Neurological Disorders Flashcards
Migraine hx to ask in children
Assess;
- severity, frequency, impact on life
- quality of attacks: intensity and site of pain, ass. Sx?
- Timing: associations? duration,
- ?cause (triggers or emotional problems)
- general health between attacks
consider 8wk headache diary
Acute migraine Mx (12-17)
- P/I for pn
- Nasal sumatriptain (PO not licensed <18), consider aspirin if >16 (Reye’s)
- Combination nasal sumatriptan + NSAID/paracetamol (consider anti-emetic)
Arrange 1m FU ask to return if worsening Sx
Migraine Prophylaxis in children
Topiramate or propranolol
(topiramate risks foetal malformation)`
Headaches in children
Exclude red flags
Rescue Mx:
- P/I, antiemetics, nasal triptans, physical eg cold compress
Prophylaxis:
- Na channel blockers, beta blockers, tricyclics, acupuncture
Psychosocial:
- identify stressors, relaxation techniques
Na channel blockers for headache
topiramate and valproate
Febrile Convulsions During seizure Mx
Protect from injury (cushion head)
Remove harmful objects nearby
do NOT restrain or put anything in mouth
When seizure stops check airway and put in recovery position
If Seizure >5m:
- rectal diazepam, repeat at another 5m OR one dose buccal midazolam
Call 999 if:
10 mins after first dose seizure has not stopped or there is ongoing twitching, another seizure before child regained consciousness
Measure blood glucose if non-rousable/convulsing
Doses of rectal diazepam for febrile seizure
<1m 1.25-2/5mg
1m-1y= 5mg
2-11y= 5-10mg
Dose of buccal midazolam for febrile seizure
<6m = 300ug/kg (max 2.5mg) 6m-11m = 2,5mg 1-4y = 5mg 5-9y = 7.5mg
After febrile seizure
Identify and manage cause (?meningococcus/traffic lights)
Arrange immediate hospital assessment if:
- first febrile seizure/second seizure if not assessed before
- diagnostic uncertainty
- seizure >15m
- focal features persisting
- seizure recurred within same febrile illness or within 24hr
- incomplete recovery by 1hr
- <18m old
- currently taking Abx
- parents anxious
- suspected cause eg pneumonia
If no apparent focus of infection consider admission and monitoring
If febrile seizures can be Mx at home
Tell Parents: NOT epilepsy, risk of epilepsy in future only slightly elevated, NOT harmful if short, 1/3 will have them Advise Parents: Make area safe, leave alone, check airway, medical help/ambulance (>5m) Managing fever: does NOT prevent recurrence, P/I, fluids NO prescription to cover seizures, Arrange FU
PACES counselling febrile seizure
explain dx, seizures but not epilepsy 1/3 risk of recurrence explain Mx of seizure Ambulance >5mins 2% increased risk of epilepsy Don't try and cool the child P/I if distressed but not at -anti-pyrexial
Epilepsy first seizure
All patients suspected of first epileptic seizure to see neurologist (first fit clinic) Advice: recognition record avoid dangerous activities seek help if another one
Rx NOT usually given for which epilepsy?
childhood rolandic
AED therapy considerations
NOT all children w/seizures need AED
Base choice on: seizure/epilepsy type, frequency, side effects
Monotherapy at minimum dose
ALL AEDs have potential SE
AED levels not checked regularly but may be measured to check adherence
Children w/>5m seizures given rescue meds (bucccal midaz)
Choice of anti-epileptic:
Generalised tonic-clonic
1L; Valproate
Alt: lamotrigine, carbamezapine, oxcarbazepine)
Adjunct: clobazam, lamotrigine, levetiracetam, valproate, topirmate
NB can exacerbate myclonic (lamotirigine), absence (carbamazepine + oxcarbazepine)
Choice of anti-epileptic:
Generalised absence
1L: ethosuxamide/valproate
Alt: lamotrigine
adjunct: combination of 2 of the 3
Choice of anti-epileptic:
Generalised myoclinic
1L: valproate
Alt: levetaricatem, topiramate
Choice of anti-epileptic:
focal
Carbamazepine, lamotrigine
Alt: levetiracetam, oxcarbazepine, valproate
Adjunct: clobzam, gabapentin, carbamazepine
SE of AEDs
Valproate: wt gain, hair loss, rare liver failure -azapine: rash , neutropenia, ataxia Lamotrigine: rash Ethosuxamide: N+V Topiramate: drowsiness, weight loss Gabapentin: insomnia Levetiracetam: sedation rare
Other Mx of intractable epilepsy
Ketogenic diet
Vagal nerve stim
surgery (only if well localised structural cause)
PACES counselling of epilepsy
Tendency to unprovoked seizure Aim to promote independence and confidence make school aware Avoid baths/swimming unsupervised Driving after 1yr seizure free
Status epilepticus
Secure airway Oxygen and pulse ox if IV access: - glucose, FBC, U+E, LFT, Ca - AED levels/tox screen if necessary if NO IV access: - rectal diaz/buccal midaz Step 1: IV loraz 2: if no response in 10m second dose IV loraz 3. if persistent start phenytoin infusion (monitor ECG/BP) 4. GA if refractory Consider dex if vasculitis/cerebral oedema possible
Guillain-Barre syndrome
Supportive
Respiratory support
IVIG
Plasma exchange
Myasthenia Gravis
Anti-cholinesterase: pyridosigmine/neostigmine
Immunosupressive therapy
Immune-modulation drugs (pred, azt, mycophenolate)
Thymectomy if thymoma present
Plasma exchange in crisis
Duchenne Muscular Dystrophy
Ix: serum CK, genetic, EMG, biopsy
PT to prevent contractures
Exercise/psych support
?Tendoachilles lengthening/scoliosis surgery
Noctural hypoxia ?CPAP
Glucocorticoids may delay wheelchair dependence
If LV ejection fraction drops give cardioprotective (carvedilol)
Noctural hypoxia
occurs in DMD
presents w/ daytime headache, irritability, loss of apetite
Myositis in children
PT to prevent contractures
Steroids for 2y
Immunosuppressants
Extradural haemorrage in children
Correct hypovol
urgent evacuation of haematoma
arrest bleed
Subarachnoid haemorrhage in children
Neurosurgical or interventional readiology
Neural tube defects in children
Back lesion closed soon after birth PT early ?walking aids Good skin care to avoid sensory loss Neuropathic bladder: indwelling/intermittent catheter Regular checks for htn, renal function, urinary function Proph. abx Ehedrine/oxybutinin may help bladder Bowel denervation: regular toileting, laxatives, suppositories Scoliosis - ?surgery Hydropcephalus - VP shunt MOST disabled = lesion above L3 at birth
Hydrocephalus
Sx relief
Reduce ICP to prevent damage
VP shunt is mainstay (can malfunction if blocked or infected)
Overdrainage can cause low pressure headche
Breath holding attacks
self resolve
behaviour modification with distraction
West syndrome (infantile spasm)
Vigabatrin or corticosteroids
POOR prognosis
Tension headache in children
not concerning
P/I
Raised ICP
CT/MRI
cerebral odema can be Mx w/mannitol IV
Idiopathic intracranial HTN
Eliminate causes eg drugs
Weight loss if overweight
Low Na diet, mild fluid restriction
Mx: acetazolamide (2L: furosemide, topiramate)
Analgesia: amitriptyline/naproxen for persistent headache
VP shunt for intractable
Cerebral Palsy RF/causes
AN: preterm, chorioamonitis, maternal resp or GU infection
Perinatal: LBW, neonatal encephaolpathy, sepsis
Postnatal: meningitis
Causes:
MRI: White matter damage (45%), BG/deep grey matter (13%), after neonatal period: meningitis (20%), other infection (30%), head injury (12%)
Signs of cerebral palsy
Possible early motor: - unusual fidget, asymmetry of movement - abnormal tone - late development (not sitting by 8m, not walking by 18m, hand preference <1y) Refer all with persistent toe walking For those at risk: clinical and developmental FU by MDT
Red flags for other disorder than CP
Absence of risk factors FHx of progressive dx Loss of previously attained unexpected FNS MRI not consistent
MDT for CP
Main heroes: paediatrician, nurse, PT, OT, SALT, dietetics, psych
Side dishes: ortho, visual and hearing
Prognosis of CP
Walking: if sitting by 2, likely to be walking unaided by 6
Speech: 1/2 struggle with communication, 1/3 SALT difficulties
Life expectancy: depends on serverity
Eating, drinking, swallowing in CP
assessed by SALT trained in dysphagia
?video fluoroscopy
Create individualised plan
Speech language and communication
comms difficulty doesnt equal learning difficulty
Interventions: posture, breath control, rate of speech
Consider augmentative/alternative systems eg pictures/signs
Other Factors in CP
Optimise nutritional status Manage saliva control (?glycopyrronium) Low bone density (assess diet and offer calcium/vit D) Pain, discomfort, distress: paracetamol ?baclofen Sleep: optimise hygiene, ?melatonin Mental health Visual impairment Heating impairment Behavioural GORD Constipation Epilepsy (1/3)
Sumary of CP
PT; encourage movement, improve strength, prevent ROM loss Speech OT Meds: - stiffness: baclofen, diazepam - sleep: melatonin - constipation: laxatives - saliva anticholinergic
PACES of CP
dx: damage to brain that occured early during development
damage wont get worse but ways it manifests will change
Refer to specialist in devlopment
will see many people: Dr, OT/PT, nurses, SALT, dietician
Meds available to help w/Sx
Autism spectrum disorders Ix
Hearing, speech and language assessment
Cognitive assessment (WISC, WPPSI)
Autism assessment (ADOS, 3Di)
Childhood autism rating scale
ASD psychosocial interventions
Aim to increase attention, engagement, reciprocal communication
Aim to increase understanding of childs pattern of communucation
Expand communication, interactive play, social routines
Factors that increase risk of difficult behaviour in ASD
Impairment in communication Physical dx mental health dx Environment (light, noise) Routine change Developmental change (puberty) Exploitation/abuse
Pharmacological intervention in ASD
consider antipsychotic if psychosocial interventions fail
r/v at 3-4wks, stop at 6w if no indication
?melatonin for sleep
?methylphenidate for attention difficulty
PACES ASD
Explain is a spectrum hard to give prognosis
Is characterised by difficulty in social interaction, language impairment, ritualistic behaviours
Mx: psychosocial interventions, SALT w/focus on behaviour, education assessment and plan
- some symptomatic drugs
National Autistic society
ADHD Ix
Rating scale (Conners) refer to CAMHS
ADHD MDT members
Paediatrician, psychiatrist, ADHD nurse, mental health and learning disability trust, CAMHS, parent groups, school
Risk groups for ADHD
Preterm Oppositional defiant disorder conduct disorder Mood disorder Epilepsy ASD Learning difficulty
Children having behaviour/attention problems that adversely impact on their development or family life
Consider watchful waiting for 10w
Offer referral to group based ADHD support for parents
Refer if severe
Criteria for ADHD
Meet DSM5/ICD10 (impaired attention, over activity, onsey <6y, impairment in 2+ settings, other dx excluded)
Cause at least moderate impairment (bio, psycho, social)
Children <5 w ADHD
1st line: ADHD focussed group parent training programme (10-16 meetings, groups of 10)
If fails seek specialist
NOT medication unless specialist advice
remember dietary advice
Children >5 w/ADHD
Recommend ADHD focussed group parent training programme
Offer individualised programmes if complex
Offer meds if sx persistent and causing significant impairment despite environmental modification
Consider CBT if social sx
Sx relief: clonidine, antipsych
remember diet
Medication in ADHD
Methylphenidate
6 week trial, if unsuccessful consider lisdexamphetamine
If responding but SE too much
Offer atomoxetine or gaunfacine if both MP and (lis)dexamphetamine fail
Establish baseline medical state and perform ECG before meds
Meds require monitoring
Medication monitoring in ADHD
Use Sx rating scale (Conners)
Measure height every 6m and weight every 3m
(consider treatment holiday if necessary)
HR and BP every 6m
Monitor for development of tics after starting stimulant meds
Monitor sexual dysfunction, seizure, sleep disturbance, worsening behaviour
SE of ADHD meds
anorexia
mood change
palpitations
tics
