Neurology Flashcards
1
Q
Febrile seizure evaluation and management
A
Hx
- Assess simple vs complex
- > focal/generalised
- > under 10mins/over 10 mins
- > full recovery/incomplete recovery by 1hr
- > single episode/more than 1 episode
- Source of fever
- > UTI symptoms
- > cough/wheeze/SOB
- > headache/meningism/photophobia
- > nausea/vomiting/diarrhoea
- > rashes
- > otitis media
- Past hx
- > previous seizures
- > prematurity
- > developmental delay
- > neuro/lung/heart disease
- > immunosuppression
- Family hx
- > seizures/epilepsy
- Medications
- > recent antibiotics
- Social
- > sick contacts
- > recent travel
- > immunisations
Exam
- Vitals
- > haemodynamically stable
- > febrile
- Colour
- > pallor
- > mottled
- > cyanosed
- Behaviour
- > lethargy/unresponsive
- > weak/high pitched cry
- Ears/nose/throat
- Resp
- > increased work of breathing
- Circulation
- > signs of dehydration
- Neuro
- > bulging fontanel
- > meningism
- > focal neuro signs
- Rheum
- > joint swelling
- > non weight bearing
- > rash
Investigations
- Fever without focus
- > FBC
- > VBG (lactate/pH/glucose/electrolytes)
- > CRP
- > Blood culture
- > Urine MCS
- Fever with focus
- > no investigations needed for seizure alone
- > investigate accordingly
- Consider if prolonged/complex
- > LP
- > CNS imaging
- > no role for EEG
Management
- First febrile seizure
- > usually viral/antibiotics not required
- > anti-pyretics not recommended as treatment/prophylaxis
- Complex seizure
- > refer to paediatrician/neurologist
- > give ibuprofen
- > give rectal diazepam/buccal midaz (prevent recurrence)
- Febrile with past hx
- > no evidence for prophylactic anti-pyretic or benzo
- Two/more simple febrile
- > refer to paediatrician/neurologist
- > consider anticonvulsant
- Febrile status
- > over 5 mins = rectal diazepam/buccal midaz
- > still seizing at 15 mins = repeat dose
- > still seizing = IV phenytoin
- > still seizing = IV diazepam
2
Q
Afebrile seizure evaluation and management
A
Initial response
- Establish seizure has stopped
- Vitals
- > haemodynamic stability
- Primary survey
- > injuries
- Safety
- > sit/lie down
Hx
- Prior
- > triggers
- > aura
- > headache
- During
- > duration
- > awareness
- > movements (focality)
- > injuries
- Post
- > hemiparesis/aphasia
- > post ictal confusion
- Past hx
- > previous episodes/treatment compliance
- > significant comorbidities (neuro/metabolic/endocrine)
- > developmental delay
- Family hx
- > seizures/epilepsy
- Medications
- > any pro seizure drugs
- Psychosocial
- > impact on work/ADLs
- > driving
- > drugs and alcohol
Exam
- alertness and orientation
- focal neurological signs
- meningism
- cardiovascular exam
- systems review for infective source
- assess for injuries
Investigations
- Blood glucose
- ECG
- FBC
- VBG
- > electrolytes
- > acid base
- Urea and creatinine
- Toxicology screen (if indicated)
- bHCG if female (treatment)
- MRI brain
- > structural lesion
- EEG
- > relatively low sensitivity
- > best within 48hrs
- Lumbar puncture
- > if infection suspected
Management
- Admit
- > multiple seizures/status
- > prolonged confusion
- > focal features
- > positive investigations
- Discharge
- > normal evaluation
- > returned to baseline
- > organise follow up/EEG
- Safety
- > explain risk of recurrence
- > teach first aid (provide written information)
- > no driving/heavy machinery until cleared by neurologist
- > certificate needed to drive
- > avoid swimming/bathing alone (cold tap first)
- > avoid stress/drugs and alcohol/sleep deprivation
- Anticonvulsants
- > not usually given if normal evaluation + first seizure
3
Q
Meningitis evaluation and management
A
Hx
- Infant
- > fever
- > headache
- > photophobia
- > nausea and vomiting
- > altered level of consciousness
- > seizures (consider encephalitis)
- > leg pain (meningococcal)
- Neonate
- > irritability/drowsiness
- > poor feeding
- > hypo/hypertonia
- > vomiting and diarrhoea
- > temperature instability
- Past
- > preceding URTI
- > immunisation status (HiB)
- > recent antibiotic exposure
- > neuro anatomy/immunosuppression
Exam
- Vitals
- > febrile
- > tachycardia
- > tachypnoea
- > desaturation
- high pitched cry
- full fontanel
- neck stiffness
- focal neuro signs
- kernig/brudzinski signs
- non blanching (usually) purpuric rash (late sign)
Investigations
- Blood cultures
- CSF
- > gram stain + culture
- > biochem
- > meningococcal PCR (seperate tube) if suspected
- > PCR multiplex (entero/paraecho/neisseria/strep/HSV)
- VBG
- > lactate
- > acid base
- > glucose
- > sodium (SIADH)
- FBC
- > WCC above 15
- Coags
- > if purpura
- MRI
- > if suspected raised ICP/focal neuro/encephalitis
- > not routine
- > CT not sufficient to exclude ICP
- EEG
- > if encephalitis suspected
Management
- IV access
- > fluid bolus 10mL/kg if shocked
- > analgesia
- Antibiotics (ASAP)
- > neonate = benpen + cefotaxime IV
- > child = cefotaxime IV + vanc if gram +ive stain
- Steroids (prevents hearing loss)
- > neonate = not recommended (neurodevelopment)
- > child = dexamethasone IV before/just after antibiotics
- Encephalitis
- > aciclovir
- Fluids
- > over/under hydration worsens outcomes
- > SIADH common/risk of raised ICP
- > normal saline + glucose
- > refer to RCH guidelines for rates
- Prevention
- > droplet precautions first 24hrs
- > prophylaxis for contacts
- > Neisseria/Hib/strep notifiable
- Monitor
- > weight
- > HC
- > vitals
- > glucose
- > electrolytes
- > urea/creatinine
- Follow up
- > formal audiology at 2 months
- > neurodevelopment
