Neuro Flashcards
What trimester does the brain and spinal cord develop
First. Susceptible to infection, substance abuse and maternal dietary deficiencies
When does the nervous system develop until
Age 4
Vertebrae in children
Not completely ossified, greater risk for cervical spine injury and compression fractures
Neuro – history
Most important part of the neuro exam. Fam history of seizures, degen neuro diseases, sensory defects, Neural tube defect (NTD). History of pregnancy: maternal illness, placental dysfunction, fetal distress, prematurity, meconium staining, apgar score. Child health history: delayed motor or speech development, hypotonia, seizures, childhood illnesses. Parental concerns: vision, hearing, development.
Infant/Child assessment
Height, weight, blood pressure, head circumference. 3 and 9 rule for head circumference. Newborn 35, 3 month 40, 9 month 45. 3 year 50. 9 year 55.
Hydrocephalus
Excess CSF in intracranial space, and specifically in the intraventricular spaces within the brain causing dilation of the ventricles and a wide range of symptoms.
Two primary causes of hydrocephalus
Congenital .5-1% or Aquired from lesions, tumors, infection, intracrainial bleed, myelomeningocele. Need shunt to drain CSF
Infancy s/s hydrocephalus
Protruding forehead or bossing – sunset eyes, Depressed eyes or setting sun where the eyes rotate down making the sclera visible above the pupil. Sluggish pupils. Irritable, lethargy, feeding poorly, changes in LOC, arching of back (opisthotonus), lower extremity spasticity., May cry when picked up or rocked but quiet when still.
Childhood hydrocephalus
Headache on awakening that improves with vomiting or sitting up. Papilledema, strabismus, ataxia. Irritable, lethargy, apathy, confusion, incoherent
Hypotonia epidemiology
Neuromuscular – muscular dystrophy or spinal muscular atrophy v Nonneuromuscular which is not common. Hypoxic due to ischemic ecephalopathy or premature birth with intraventricular hemorrhage
Muscular Dystrophy
Group of progressively degernative inherited diseases that affect muscle cells of specific muscle groups – leads to weakness and atrophy. Most identified in early childhood characterized by progressive muscle weakness
Pseudohypertrophic (Duchenne) MD
Most severe and common type seen in childhood. X linked, inherited recessive disorder seen only in boys
Clinical manifestations of MD
Children have a hx of meeting motor dev by earlier years, s/s get more obvious by age 3. Difficult running, riding a bike, climbing stairs. Later abnormal gait is apparent – waddling and lordosis (exacc curv of lumbar spine).
Gowlers Sign
when they fall they rise from the floor by rolling on stomach, pushing up on their knees and walking hands up their legs to stand up. Seen in MD.
Pseudohypertrophy
Muscles in thighs and arms become enlarged from fatty infiltration and feel firm or “woody” upon palpation
Progression of MD
Contractures and deformities involving the large and small joints are common. Fine motor skills are kept though. By age 12 ambulation is impossible and they need a wheelchair. Facial and resp muscles affected later in the terminal stages of the disease – cardiomegaly, resp tract infections, cardiac failure. Moderate obesity, decreased IQ, shortened lifespan
Therapeutic Mgmt MD
Maintain ambulation and independence for as long as possible. Mobile as possible with braces, surgery, PT. Maximize self sitting, resp function, self care, prevent obesity, prevent resp tract infections
Types of Partial seizures
Simple, comlpex, partial evolving into generalized
Generalized seizure types
Absense, myoclonic, tonic, atonic, clonic, tonic-clonic
Neonatal Seizures
brief and subtle – eye blinking, mouth and tongue movement, bicycling movements of limbs. Cannot be provoked or consoled. Autonomic changes – body temperature changes, pulse irregularities. EEG less predictable.rhythmic twitching - rigid posture - jerking extremities. Subtle chewing, salivation, blinking, changes in skin color
Neonatal seizure pathophys
Myelinization of CNS is incomplete during the first months of life
Major causes of seizures in children
Birth injuries (atoxia) or congenital defects of CNS. Acute infections in late infancy or early childhood. Idiopathic if older than 3.
Epilepsy
A chronic disorder characterized by recurrent, unprovoked seizure activity and may be inherited. Result of brain or CNS irritation. Seizures are abnormal sudden excessive discharge of electrical activity within the brain.
Tonic Clonic
Grand mal. 2-5 minutes with a tonic phase of stiffened and rigid muscles of arms and legs with immediate loss of consciousness. Followed by a clonic or rhythmic jerking of all extremities. Bites tongue, incontinent. Fatigue confusion and lethargy may last up to an hour
Seizure observations
Tongue biting, clenching jaw, incontinence, dyspnea, apnea, cyanosis. One to three minutes, Postictal confusion, amnesia and difficulty speaking. May have headache, muscle soreness, drowsy. Can sleep immediately after.
Absence seizure
Petit mal. More common in children. Brief period of loss of consciousness and blank staring. Return to baseline immediately after.
Myoclonic
Brief jerking or stiffening of extremities. Singly or in groups. Few seconds, can be symmetric or asymmetric.
Atonic
aka Akinetic, drop attacks. Sudden loss of muscle tone. Lasts for seconds, post ictal confusion. Causes the client to just drop.
Complex partial seizure
`Lose consciousness for 1-3 minutes. Automatisms. Not aware of the behavior – lip smacking, patting, picking at clothes. Afterwards has amnesia. Usually temporal lobe affected.
Simple partial seizure
Conscious through out episode. Usually an aura before the seizure - deja vu, smell, sudden onset of pain. Unilateral movement of the extremitiy. May have unusal sensations like change in heart rate, flushing, epigastric discomfort.
Unclassified seizures
Half of all seizures, Occurs for no reason and do not fit into category
Febrile seizures
2-5% children. 6 months to 6 years. The younger the child the more likely they are to re occur. Familial tendency. Phenobarbital or diazepam during emergency, Teach fever reducing measures. Temp is usually > 101.8, occurs while the temp is increased not after. Seizure usually over before getting to the ER.
Febrile seizures caused by
nervous system is immature. Will not create any brain damage.
Mgmt Febrile Seizures
Tempid baths are ineffective. Vigorous use of antipyretics. Protect from injury during seizure. Call 911 if > 5 minutes
Tx Febrile seizures
Fever reduction, eval history (episodic and family), seizure control if ongoing – can give Diazepam rectally
Prophylaxis w medications for febrile seizures
If focal or prolonged, if neurologic anomalies, if first degree relative has seizure history, if the child is less than one year old, if multiple series in 24 hour period
Need a CT in first time seizure patients if
structural lesions, partial onset, age > 4, no identified cause
CT in recurrent seizure patients if
change in pattern, prolonged post ictal, worsening mental status
Seizure treatment
Correct underlying pathology, if any antipyretics ineffective in febrile seizures the anti-epileptic decision is trial and error. Antiepileptics are not 100 percent effective.
Seizure tx if febrile
Supportive, reassurance, antipyretic, oral valium, Do not need to refer to peds neuro unless they are frequent or one occurs w out fever
Neonatal seizure tx
phenobarbital
Generalized tonic clonic tx
phenytoin, phenobarb, carbamazepine, valproic acid, primidone
Absense seizure tx
Ethosuximide, valproic acid
New anti epileptics
Felbamate, gabapentin, lamotrigine, topamax, vigabatrin
If giving seizure meds consult with
neurologist
Concussion definition
process involving traumatic biomechanical forces either a direct blow to the head, face or neck. Rapid onset, short lived impairment of neurological function and it resolves spontaneously. Functional disturbance not a structural injury, may or may no involve loss of consciousness, resolution is sequential, post concussive symptoms may be prolonged. No abnormality seen on standard structural neuroimaging studies
Energy Crisis
Release of amino acid neurotransmitters - changes in permeability of cell wall - influx of sodium and or efflux of potassium - pH of the cell changes leading to influx of calcium
Clinical concussion features - symptoms
somatic (headache), cognitive (feel like in a fog), and or emotional symptoms (lability)
Physical signs concussion
loss of consciousness, amnesia
Behavioral changes concussion
Irritability
Cognitive impairment
slowed reaction times
Sleep disturbances
drowsiness
Concussion mgmt
Refer to concussion specialists or peds neuro. R/o more serious intracranial pathology: side line eval/neuro exam, CT MRI, Educate about natural course of concussion. Post injury mgmt. Prevent second impact syndrome. Prevent behavioral effects of injury. Prevent emergence of post concussion syndrome.
Concussion headache
Can be delayed up to 3 weeks after MTBI. Acute post traumatic headaches are self limited. Can give nsaid, acetaminophen. Can treat acute/post traumatic migraine with amitriptyline or topamax or beta block, SSRI
Post concussive syndrome
Symptoms include at least three of the following after traumatic brain injury: headache, fatigue, dizziness/vertigo, impaired memory, difficulty concentrating, insomnia, irritable, lowered stress tolerance/emotional/alcohol. Other associated symptoms include noise sensitivity, neck pain, non-dermal paresthesias, interference with social role functioning
Predictors for the development of post concussive syndrome include
Female sex, ongoing litigation?, low socioeconomic status, prior headaches, prior TBI, prior psych illness
NJ Bill A2743
Parents must sign concussion information form. Coaches, school physicians, and athletic trainers need to undergo a concussion training program. Requires student athletes to be removed from play if suspected concussion. Need medical clearance before returning.
Most peds headaches are benign but these are those that need urgent diagnosis and treatment
SAH, intracranial bleed, neoplastic lesion, encephalitis, meningitis, intracranial venous thrombosis, vasculitis, metabolic disorders
Red Flags
Triptans
Axert and Nasal Imitrex approved for 12 and up. Contraindications are cerebrovascular, cardiac or peripheral vascular disease, uncontrolled HTN, hemiplegic, basilar migraine
Alt treatments for peds headache
Vitamin cocktail for 3 months: Mg 250 and b2 200 BID CoQ10 100 TID
Neonates most common cause of meningitis
group B strep and gram negative enteric bacilli
Infants and young children meningitis causes
strep pneumonia, n. meningitis, h influenza B. HIB is the most common cause
Children older than 5 most common causes of meningitis
strep pneumonia and n meningitis.
Clinical manifestations of Meningitis
acute symptoms rapidly appear within 24 hours. URI or GI symptoms days before. May suddenly have shock and DIC.
Nonbacterial meningitis – Aseptic Meningitis
Viruses. A/w other diseases like measles, mumps, herpes, leukemia. Abrupt or gradual. Headache, fever, malaise. 2 months: strep, hib, n gonn.
