of ___% throughout childhood
~1
One of the most common reasons for seizures in children is febrile seizures. They occur in ___% of children between ages ___. Discuss the general presentation.
2-5; 6 months-5 years; generalized
Usually occur on the first day of the febrile illness
Fever >38 degrees
Tend to be developmentally normal
Often have a +family history (other first-degree relatives with febrile seizures as children)
Most are generalized
Discuss febrile seizures vs. a CNS infection causing seizures in the setting of fever.
Febrile seizures - a fever, typically caused by a benign illness like a viral infection - triggers a seizure in a susceptible host (young child, positive family history, etc.)
CNS infection - infection itself causes both the fever and the seizure. Prolonged fever prior to the event, especially with irritability or inconsolability, is an indication of a more serious CNS condition
True or false - febrile seizures are hreditary.
True - the exact mode of inheritance is still unclear.
When should an LP be obtained in the setting of possible febrile seizure?
A child age 6-12 months with incomplete or unknown immunizations against Hib or S. pneumoniae, particularly if the child’s neurologic status is worrisome or difficult to obtain.
Evaluation of a first febrile seizure?
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 exam are normal, then he likely has a febrile seizure and no further workup is necessary.
Evaluation of a first non-febrile seizure with EEG?
EEG - useful adjunct to H&P, but a routine interictal (between seizures) EEG will show an epileptiform abnormality in only ~60% of infants and children, and less in adolescents and adults.
May be useful to identify epilepsy syndromes based on both the patient’s history and EEG pattern
Evaluation of a first non-febrile seizure with MRI?
Frequently performed; brain MRI is much more likely to be abnormal in children with focal seizures than in generalized or febrile seizures
Can identify brain parenchymal malformations, vascular malformations, and temporal sclerosis
Evaluation of a first non-febrile seizure with CT?
Little use in the evaluation of a child with suspected epilepsy
Exceptions include trauma and the investigation of calcifications, such as in CMV infections or tuberous sclerosis
Compare the incidence, duration, frequency, and type of simple vs. complex febrile seizures.
Simple:
More common, <15 minutes, 1x in a 24-hour period, generalized
Complex:
Less common, >15 minutes, >1x in a 24-hour period, focal
Discuss the risk of recurrence in a child with a febrile seizure.
First febrile seizure before 12 months, recurrence risk is ~50%
First febrile seizure after 12 months, recurrence risk is ~30%
Parents should be reassured that recurrent, simple febrile seizures have no long-term effects in terms of child development
Discuss the risk of epilepsy in a child with a febrile seizure.
Risk of developing risk is slightly increased above the 0.5-1% baseline population risk
More common among children with early, recurrent febrile seizures, especially with a family history of epilepsy
Complex febrile seizures - increased risk
Abnormal development - increased risk
Guidance about febrile seizures for caregivers regarding treatment for fever
Give acetaminophen or ibuprofen if he is uncomfortable
Not helpful in preventing recurrence of febrile seizures
Guidance about febrile seizures for caregivers regarding what to do in the event of seizure?
Place child on his side so he won’t choke on stomach contents or saliva
Ensure a safe setting to prevent injury
Nothing should be placed in the child’s mouth to keep him from biting his tongue
Do not restrain the child’s movements during the seizure
Remain as calm as possible
Most seizures stop on their own within a few minutes
Call 911 if the seizure lasts >5 minutes
Guidance about febrile seizures for caregivers regarding medications?
While there are some medications that may prevent future seizures, the child would have to take them either all the time or intermittently when sick. Experts agree that such medications should not be used in children with simple febrile seizures because of the potential for serious AEs.
Which medications are effective in preventing recurrence of simple febrile seizures?
Phenobarbital (poor adherence, serious side effects in at least 20% of patients), primidone (high side effect profile), VPA (hepatotoxic)
Diazepam given at the start of the febrile illness can be effective in preventing recurrent febrile seizures - sedating side effects that may cloud the presentation of a serious CNS infection led to not recommending this
Which medications have not been shown to be effective in preventing febrile seizure recurrence?
Carbamazpeine, phenytoin
Primary ___ infection is associated with ~20-30% of first febrile seizures in children.
HHV-6 (roseola)
Describe the presentation of tension headaches.
Often occur in the setting of emotional stress, fatigue, lack of sleep, and other stressors
Most often episodic
Generally worsens throughout the day
Mild to moderate intensity
May feel like a band around the head or involve the occipital area with accompanying tenderness of the posterior muscles of the neck
What is the most common cause of recurrent headache in children?
Migraine headaches
Although uncommon, migraines can first manifest as what 3 periodic syndromes seen exclusively in the pediatric age group?
- Cyclical vomiting
- Abdominal migraines
- Benign paroxysmal vertigo
What are the symptoms of migraines?
More severe than tension headaches
Often throbbing in nature
Often accompanied by photophobia and/or phonophobia, abdominal pain, N/V
Common precipitating factors of migraines?
Stress, bright lights, odors (such as perfumes), foods
Alleviating factor of migraines?
Frequently relieved by sleep
Risk factor for migraines?
Family history in about 50% of those with migraine headaches
Describe a “classic” migraine (vs. common)
Accompanied by an “aura,” which can include visual symptoms (bright spots in the visual field), speech changes or sensory abnormalities (such as paresthesias
Describe a “common” migraine (vs. classic)
Migraine without an aura, typically unilateral, frontal or temporal in location, but may involve any part of the head
What is the most frequent type of migrainous headache seen in children?
Common migraine
List red flag symptoms for life-threatening causes of headaches.
Occurring with forceful vomiting after lying down (increased ICP)
Sudden onset (intracranial hemorrhage)
Awakens from sleep (increased ICP)
Accompanied by fever and photophobia (meningitis, encephalitis)
Worsens with cough or Valsalva (increased ICP)
Progressively worsening in frequency or severity
Discuss the relationship between development and migraines.
Normal development is reassuring, but does not exclude serious pathology. Abnormal development would cause the clinician to consider a potential relationship between the delay and headaches. If the child has always been delayed, a link may be unlikely. Loss of milestones, however, would be very concerning and would cause one to consider a neurologic process.
Genetic basis for migraine headaches?
Twin studies and the familial nature of migraines point to a genetic basis. However, no genes have clearly been linked to the common varieties of migraine. Studies of families with a rare form of migraines (Familial Hemiplegic Migraine - FMH) demonstrate evidence for the involvement of calcium channel gene mutations and alterations in the gene for a sodium/potassium ATPase.
Fever and tachycardia in a child with headache may indicate what?
Serious infectious process such as meningitis, encephalitis, intracranial abscess (such as from complications of sinusitis or otitis media), or even sepsis
What is Cushing’s triad and what does it suggest?
Elevations in BP, bradycardia, and irregular respirations
Increased ICP
What causes an abnormal Romberg test?
Diseases resulting in decreased position sense or abnormal vestibular function will lead to a + test only with eyes closed (vision helps compensate for the abnormality)
Patients with cerebellar pathology have a + test with eyes open and closed
What is Idiopathic Intracranial Hypertension (previously known as pseudotumor cerebra)?
Increased ICP in the absence of intracranial mass lesion or hydrocephalus, often mimics brain tumors in presentation. Thought to occur because of alterations in CSF absorption and/or production, or abnormalities in vasomotor control and cerebral blood flow
Symptoms of idiopathic intracranial hypertension?
Headache (most common presenting complaint), vomiting may occur, diplopia secondary to paralysis of the abducens nerve may be present
Causal/predisposing factors of idiopathic intracranial hypertension?
Obesity, medications (vitamin A derivatives, tetracycline, OCs, steroids, etc.), metabolic disorders (galactosemia, hypoparathyroidism, etc.), infections (sinusitis, chronic otitis media, etc.)
How is idiopathic intracranial hypertension diagnosed?
Increased ICP with associated symptoms such as headache and vomiting + normal brain anatomy + normal CSF
Brain imaging is usually normal; in some children ventricles may be small; no mass lesion is seen
Dx with an elevated CSF opening pressure during a lumbar puncture
Complications of idiopathic intracranial hypertension?
Blindness resulting from transmission of elevated CSF pressure to the optic nerve sheath.
What information should be included in a headache diary?
Character, duration, location, associated symptoms, activity at the time of the headache, potential triggers, alleviating factors
What is ataxia?
Lack of coordination of muscle movements; non-specific neurological sign which can result from dysfunction in various parts of the nervous system that coordinate movements, such as the cerebellum, the inner ear, and the dorsal columns. It can be congenital or acquired.
DDx - acquired ataxia (10)
- Post-infectious cerebellitis (aka acute cerebellar ataxia)
- Infectious cerebellitis
- Medication or toxin
- Intracranial mass
- Opsoclonus-myoclonus syndrome
- Migraine headache
- Hydrocephalus
- Metabolic disease (MSUD, pyruvate decarboxylase deficiency, etc.)
- Neurodegenerative disease (ataxia-telangeictasis and Friedreich ataxia)
- Psychiatric illness (conversion disorder)
What is the most common cause of acute ataxia in children?
Post-infectious cerebellitis
Describe the presentation of post-infectious cerebellitis.
Primarily a diagnosis of exclusion in children 1-3 years
Occurs several weeks after a viral infection (e.g., varicella or coxsackie)
Sudden onset of ataxia, vomiting, nystagmus (in ~50%) and dysarthria (in some)
Not typically associated with fever or other systemic manifestations
Possible pathogenesis of post-infectious cerebellitis?
Autoimmune response leading to cerebellar demyelination
CSF in post-infectious cerebellitis?
May be normal or have a pleocytosis; eventually the CSF protein is elevated
Prognosis of post-infectious cerebellitis?
Majority of children recover completely within a few months
Etiology of infectious cerebellitis?
May be viral or bacterial
Viral pathogens include mumps, enterovirus, EBV
Bacterial pathogens include those that cause bacterial meningitis (S. pneumoniae, N. meningitidis, Hib)
Presentation of infectious cerebellitis?
Ataxia, fever, mental status changes
Examples of medications and toxins that can cause acute ataxia?
Anticonvulsant, alcohol, sedating antihistamines
Presentation of ataxia in medication/toxin abuse?
May be accompanied by nystagmus and dysmetria, usually bilateral due to the diffuse involvement of the cerebellum including the vermis and hemispheres
Ataxia due to an intracranial mass is most often associated with tumors in what parts of the brain?
Cerebellum or frontal lobe
What is opsoclonus-myoclonus syndrome?
Paraneoplastic syndrome that occurs most often with neuroblastoma
Presentation of opsoclonus-myoclonus syndrome?
Younger child (6 months-3 years) Ataxia accompanied by intermittent jerking movements (myoclonus) and erratic, jerky conjugate movements of the eyes (opsoclonus)
What types of migraines can cause recurrent intermittent episodes of acute ataxia?
Basilar artery migraines or hemiplegic migraines
May be accompanied by intermittent loss of vision, change in speech, headache, and vomiting
How does ataxia associated with hydrocephalus present?
Generally insidious in onset, quite chronic with increasing loss of coordination over weeks to months. Usually associated with headache and vomiting
Type of ataxia seen in metabolic disease?
Intermittent or chronic with intermittent exacerbations
Presentation of a neurodegenerative disease causing ataxia?
Most affected children are younger than 10, and their symptoms include a loss of developmental milestones, ataxia, and other neurologic symptoms
What happens in conversion disorder?
Hysterical involuntary disturbance in gait (patient truly believes something is wrong but no physical pathology exists) known as astasia abasia
Unlike true ataxis, this gait is wildly erratic and involves lurching of the body which requires extraordinary balance
The child is generally able to sit without difficulty, but when put in a standing position, immediately begins to sway at the waist
These patients will rarely fall.
Presentation of basilar migraine?
Often young women or children
First develop visual phenomena like those of a typical migraine except that they are bilateral
Transient cortical blindness may also occur
May have associated vertigo, ataxia, incoordination of the limbs, dysarthria, and bilateral limb and perioral paresthesias
Sometimes followed by a transient loss or impairment of consciousness or by a confusional state
This is followed by a throbbing headache (usually occpipital) often associated with N/V
What is nystagmus?
Rhythmic oscillation of the eyes, analogous to tremor in other parts of the body; may occur in 1+ planes (horizontal, vertical, or rotary)
Usually quicker in one direction that in the other
Defined by its quicker phase
What causes nystagmus?
Cerebellar disease (when due to cerebellar disease, most prominent when looking toward the side of the lesion) Tumor, toxins, cerebellitis, MS
What causes periodic alternating nystagmus?
Diffuse cerebellar lesions and patients with midline cerebellar lesions arising from the vermis or the nodule, such as cerebellar medulloblastoma
What is the role of the cerebellum?
Motor control, coordination, precision, and balance control
Why do mass lesions in the cerebellum often lead to obstructive hydrocephalus?
Due to the close proximity of the cerebellum to the 4th ventricle
Symptoms caused by cerebellar lesions within the vermis?
Dysarthria, truncal ataxia, and gait abnormalities
Symptoms caused by cerebellar hemispheric lesions?
Ipsilateral limb abnormalities, nystagmus, tremor/dysmetria, sparing of speech
Patients fall toward the side of the lesion and have worse nystagmus when they look towards the side of the lesion
Symptoms caused by lesions of the deep cerebellar nuclei?
Resting tremor, myoclonus, opsoclonus (seen in neuroblastoma)
___ is contraindicated in a patient with increased ICP and focal findings on neurologic exam. Why?
LP; may lead to brain herniation
Visualization of a suspected brain tumor?
MRI (excellent detail of the posterior fossa)
CT is not good in visualizing the posterior fossa as well. Would be used if intracranial hemorrhage needed to be ruled out
How do infratentorial lesions usually present?
Cerebellar signs and signs of raised ICP
How do cerebellar hemispheric lesions present?
Hypotonia and hyporeflexia
How do supratentorial lesions usually present?
Focal motor and sensory abnormalities on the opposite side of the lesion
How do brain stem tumors usually present?
CN and gaze palsies
Incidence of brain tumors in children?
Most common solid tumor in children, second most common form of childhood cancer (#1 - leukemia)
Incidence has been increasing over the past several decades for unclear reasons
Incidence peaks in the first decade of life, with a second peak in the 8th decade of life
Discuss survival of brain tumors in children.
Mortality rate has decreased by 20% in children since 1975, though this is disproportionately less than that seen with other childhood cancers
Deaths caused by childhood brain tumors are the highest among all childhood cancer deaths
Morbidity associated with brain tumors is significant
Brain tumors are more common in the ___ age group.
Younger (<7 years)
Incidence of childhood brain tumors in M vs. F
Males are slightly overrespresented, but this can be accounted for by the higher male incidence of 2 types of brain tumors (ependymomas and medulloblastomas)
Which type of tumor (supra vs. infra) are more common in chidren?
Supratentorial - first 2 years of age
Infratentorial - dominate for the rest of the first decade
Supratentorial - more common in adolescence and adulthood
Risk factors for childhood brain tumors?
Exposure to ionizing radiation
Certain genetic syndromes (tuberous sclerosis, neurofibromatosis, Li-Fraumeni syndrome - very rare)
Histologic classification of the 4 most common brain tumors in children?
Medulloblastoma (20%)
Juvenile pilocytic astrocytoma (20%)
Low-grade astrocytoma (15%)
High-grade astrocytoma (7%)
Most common pediatric brain tumor?
Medulloblastoma (aka infratentorial neuroectodermal tumor)
Malignant tumor that may spread through the CNS, capable of metastasizing to extracranial sites
Prognosis and Rx of medulloblastoma?
Prognosis depends on size and dissemination
Rx - surgical resection, radiation, chemotherapy
What tumor has the best prognosis of all infratentorial tumors in children?
Astrocytoma of the cerebellum
often have a cystic component
Prognosis and treatment of astrocytoma of the cerebellum?
Prognosis - 5-year survival is ~90% with complete resection, 50-70% with partial resection
Rx - surgical resection; radiation reserved for patients with high-grade astrocytomas, partial resections, or those patients in whom postop tumor progression is evidence
Prognosis and Rx of brain stem glioma?
Prognosis ranges from quite grave (aggressive, resulting in diffuse infiltration of the pons) or quite good (low-grade, resulting in a focal tumor in the midbrain or medulla)
Rx - surgical resection alone for low-grade
Ependymomas arise from within the ___ and cause symptoms related to ___.
Fourth ventricle; hydrocephalus
Prognosis and Rx of ependymoma?
5-year survival is ~50%
Rx - surgical resection followed by radiation
General Rx for CNS tumors?
Except for unresectable tumors, therapy usually begins with surgery to establish the histologic diagnosis and to reduce tumor burden
Radiotherapy, chemotherapy, and other adjuvants such as BM transplantation may also be indicated based on histology
Complications of brain tumor or treatment?
Obstructive hydrocephalus, seizures, hypothalamic-pituitary hormonal insufficiency
Long-term sequelae of childhood brain tumors are most often from the effects of chemo and/or radiation. The most common are?
Neurocognitive defects ADD Learning disabilities Endocrine abnormalities Stroke Overall IQ deficits
The rate of overall IQ deficits following childhood brain tumors are associated with what risk factors?
Younger age at time of treatment Longer time elapsed since treatment Female gender Hydrocephalus Use of radiation therapy and its extent and dose
What emergency conditions cause altered mental status due to a lack of cellular substrate and must be reversed quickly to prevent cellular damage?
Hypoxia
Shock
Hypoglycemia
List specific CNS conditions that can lead to acute altered mental status (#).
Infection (sepsis, meningitis, encephalitis)
Poisoning/toxic ingestion
Increased ICP (CNS tumor, hemorrhage)
Trauma
Metabolic disturbance (e.g., diabetic ketoacidosis)
What is the most sensitive measure of adequacy of circulation?
Heart rate - tachycardia is the first and most subtle sign of possible inadequate perfusion
Capillary refill time and strength of peripheral pulses are useful, but not as sensitive.
BP is not a sensitive measure of volume status or circulation because the body’s protective mechanisms maintain blood pressure, so hypotension is a late sign of shock. Pulse pressure may widen before systolic BP drops
How are airway and breathing assessed?
Describing the effort and rate of breathing (look at the chest to count RR and describe WOB)
Listening to how the patient’s lungs sound (listening for wheezes, rales, rhonchi, diminished breath sounds)
Checking the patient’s oxygenation (pulse ox)
If the patient does not seem to be moving air when breathing, you should first check the airway to determine if there is an obstruction (position the neck and/or perform the jaw thrust)
The best position to open the airway depends on the age of the patient. In general, the opening of the ___ should be aligned with the ___.
External ear canal; anterior aspect of the shoulder
Airway positioning - infant
Place a blanket under the shoulders to tip the head into a “sniffing” position (nose tipped slightly upward)
Airway positioning - 1-3 year old
Neutral position keeps the head slightly tipped back
Airway positioning - 4-8 years old
Extend the neck (extend more with age)
Airway positioning - child/adolescent
Hyperextend the neck
When assessing breathing, always listen to the chest in the ___. Also, look at the alignment of the ___.
Axillae; trachea (if deviating from the midline significantly, check for distended neck veins - could be a sign of tension pneumothorax)
In addition to the ABCs of emergency care, what are the D’s and E’s?
D - Disability (quick neurologic assessment for signs of increased ICP and clues for poisonings) - assess mental status, evaluate pupils (size and reaction to light) + Dextrose (check for hypoglycemia)
E - Exposure (expose and examine all parts of the patient) and Environment (keep the patient warm)
Findings in adult patients with bacterial meningitis? Children? Infants?
Adults: nuchal rigidity (57-92%), fever (66-100%), altered mental status (44-96), Kernig’s or Brudzinski’s sign (61%)
Children: less reliable findings, present in only about 50%
Infants - presence of a bulging fontanelle and focal seizures are the only presenting signs or symptoms significantly associated
Leading cause of bacterial meningitis in children?
N. meningitidis (since Hib and pneumococcal vaccines)
Although outbreaks of bacterial meningitis can occur in institutions such as child care centers, schools, colleges, and military recruit camps, most cases are ___.
Sporadic (<5% associated with outbreaks)
Peak incidence of meningococcal disease in chidlren?
<12 months of age, another peak at 16-21 years
Which serogroups of N. meningitidis account for ~30% of total reported cases?
Among young adults, what serogroups cause most causes?
In infants?
B, C, Y
Young adults - C, Y, W-135 (vaccine)
Infants - B (no vaccine currently in the US)
Risk factors for meningococcal disease?
Persons living in close accommodations (dorms, military boot camps), complement deficiency, anatomic or functional asplenia
Transmission of meningococcal disease + incubation period?
Respiratory droplets, requires close person-to-person contact; 1-10 days
Acute systemic meningococcal disease is most frequently manifested by what three syndromes?
Meningitis
Meningitis with accompanying meningococcemia
Meningococcemia without clinical evidence of meningitis
Early signs of meningococcal disease?
Fever, chills, malaise, myalgia, prostration, rash (macular, maculopapular, petechial, purpuric)
Signs of more fulminant meningococcal disease?
Purpura, limb ischemia, coagulopathy, pulmonary edema, shock
Overall case-fatality rate of meningococcal disease?
10% (and is higher in adolescents)
Sequelae of meningococcal disease?
Hearing loss, neurologic disability, loss of digits or limbs, scarring
DDx - fever and petechiae (adolescent?) 4
- Meningococcal sepsis
- Toxic shock syndrome
- Rocky Mountain Spotted Fever
- Bacterial endocarditis
Patients presenting to the ED with fever and a rash must be started on antibiotics as soon as possible. Most ED physicians will start a patient on…
- Ceftriaxone (GN such as N. meningitidis, GP such as S. aureus, GAS, and S. pneumoniae)
- Vancomycin (resistant S. pneumoniae, MRSA)
- Doxycycline (RMSF in endemic areas)
Once a definitive diagnosis of meningococcal disease is made, how is treatment narrowed?
Switch to penicillin G to eradicate organism from blood and CSF, then treat with either rifampin (children/young adults) or ciprofloxacin (adults) to eliminate the carrier state, or 5-7 days of ceftriaxone
Guidelines for meningococcal prophylaxis?
Close contacts warrant prophylaxis
- Adults: ciprofloxacin
- Children (<18 years): oral rifampin or IM ceftriaxone
- Pregnant women: azithromycin
DDx - acute onset altered mental status (2 year old) - 4
Infection (sepsis, meningitis, encephalitis) Toxic ingestion Trauma Seizure Electrolyte/glucose abnormalities
General DDx - Altered Mental Status (AEIOU and TIPS)
Alcohol, ingested toxins Epilepsy, encephalitis, endocrine, electrolyte Infection (meningitis/sepsis) Overdose, opiates, oxygen deprived Uremia (renal failure) Trauma, temperature Insulin Psychosis Stroke, shock, space occupying lesions
Initial treatment to address tachycardia, hypotension, hypoxia, and hypoglycemia?
- Bolus of 20 cc/kg normal saline (tachycardia and hypotension)
- Oxygen
- Bolus of 10% or 2% solution of dextrose (D10 or D25)
Acute onset of altered mental status associated with hypoglycemia raises the suspicion of ___ or ___.
Toxic ingestion; serious infection
List 5 common drug classes leading to classic toxidromes.
- Cholinergic (organophosphates)
- Anticholinergic (diphenhydramine, TCAs)
- Sedative-hypnotic (benzodiazepines, barbiturates)
- Opioids (codeine, morphine, heroin)
- Sympathomimetics (cocaine, amphetamines, pseudoephdrine)
Toxidrome of cholinergics?
Miosis and blurred vision
Increased gastric motility (N/V, diarrhea)
Excessive tearing, salivation, sweating, and urination
Bronchorrea and bronchospasm
Muscle twitching and weakness
Bradycardia
Seizures and coma
SLUDGE (salivation, lacrimation, urination, defecation, GI motility, emesis)
Toxidrome of anticholinergics?
Mydriasis (dilated pupils) - blind as a bat Dry skin - dry as a bone Red skin (flushed) - red as a beet Fever - hot as Hades Delirium and seizures - mad as a hatter Tachycardia Urinary retention Ileus
Toxidrome of sedative-hypnotics?
Blurred vision (miosis or mydriasis) Hypotension Apnea and bradycardia Hypothermia Sedation, confusion, delirium, coma
Toxidrome of opioids?
Miosis (constricted pupils) Respiratory depression Bradycardia and hypotension Hypothermia Depressed mental state (sedation, confusion, coma)
Toxidrome of sympathomimemtics?
Mydriasis
Fever and diaphoresis
Tachycardia
Agitation and seizures
What types of medications can cause mydriasis?
Anticholinergic
Sympathomimetic
Sedative/hypnotics (can cause either)
What are two common medications seen in accidental ingestions in toddlers?
Iron
Acetaminophen (most common, commonly co-ingested)
In the setting of a suspected ingestion, what lab studies should be ordered?
- Glucose
- Electrolytes and/or blood gas (metabolic acidosis/AG - aspirin or NSAID toxicity)
- EKG (TCAs, etc. can cause EKG changes and dysrhythmias)
- Calcium (affects cardiac function)
- Toxicology screen from the urine or blood (doesn’t include levels of all drug that might have been ingested)
- Acetaminophen
List # decontamination treatment options.
- Activated charcoal (increases surface area for toxin absorption)
- Cathartic agent (induces defecation)
- Nasogastric lavage (removes pill fragments from stomach)
- Syrup of ipecac (induces vomiting)
When is activated charcoal indicated? Contraindicated?
Indicated - strong acids, alkalis, heavy metals
Contraindicated - loss of protective airway reflexes (risk of aspiration)
A single dose of a ___ may be given with the initial dose of charcoal.
Cathartic agent
True or false - nasogastric lavage has not demonstrated consistent clinical benefit and is not recommended.
True
Recommendations for syrup of ipecac? Contraindications?
Not first-line due to potential side effects
Contraindicated with a risk of aspiration with an altered mental status and the potential for serious cardiac side effects and seizures
Mechanism of TCAs?
Inhibition of synaptic reuptake of NE and 5-HT
Antagonism of muscarinic ACh receptors and peripheral alpha receptors
Blockade of sodium channels and GABA receptors
Presentation with TCA toxicity?
Altered mental status Anticholinergic signs and symptoms Hypotension (hallmark) Dysrhythmias Seizures
Cause of hypotension in TCA toxicity?
Direct myocardial depression from sodium channel blockade and peripheral vasodilation from alpha-1 adrenergic blockade
Most common cause of death from TCA OD?
Refractory hypotension
List management steps for a patient with a TCA ingestion.
- Continuous cardiac monitoring + serial EKGs for 6 hours (minimum)
- Serum alkalization
- Dose and frequency
- Target pH + close monitoring of blood gases
- Antiarrhythmics
- Rx hypotension
- Rx seizures
What is the triad seen in cardiotoxicity?
Conduction delays
Dysrhythmias
Hypotension
Mainstay treatment for cardiotoxicity?
Serum alkalization and sodium loading
When is serum alkalization and sodium loading indicated?
QRS > 100 msec R wave in AVR > 3 mm Wide-complex tachycardias Fluid-refractory hypotension Seizures
How is serum alkalization done?
Hypertonic sodium bicarbonate (1 mEq/kg bolus initially and every 3-5 minutes until QRS narrows and hypotension improves)
Continue for 12-24 hours after the EKG normalizes because of the drug’s redistribution from the tissues
Target pH = 7.50-7.55
How should life-threatening dysrhythmias be treated?
Lidocaine
Class IA (Na channel blockers) and Class III (can prolong QT interval) may also be contraindicated
How should hypotension be treated?
Volume expansion and serum alkalization
NE in refractory situations
Beta-adrenergic agonists and dopamine are contraindicated
How should seizures be treated?
Generally brief
Benzos, barbiturates, or propofol may be used
Phenytoin is controversial
Ingestion of nortriptyline 2.5 mg/kg or higher in a 2-year-old will cause significant symptoms. Peak effect?
7-8 hours after ingestion
One 10 mg tablet of glipizide can cause significant hypoglycemia in a 2-year-old. Peak effect?
2-3 hours after ingestion, but can last 24 hours
