Lecture 10 - Neurology Flashcards
Epi of headaches
3% (age 3-7 years)
4-11% (Age 7 -11 years)
8-23% (age 11-15 years)
slightly more common in boys than girls <7 years
by adolescents MC in girls than boys
What are the different classifications of HAs?
Acute
Acute recurrent
Chronic non-progressive
Chronic progressive
Tension HA
one of the most common types in childhood
less debilitating than migraine
non-pulsating pressure/tightness
pain mild to moderate
not associated with N/V, photo/phonophobia
last for an hour to several days
may be episodic (<15 days per month) or chronic (>/=15 days per month)
Migraines epi
1-3% in age 3-7 years
8-23% in adolescents
without aura > aura
What makes dx migraines challenging in children?
vomiting and vertigo may be more prominent than HA
can be bilateral or unilateral in children
frontal or temporal
Migraine withOUT aura criteria
at least 5 migraines with the following criteria:
- HA lasts 1-72 hours
- has at least 2 of the following characteristics:
- –unilateral (although may be bilateral or frontal in children)
- –pulsing quality
- –moderate or severe pain
- –aggravation by physical activity
- at least 1 of the following:
- –N and or V
- –photophobia
- not attributed to another disorder
Migraine WITH aura criteria
at least 2 migraine HAs with the following criteria:
- Aura consisting of at least one of the following:
- –visual sxs or loss of vision
- –sensory sxs (pins and needles, numbness)
- –dysphasic speech disturbance
- migraine HA that beings during aura or follows aura within 60 min
What are red flags for HA?
sleep-related HA HA associated with cough, defection Explosive or sudden onset of HA progressive pattern - increased severity or frequency neurologic signs/sxs -altered mental status -papilledema -abnormal eye movements
systemic sxs: fever, weight loss, rash, vomiting (vomiting»_space;»>nausea)
What are causes of intracranial HTN?
Traumatic brain injury/intracranial hemorrhage -subdural, epidural, or intraparenchymal hemorrhage -ruptured aneurysm -diffuse axonal injury -arteriovenous malformation CNS infections Ischemic stroke Neoplasm Vasculitis Hydrocephalus Hypertensive encephalopathy Idiopathic intracranial HTN
What are the indications for neuroimaging for a child with HA?
1) NOT indicated on routine basis in children with recurrent HA and normal neurological exam
2) should be considered in children with abnormal neurological exam, coexistence of seizures or both
3) should be considered in children with historical features to suggest recent onset of severe HA, change in HA type, or other associated features suggesting neurological dysfunction
When is MRI an appropriate assessment in a child with HA?
r/o structural intracranial lesions, inflammation, ischemia
When is a CT an appropriate assessment in a child with HA?
if concern for hemorrhage or fx
When is LP an appropriate assessment in a child with HA?
meningitis, suspicion for increased ICP (measure opening pressures)
What are lifestyle modifications used to manage HAs?
sleep, diet, hydration, caffeine, exercise
treat underlying depression/anxiety
Acute HA management
early intervention
OTC tx effective for migraine
can add caffeine no more than 9 days a month
Triptans in use for HA management?
children >6 y/o
NSAID use >2 to 3 days/week (<15 days/month)
acute treatment with triptans or caffeine <10 days/month)
What preventative treatment do we have for HA?
antiepileptics beta blockers CCB antihistamines antidepressants no FDA approved indication for HA in children
considered for >/=4 days of debilitating HAs/month
Topiramate shown more effective than placebo in management of pediatric migraine
Seizure epi
1% prevalence of epilepsy
3% prevalence of febrile seizures
generalized seizures are more common in children than adults
How are seizures dx?
Mainly on HX
EEG - if normal: - does NOT r/o epilepsy if abnormal: -does not dx epilepsy unless seizure is recorded -helps classify type of epilepsy
What are the different types of generalized seizures?
tonic clonic tonic clonic absence atonic mytonic
What are the different types of focal seizures?
simple partial
complex partial
secondary generalized
Febrile Seizure
convulsion associated with an elevated temperature greater than 38C
3 months - 6 years
MC neuro disorder of infants and young children
peak incidence 12-18 months
What is the MC neuro disorder or infants and young children?
febrile seizure
What are the risk factors of febrile seizures?
peak temperature during illness
1st degree relative with febrile seizures
neurodevelopmental delays
increased exposure to herpesvirus 6
vaccinations with DTaP, influenza may be associated
almost 50% have NO identifiable risk factor
What are the two types of febrile seizures?
Simple febrile seizure (MC)
- generalized
- duration less than 15 minutes
- single seizure in a 24h period
Complex febrile seizure
- focal clinical manifestation
- duration longer than 15 minutes
- more than one in 24 hour
When is an LP appropriate for febrile seizures?
infants <12 months
meningeal signs or sxs or other clinical features that suggest a possible meningitis or intracranial/CNS infection
What is the treatment for febrile seizures?
antipyretics do NOT help
rectal diazepam can be used in short term for children with recurrent or prolonged febrile seizures
What is the prognosis of febrile seizures?
education, reassurance, and counseling
risk of recurrence ~30-50%
no increased risk of developmental or scholastic problems
risk of epilepsy increases from 1% - 2.5%
-family history of epilepsy
-complex febrile seizures
-neurodevelopmental abnormalities
Status epilepticus
at least 30 minutes of continuous seizure activity or intermittent convulsive activity without regaining consciousness
1/3 - initial event
1/3 established epilepsy
1/3 other (trauma, stroke, meningitis, ingestion)
Broselow tape
color coded tape
each color corresponds to estimated weight class
often paired with pediatric color coded crash cart
obesity should be taken into account
What is the management of status epilepticus?
ABC
IV access
check blood glucose
Benzodiazepines - first line
-Lorazepam (ativan) preferred choice in status epilepticus because rapid (3-5 min) onset and long (12-24 hour) half life
- diazepam (valium) - rectal
- midazolam (versed) - IM
Benzos may be repeated every 5 minutes for a max of 3 doses
if still seizing after 3 doses of Benzos –alternative treatment
Phenytoin (Dilantin) is next drug of choice
-given slowly to avoid cardiac dysrhythmia and hypotension
Phenobarbital added if third medication is needed (risk of respiratory depression - be prepared to intubate)
What do you do after giving 3 doses of ativan over 15 minutes to a child having a seizure?
given phenytoin
-given slowly to avoid cardiac dysrhythmia and hypotension
Phenobarbital added if third medication is needed (risk of respiratory depression - be prepared to intubate)
Epilepsy definition
2 or more unprovoked afebrile seizures
What is the treatment of epilepsy treatment?
antiepileptic drugs recommended after 2 or more afebrile seizures
partial complex: Oxcarbamexpine, levetiracetam
generalized:
- tonic clonic - lamotrigine, valproate, topiramate
- absence - valproate
antiepileptic therapy continued for at least 2 years after the last seizure
Concussion
a brain injury defined as a complex pathophysioloigcal process affecting the brain, induced by traumatic biomechanical forces
often referred to as a “mild TBI”
Who is at highest risk of concussion?
middle and high school age children
What are the signs and sxs of concussions?
+/- preceding loss of consciousness
min to hours:
HA, dizziness (vertigo or imbalance), lack of awareness, N/V
hours to days:
mood and cognitive disturbances
sensitivity to light and noise
sleep disturbances
SAC Tool
standardized assessment of concussion tool
- orientation
- immediate memory
- concentration
- delayed recall
- neurologic screening
- exertional maneuvers
- includes a graded sxs checklist, a brief neurologic examination, and records the presence of post-traumatic and retrograde amnesia
PECARN rule
findings associated with very low risk of significant traumatic brain injury in children
Return to school rule for TBI?
may return after they can concentrate on a task and tolerate visual and auditory stimulation fro 30-45 minutes
Return to play rule for TBI?
Zurich guidelines for return to play following concussion
the following are requirements for return to play protocol:
- successful return to school
- sxs free and off any medications prescribed to treat the concussion
- normal neurologic examination
- back to baseline balance and cognitive performance measures
Zurich guideline for return to play after TBI
0 - no activity
1 - light exercise
5 - normal game play
