Neurology Flashcards
Difference between simple and complex febrile seizure***
> Simple
- Duration <15 minutes
- Generalized seizure
- Does not recur during the febrile episode
> Complex
- Duration >15 minutes
- Focal features
- > 1 seizure during the febrile episode
- Residual neurological deficit post-ictally, such as Todd’s paralysis
Dosage for per rectal diazepam to stop seizure
- 2-5 years old: 0.5mg/kg
- 6-11 years old: 0.3 mg/kg
- > = 12 years old: 0.2 mg/kg
Definition of febrile seizure***
- Seizure occurring in association with fever in children between 3 months and 6 years of age
- No evidence of intracranial pathology, metabolic derangement or history of previous afebrile seizure
Causative organism for meningitis*
- Viral infection (commonest): Enterovirus (80%), EBV, adeno virus
- Bacterial infection
1 month - 6 years: H. influenza, S. pneumoniae, N. meningitis
>6 years: S/ pneumoniae, N. meningitidis
Sign of meningitis**
- Meningism: neck stiffness, Kernig’s sign, Brudzinski’s sign
- Increase ICP: bulging anterior fontanelle, papilledema, bradycardia, sunset eye
- Sign of shock (septicemia)
CSF finding of bacterial vs viral meningitis**
Bacterial
- Turbid
- Pressure usually elevated
- WBC 100-60,000 PMN predominated
- Glucose <40%
Viral
- Usually clear
- Pressure normal
- WBC rarely >1000, mononuclear cell predominate
- Glucose generally normal
Management of meningitis*
> Supportive
- Monitor vital sign and input/output 4 hourly
- NBM
- Maintenance IV fluid
- Fit chart
- Daily CNS assessment
> Medical
- Antibiotic ASAP
- Steroid: decrease sequel of bacterial meningitis; give before or with first antibiotics
- Management of increase ICP: 30” bed head elevation, IV mannitol
- Antipyretic agent
Risk factor of recurrent febrile seizure*
- Family history of Febrile seizure
- Age <18 months
- Low degree if fever during first Febrile seizure
- Brief duration (<1 hour) between onset of fever and seizure
Investigation for febrile seizure***
> Blood
- FBC: r/o infection
- BUSE: r/o hypo/ hypernatremia (+hypo/hypercalcemia, hypomagnesemia -> can cause seizure)
- Serum calcium and magnesium
- Random BS: r/o hypoglycemia
- Blood C&S: r/o septicemia
> Urine
- UFEME + C&S: r/o UTI
> Other
- Lumbar puncture: must done unless CI if suggestive of intracranial infection, persistent lethargy
Management of febrile seizure***
- Antipyretics: PCM 15mg/kg 6 hourly
- Rectal diazepam (0.5mg/kg): if high risk of recurrent febrile seizure
During seizure:
- Take note of time of onset + duration
- Wipe any vomitus or secretion from the mouth
- Do not insert any objects into the mouth
- Lay the child on left lateral side (to open the airway + prevent aspiration)
- Rapid sponging, remove cloth to lower temperature
- If second attack -> go to hospital
Do we give antiepileptic drugs in febrile seizure
- No
- The risk and potential side effects outweigh the benefits
- Eg: Carbamazepine, Clonazepam, Sodium valporate
Causes of seizure*
- Genetic
- Structural (eg: head trauma, ischemia, bleeding, tumor, neurodegenerative disease)
- Metabolic (eg: glucose transporter deficiency, creatinine deficiency syndrome)
- Immune (eg: immune-mediated CNS inflammation)
- Infection (eg: TB, meningitis, encephalitis)
Explain Kernig’s and Brudzinski’s sign
- Kernig’s sign +ve (can do in 1 year plus): Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degree
- Brudzinski’s sign +ve (can do in 1 year plus): Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed
Complication of cerebral palsy*
> General
- Intellectual disability
- Aphasia and dysarthria (67%)
> Head
- Epilepsy (40%)
- Visual impairment (20%)
- Hearing loss (20%)
> Respiratory
- Aspiration pneumonia
> GIT
- Sucking and swallowing difficulty
- FTT
- GERD
Definition of epilepsy*
- Tendency to have recurrent seizure without provoking factors
- At least 2 unprovoked seizure occurring >24 hours apart
Treatment option for epilepsy
- For recurring seizure >= 2 episodes
- Daily medication (eg: anticonvulsant)
- Epilepsy surgery: remove cause of seizure
- Nerve stimulation: stimulate vagus nerve -> influence neurotransmitter release
- Ketogenic diet? (mechanism unclear)
Anticonvulsant and their side effects*
- Carbamazepine
§ Steven-Johnson syndrome
§ Agranulocytosis - Lamotrigine
§ Steven-Johnson syndrome - Sodium valproate
§ Hepatic toxicity
§ Pancreatitis
§ Encephalopathy - Vigabatrin
§ Peripheral visual field constriction (tunnel vision)
Definition of breakthrough seizure
- An epileptic seizure which occurs despite the use of antiepileptic drugs that have otherwise successfully prevented seizures in the patient.
Contraindication of lumbar puncture
- Hemodynamically instable
- Glasgow coma scale ≤ 8
- Abnormal doll’s eye reflex/ unequal pupils
- Lateralized signs/ abnormal posturing
- Immediately after a recent seizure
- Papilledema
Complication of meningitis**
> Early
- Local cerebral infarction
- Subdural effusion
- Cerebral abscess
- SIADH*
> Late
- Hydrocephalus
- CN palsy
- Hearing loss
- Epilepsy
- Developmental delay
Definition of status epilepticus***
- Single epileptic seizure >30 minutes duration OR
- Series of epileptic seizures during which function is not regained between ictal events in a 30 minutes period.
Management of status epilepticus ***
“Refer OneNote Epilepsy”
Causes of raised ICP
- Traumatic brain injury/ intracranial hemorrhage
- CNS infection
- Ischemic stroke
- Neoplasm
- Hydrocephalus
- Hypertensive encephalopathy
Differential diagnosis for febrile seizure
> Shaking chills
- Fine rhythmic oscillatory movement about a joint
rarely involve facial or respiratory muscles
> CNS infection
- Apart from seizure, got altered consciousness, petechial rash
Normal weight gain for children
- Regain birth weight by 2nd week
- Double at 5 months
- Triple at 1 y/o
Immunization schedule in Msia
“Refer Peads protocol P9”
Management of shock - Fluid resuscitation steps
- Corrected with fluid bolus of 10-20ml/kg (10 in DKA/ intracranial pathology; 5-10 if got associated cardiac condition)
- Always reassess circulation - give repeated bolus if necessary
- Measure blood glucose: treat hypoglycemia with 2ml/kg 10% Dextrose solution
Management of shock - Fluid maintenance steps
“Holliday-Segar formula”
- First 10kg: 100ml/kg @ 4ml/kg/hour
- Subsequent 10kg: 50ml/kg @ 2ml/kg/hour
- All additional kg: 20ml/kg @ 1ml/kg/hour
