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CCP 347 Neurological Emergencies Flashcards

1
Q

AEIOUTIPSO acronym for differentiation of altered mental status in Peds

A 
A - Alcohol
E - Encephalitis / meningitis
I - Insulin
O - Overdose
U - Uremia / metabolic encephalopathy
T - Trauma / tumour
I - Intracranial hemorrhage / infarction
P - Psychiatric
S - Seizure
O - Other
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2
Q

common causes of altered mental status in Infants

A 
Meningitis
seizures
CNS trauma
metabolic abnormalities
dehydration
hypo / hyperthermia
intussusception
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3
Q

common causes of altered mental status in adolescents

A

Alcohol/recreational drug overdose
trauma
psychiatric

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4
Q

causes of status epilepticus in neonates

A 
Congenital CNS infection
CNS malformation
Perinatal asphyxia
Intracranial haemorrhage
Drug withdrawal
Neonatally acquired infection : meningitis, sepsis
Metabolic - Hypoglycemia
- Inborn error of metabolism
- Hypo Ca/Mg/Na
Idiopathic
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5
Q

causes of status epilepticus in infants/older child

A 
Febrile convulsion (6 months - 6 years)
CNS infection
Chronic encephalopathy / seizure disorder
Changes in anticonvulsant drug levels
Trauma - accidental & NAI
Metabolic - Hypoglycaemia / Na+ / Ca+
Poisoning - accidental or otherwise
Associated with renal or liver disease
SOL : tumour / AVM
Idiopathic ( * 50% * )
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6
Q

causes of status epilepticus in older child/adolescent

A

Epilepsy / inadequate drug levels / other trigger
CNS infection
Toxins (Accidental ingestions)
Toxins (Intentional ingestions): prescription & “substance”
SOL : tumour / AVM
Trauma
Cerebral degenerative disease / neurocutaneous
Idiopathic

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7
Q

common causative organisms for meningitis in neonates

A

Group B Strep
Gram negatives
Staph epidermadis
Listeria monocytogenes

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8
Q

common causative organisms for meningitis in Infants and children older than 1 month

A

Streptococcus pneumoniae

Neisseria meningitidis

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9
Q

Antibiotic therapy for Meningitis in neonates

A

Cefotaxime and Ampicillin ( and Acyclovir)

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10
Q

Antibiotic therapy for Meningitis in Older infants and children

A

Cefotaxime, Vancomycin (and Acyclovir)

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11
Q

Most common viruses responsible for Acute Viral Encephalitis

A 
Herpes simplex
Mumps
Measles
Varicella-zoster
Influenza
Enterovirus
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12
Q

MAP target for ICP management in Peds

A

Upper limit of normal range for that age category

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13
Q

define seizure

A

a paroxysmal event characterized by temporary involuntary changes in the patient caused by abnormal and excessive activity of a group of cortical neurons.

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14
Q

sub types of generalized seizures

A 
Tonic-clonic
Absence
Myoclonic
Clonic
Tonic
Atonic
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15
Q

sub types of focal seizures

A 
Simple Partial (normal mental status)
Complex Partial (altered mental status)
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16
Q

seizure mimics in neonates

A 
Jitteriness
Benign neonatal sleep myoclonus
Nonepileptic apnea
Opisthotonos (hyperextension, back arching, spasticity – either physiologic or pathologic in cases of meningitis, tetanus)
Normal movement
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17
Q

seizure mimics in infants and children

A 
Syncope
BRUE
Breath-holding spells
Migraine with aura (vomiting, motor deficits, altered LOC)
Sydenham’s chorea
Various sleep disorders – narcolepsy, cataplexy
Tics
Psychogenic non-epileptic seizures
Panic attacks
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18
Q

priority care goals in convulsive status epilepticus (CSE)

A
  1. Maintenance of adequate airway, breathing and circulation (ABCs).
  2. Termination of the seizure and prevention of recurrence.
  3. Diagnosis and initial therapy of life-threatening causes of CSE (e.g., hypoglycemia, meningitis and cerebral space-occupying lesions).
  4. Arrangement of appropriate referral for ongoing care or transport to a secondary or tertiary care centre.
  5. Management of refractory status epilepticus (RSE).
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19
Q

describe non-convulsive status epilepticus

A
  1. altered mental status.
  2. Patients may demonstrate confusion, unresponsiveness, abnormal motor movements, twitches, lip smacking, or automatisms.
  3. confirmed on EEG
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20
Q

The number one cause of status epilepticus in peds

A

febrile illness.

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21
Q

What is the definition of status epilepticus?

A

status epilepticus is typically defined as:

  1. 5 minutes or more of continuous seizure activity (clinical or electroencephalographic)
  2. Recurrent seizure activity without return to baseline between seizures.
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22
Q

1st/2nd/3rd line agents for peds status epilepticus

A

1st line: Benzos

2nd line: Fosphenytoin/Phenytoin/phenobarbital/Keppra

If refractory to a first line agent and a second line agent = you have refractory status epilepticus; consider these agents (in consultation with PICU):

Phenobarbital
Pentobarbital
Midazolam infusion (post-intubation)
Levetiracetam
Propofol
Ketamine
Full laboratory investigations for metabolic abnormalities
Treatment of hyperthermia
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23
Q

What is the definition of a simple febrile seizure?

A
  1. generalized seizure occurring in the presence of a fever without CNS infection
  2. Occurring in a developmentally and neurologically normal child
  3. Less than 15 minutes
  4. Between 6 months and 5 years
  5. Normal neurologic examination pre and post-seizure
24
Q

What is the definition of complex febrile seizures?

A
  1. Multiple seizures occurring within 24 hours
  2. Seizure lasts longer than 15 minutes
  3. Seizure occurs outside of normal age range
  4. Focal component to seizure.
25
Q

discuss the link between meningitis and febrile seizures

A
  1. Meningitis should be considered in any patient with seizures and fever, although a child whose mental status is normal before and after the seizure is very unlikely to have meningitis.
  2. infants younger than 3 months presenting with febrile seizures should always be evaluated in hospital for meningitis.
  3. Infants <3mo are not only at higher risk for serious bacterial infections, including meningitis, but their mental status is difficult to assess accurately
26
Q

Describe the management of febrile seizure according to the CPS

A
  1. Maintenance of adequate airway, breathing and circulation (ABCs).
  2. Termination of the seizure [intervene if > 5 mins] and prevention of recurrence.
  3. Diagnosis and initial therapy of life-threatening causes of CSE (e.g., hypoglycemia, meningitis and cerebral space-occupying lesions)
27
Q

What is the most common cause of status epilepticus in children versus adults?

A

Children:

Febrile status epilepticus (~30%)

Adults:

Acute symptomatic causes (> 50%)
Structural brain lesion (acute or longstanding)
Toxic cause
Metabolic cause
Remote symptomatic causes / low antiepileptic drug levels

28
Q

discuss Abnormal Tone in neonates/infants

A
  1. A term baby has a natural flexion of the arms and legs. 2. Abnormal tone is described as either decreased (hypotonic) or increased (hypertonic).
  2. Hypotonic can be described as floppy or flaccid.
  3. Hypertonic can be described as rigid or spastic
29
Q

discuss “Jitteriness” in neonates/infants

A
  1. Can be confused with seizures.
  2. Can be described as tremulous but subside when the limb is held.
  3. Most common causes are hypoglycemia, hypocalcemia, NAI, encephalopathy.
  4. Can be benign.
30
Q

discuss Seizures in neonates/infants

A
  1. Presents as clonic movements or tonic posturing but not the classic tonic clonic movements
  2. Can be very subtle and non suppressible with a hand
31
Q

Focused Antepartum neuro history

A 
Maternal health
dosage and duration of medications
maternal substance use
congenital hereditary disorders
family history of sleep myoclonus
Perception of fetal movements
32
Q

Focused Intrapartum neuro history

A 
Nature of labour
analgesia
type of delivery
difficulty of delivery
Indicators of fetal compromise
FHR variabilities
33
Q

Focused Neonatal neuro history

A 
Umbilical cord gas
condition at birth
time of onset of respirations
resuscitation history
gestational age
feeding history
34
Q

focused neonatal neuro physical exam

A
  1. Observation: LOC and activity, posture, spontaneous movements
  2. Full vital signs
  3. Exam: Head circumference, evidence of external injury, abnormal movements, posture and tone, Fontanelles, Primary Reflexes (suck, moro, grasp)
35
Q

Causes of Abnormal Tone in neonates

A 
Neonatal Encephalopathy
Sepsis
Hypoglycemia
IVH
Medication/anesthesia
Chromosomal Abnormality
Congenital CNS
Inborn errors of metabolism
Hypermagnesemia
Spinal cord injury
36
Q

Neonatal seizures/status epilepticus treatment pathway

A 
Phenobarb 20 mg/kg then 10 mg/kg x2
Phenytoin 20 mg/kg
Keppra 40-60 mg/kg
Midazolam or lorazepam
Midazolam infusion
Pyridoxine
37
Q

when do you cool neonatal HIE

A

Therapeutic cooling if less than 6 hours from birth

38
Q

describe the “Pull to sit maneuver” for Clinical Assessment of Tone

A
  1. Hold babies hands and slowly pull to the sitting position.
  2. A term babies head will be balanced over the torso in the sitting position, hypotonic head stays back and hypertonic head won’t drop forwards.
39
Q

“Ventral Suspension maneuver” for Clinical Assessment of Tone in baby

A
  1. Baby is placed in the prone position over the examiners hand.
  2. Normal tone has some flexion at or above midline, “wet noodle” is hypotonic
40
Q

common causes of neonatal seizures at time of birth

A
  1. Acute drug withdrawal (narcan admin)

2. local anesthetic injected into fetal scalp during a pudendal block

41
Q

common causes of neonatal seizures at Day 1

A

HIE: presents at 6-18 hours
Hypoglycemia
Metabolic abnormalities; hypocalcemia
Trauma

42
Q

common causes of neonatal seizures at Day 2-3

A

Neonatal Abstinence Syndrome
Neonatal Stroke
Metabolic disturbances
Meningitis

43
Q

common causes of neonatal seizures at Day 3-7

A 
Neonatal stroke
Hypocalcemia
Brian malformation
Meningitis/encephalitis
SAH
44
Q

common causes of neonatal seizures at Day 7

A

NAS – methadone withdrawal

Meningitis

45
Q

criteria for Significant HIE

A 
APGAR 0-3 for >5 min
Hypotonic, Seizures, coma
Multiorgan dysfunction
Umbilical cord arterial pH < 7
Umbilical cord arterial BD > 16
46
Q

neonatal Jitteriness

A
  1. Sharp movements when stimulated.
  2. Causes: Hypoglycemia, hypocalcemia, NAS, CNS irritability
  3. Treatment: For Opiates: introduce a tapering dose of opiate or having mother breastfeed (if still using opiate)
47
Q

List some of the neurological differences seen in peds

A
  1. Open Sutures and fontanelles (which close around six months).
  2. Spinal cord ends at L3 (L1-L2 in adults)
48
Q

define SCIWORA

A

Spinal cord injury without radiographic abnormality (SCIWORA)

49
Q

Why is SCIWORA more common in infants?

A
  1. The fulcrum is located at C1/C2, rather than C5-C6 as in adults.
  2. Atlanto-axial dissociation is more frequent and is fatal.
50
Q

What does HIE stand for?

A

Hypoxic-ischemic encephalopathy

51
Q

Why is propofol not used beyond 24 hours in the sedation of paediatrics?

A

Children are at a ↑ risk of propofol infusion syndrome d/t ↑ fat distribution and ↑ dosage requirements for effect

52
Q

neonatal seizure clock

A

0-15 min: phenobarbital 20mg/kg
15-30 min: phenytoin/keppra
30-45 min: midazolam infusion
45-60 min: propofol/pentobarbital/ketamine

53
Q

paediatric seizure clock

A

0-15 min: benzo’s x2 doses
15-30 min: phenytoin/keppra/phenobarbital 20mg/kg
30-45 min: midazolam infusion
45-60 min: propofol infusion/ketamine

54
Q

Tonic seizures

A

Tonic seizures involve increased muscle tone or stiffness.

55
Q

Clonic seizures

A

Clonic seizures involve rhythmic jerking

56
Q

Myoclonic seizures

A

Myoclonic seizures involve only one or a few twitches or jerks without any particular rhythm.

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