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Neurological Disorders Flashcards

1
Q

Migraine hx to ask in children

A

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

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2
Q

Acute migraine Mx (12-17)

A
  1. P/I for pn
  2. Nasal sumatriptain (PO not licensed <18), consider aspirin if >16 (Reye’s)
  3. Combination nasal sumatriptan + NSAID/paracetamol (consider anti-emetic)
    Arrange 1m FU ask to return if worsening Sx
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3
Q

Migraine Prophylaxis in children

A

Topiramate or propranolol

(topiramate risks foetal malformation)`

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4
Q

Headaches in children

A

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

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5
Q

Na channel blockers for headache

A

topiramate and valproate

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6
Q

Febrile Convulsions During seizure Mx

A

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

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7
Q

Doses of rectal diazepam for febrile seizure

A

<1m 1.25-2/5mg
1m-1y= 5mg
2-11y= 5-10mg

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8
Q

Dose of buccal midazolam for febrile seizure

A 
<6m = 300ug/kg (max 2.5mg)
6m-11m = 2,5mg
1-4y = 5mg
5-9y = 7.5mg
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9
Q

After febrile seizure

A

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

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10
Q

If febrile seizures can be Mx at home

A 
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
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11
Q

PACES counselling febrile seizure

A 
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
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12
Q

Epilepsy first seizure

A 
All patients suspected of first epileptic seizure to see neurologist (first fit clinic)
Advice:
recognition
record
avoid dangerous activities
seek help if another one
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13
Q

Rx NOT usually given for which epilepsy?

A

childhood rolandic

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14
Q

AED therapy considerations

A

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)

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15
Q

Choice of anti-epileptic:

Generalised tonic-clonic

A

1L; Valproate
Alt: lamotrigine, carbamezapine, oxcarbazepine)

Adjunct: clobazam, lamotrigine, levetiracetam, valproate, topirmate

NB can exacerbate myclonic (lamotirigine), absence (carbamazepine + oxcarbazepine)

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16
Q

Choice of anti-epileptic:

Generalised absence

A

1L: ethosuxamide/valproate
Alt: lamotrigine
adjunct: combination of 2 of the 3

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17
Q

Choice of anti-epileptic:

Generalised myoclinic

A

1L: valproate
Alt: levetaricatem, topiramate

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18
Q

Choice of anti-epileptic:

focal

A

Carbamazepine, lamotrigine
Alt: levetiracetam, oxcarbazepine, valproate
Adjunct: clobzam, gabapentin, carbamazepine

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19
Q

SE of AEDs

A 
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
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20
Q

Other Mx of intractable epilepsy

A

Ketogenic diet
Vagal nerve stim
surgery (only if well localised structural cause)

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21
Q

PACES counselling of epilepsy

A 
Tendency to unprovoked seizure
Aim to promote independence and confidence
make school aware
Avoid baths/swimming unsupervised
Driving after 1yr seizure free
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22
Q

Status epilepticus

A 
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
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23
Q

Guillain-Barre syndrome

A

Supportive
Respiratory support
IVIG
Plasma exchange

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24
Q

Myasthenia Gravis

A

Anti-cholinesterase: pyridosigmine/neostigmine
Immunosupressive therapy
Immune-modulation drugs (pred, azt, mycophenolate)
Thymectomy if thymoma present
Plasma exchange in crisis

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25
Q

Duchenne Muscular Dystrophy

A

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)

26
Q

Noctural hypoxia

A

occurs in DMD

presents w/ daytime headache, irritability, loss of apetite

27
Q

Myositis in children

A

PT to prevent contractures
Steroids for 2y
Immunosuppressants

28
Q

Extradural haemorrage in children

A

Correct hypovol
urgent evacuation of haematoma
arrest bleed

29
Q

Subarachnoid haemorrhage in children

A

Neurosurgical or interventional readiology

30
Q

Neural tube defects in children

A 
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
31
Q

Hydrocephalus

A

Sx relief
Reduce ICP to prevent damage
VP shunt is mainstay (can malfunction if blocked or infected)
Overdrainage can cause low pressure headche

32
Q

Breath holding attacks

A

self resolve

behaviour modification with distraction

33
Q

West syndrome (infantile spasm)

A

Vigabatrin or corticosteroids

POOR prognosis

34
Q

Tension headache in children

A

not concerning

P/I

35
Q

Raised ICP

A

CT/MRI

cerebral odema can be Mx w/mannitol IV

36
Q

Idiopathic intracranial HTN

A

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

37
Q

Cerebral Palsy RF/causes

A

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%)

38
Q

Signs of cerebral palsy

A 
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
39
Q

Red flags for other disorder than CP

A 
Absence of risk factors
FHx of progressive dx
Loss of previously attained
unexpected FNS
MRI not consistent
40
Q

MDT for CP

A

Main heroes: paediatrician, nurse, PT, OT, SALT, dietetics, psych
Side dishes: ortho, visual and hearing

41
Q

Prognosis of CP

A

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

42
Q

Eating, drinking, swallowing in CP

A

assessed by SALT trained in dysphagia
?video fluoroscopy
Create individualised plan

43
Q

Speech language and communication

A

comms difficulty doesnt equal learning difficulty
Interventions: posture, breath control, rate of speech
Consider augmentative/alternative systems eg pictures/signs

44
Q

Other Factors in CP

A 
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)
45
Q

Sumary of CP

A 
PT; encourage movement, improve strength, prevent ROM loss
Speech
OT
Meds:
- stiffness: baclofen, diazepam
- sleep: melatonin
- constipation: laxatives
- saliva anticholinergic
46
Q

PACES of CP

A

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

47
Q

Autism spectrum disorders Ix

A

Hearing, speech and language assessment
Cognitive assessment (WISC, WPPSI)
Autism assessment (ADOS, 3Di)
Childhood autism rating scale

48
Q

ASD psychosocial interventions

A

Aim to increase attention, engagement, reciprocal communication
Aim to increase understanding of childs pattern of communucation
Expand communication, interactive play, social routines

49
Q

Factors that increase risk of difficult behaviour in ASD

A 
Impairment in communication
Physical dx
mental health dx
Environment (light, noise)
Routine change
Developmental change (puberty)
Exploitation/abuse
50
Q

Pharmacological intervention in ASD

A

consider antipsychotic if psychosocial interventions fail
r/v at 3-4wks, stop at 6w if no indication
?melatonin for sleep
?methylphenidate for attention difficulty

51
Q

PACES ASD

A

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

52
Q

ADHD Ix

A 
Rating scale (Conners)
refer to CAMHS
53
Q

ADHD MDT members

A

Paediatrician, psychiatrist, ADHD nurse, mental health and learning disability trust, CAMHS, parent groups, school

54
Q

Risk groups for ADHD

A 
Preterm
Oppositional defiant disorder
conduct disorder
Mood disorder
Epilepsy
ASD
Learning difficulty
55
Q

Children having behaviour/attention problems that adversely impact on their development or family life

A

Consider watchful waiting for 10w
Offer referral to group based ADHD support for parents
Refer if severe

56
Q

Criteria for ADHD

A

Meet DSM5/ICD10 (impaired attention, over activity, onsey <6y, impairment in 2+ settings, other dx excluded)
Cause at least moderate impairment (bio, psycho, social)

57
Q

Children <5 w ADHD

A

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

58
Q

Children >5 w/ADHD

A

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

59
Q

Medication in ADHD

A

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

60
Q

Medication monitoring in ADHD

A

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

61
Q

SE of ADHD meds

A

anorexia
mood change
palpitations
tics

Paeds (23 decks)

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