Neurology and Development Flashcards
What is acute cerebellar ataxia and what are potential etiologies of it?
- Focal encephalitis of the cerebellum that accounts for 50% of acute ataxia
- Etiologies include post-vaccination, as well as post/para-infectious (VZV, staph, strep, other viruses)
What are sxs that would suggest acute cerebellar ataxia?
-truncal instability, ataxia, dysphagia, dysarthria, diplopia, tremor, past-pointing
Give a differential diagnosis for acute cerebellar ataxia
-infection, toxin, trauma, tumor, stroke, demyelinating conditions
- What is the workup for acute cerebellar ataxia?
- How should it be treated?
- Obtain an MRI/CT to rule out tumor, trauma, demyelinating conditions. Consider tox screen with concerning history. If AMS or meningeal signs obtain LP and full septic workup to r/o meningitis
- Acute cerebellar ataxia requires only supportive care and most self resolve, however you should be ruling out other scary causes for a focal neurological change before hanging your hat on this diagnosis
- What is ADEM?
- What is its etiology?
- How does it present?
- Acute demyelinating encephalomyelitis-demyelinating condition of CNS white matter. Many of these patients go on to have a diagnosis of multiple sclerosis
- usually para/post-infectious
- Variable presentation depending on what is demyelinated-motor palsies, cerebellar findings, sensory losses, dysarthria, dysphagia, anything
- What workup should be done for ADEM?
- What will workup show that proves ADEM?
- How is this condition treated?
- Given the variable and acute onset w/u like any other neurological emergency-r/o toxin, stroke, infection, trauma, tumor, demyelinating conditions.
- MRI will show multifocal CNS demyelination
- Tx with IVIG and steroids
- Describe how a patient with altered mental status should be managed when they enter the emergency department
- What labwork should you consider?
- What other ancillary tests should consider?
- This is an emergency until proven otherwise!
- Assess ABCDs and start PALs if needed, start IV access, put patient on monitor, start O2
- Go through AEIOU TIPS pneumonic and obtain workup based on salient history
- Labs to consider-loaded gas, CBC+diff, blood+urine+CSF cultures, BMP+hepatic, tox screen
- other tests to consider-emergent head imaging, ekg
- What physical exam findings need to be assessed for anyone presenting with altered mental status?
- What score should you obtain?
- pupil size, activity/tone, responsiveness, detailed neuro exam, presence of meningeal signs, presence of rashes, abdominal exam, pulm exam
- Obtain a GCS score!
- How is the GCS used and what do score ranges indicate for the degree of brain injury?
- In what age group is pediatric GCS validated?
- 15 point scale scored 3-15, 13-14 indicating mild brain injury; 9-12 indicating moderate brain injury; =8 indicating severe brain injury and a need to intubate
- validated for age < 2yo
-What are the pediatric GCS scores?
- eye opening (1-4)- 1=none; 2=to pain; 3=to sound; 4=spontaneous
- verbal response (1-5)- 1=none; 2=moans to pain; 3=cries to pain; 4=cries, irritable; 5=age appropriate vocalizations
- Motor response (1-6)- 1=none; 2=decerebrate (extended) posturing to pain; 3=decorticate (flexed) posturing to pain; 4=withdraws from pain; 5=localized pain; 6=spontaneous movements
What are the non-pediatric GCS scores?
- For verbal patients >2yo
- eye opening (1-4)- 1=none; 2=to pain; 3=to command; 4=spontaneous
- verbal response (1-5)- 1=none; 2=incomprehensible sounds; 3=inappropriate words; 4=confused, disoriented; 5=oriented
- Motor response (1-6)- 1=none; 2=decerebrate (extended) posturing to pain; 3=decorticate (flexed) posturing to pain; 4=withdraws from pain; 5=localizes pain; 6=spontaneous movements
What is the AEIOU-TIPS pneumonic for ddx for altered mental status?
A-alcohol, acidosis
E-encephalopathy, epilepsy, electrolytes, endocrine
I-ingestion, intussusception, infection, insulin
O-overdose
U-uremia
T-trauma, toxin, tumor
I-ischemia, ingestion, intracranial hemorrhage, ICP
P-psychosis, poisoning
S-stroke, sepsis, seizure
Define simple and complex febrile seizures.
- Simple-generalized, age 6mo-6yr, febrile, and lasts <15minutes
- Complex-focal, febrile, lasting >15mins, or recurrent seizure w/in 24 hours
How should febrile seizures be managed?
2 categories:
1) simple febrile seizure and patient back to neurological baseline-manage the underlying cause of fever, supportive care
2) complex febrile seizure or patient not back to neurological baseline-full workup, head imaging, rule out meningitis
What education should be given to parents about febrile seizures?
- reassure parents that their child is at no increased risk of neuro complications, give return precautions, and advise that antipyretics have no benefit. Advise family to obtain quick PCP FU
- only prescribe anticonvulsants in consultation with neurologist who will follow patient in outpatient setting.
How should a first time afebrile seizure be managed?
- if generalized, short duration, patient back to neurological baseline patient can be discharged with return precautions and advice to FU w/PCP. <40% have recurrence
- If focal, prolonged, continued AMS, recurrent, hx suspicious for NAT, or patient <1yo-obtain meningitis w/u and head imaging, admit this patient
- What are the first line agents that can be given for status epilepticus?
- How are these dosed?
- what non-IV formulations exist?
- When can first line agents be repeated and when should you move to 2nd line agents?
1) ativan-preferred as it has a 4 hour duration
- IV as 0.1mg/kg, max 4 mg
2) Versed-only lasts 20 minutes
- IV loading dose as 0.1mg/kg
- IM or IN at 0.2mg/kg
3) Diastat-rectal 0.5 mg/kg for 1st dose, 0.25 mg/kg 2nd dose
-1st line agents can be repeated after 5 minutes and you should move to 2nd line agents after the 2nd dose of 1st line agent
- At what point should you be prepared to intubate for status epilepticus?
- What sedative would you use for RSI?
- What paralytic would you use for RSI?
- if patient is vomiting/aspirating or you are giving your 2nd 1st line agent as the increased sedation can lead to problems protecting the airway.
- Sedative-if hemodynamically stable use versed or propofol, if hypotensive use etomidate
- Paralytic-succinylcholine, if contraindicated use rocuronium
- What are the 2nd line agents that can be given for status epilepticus?
- What should you be doing if administering a 2nd line agent?
- How are these dosed?
- what non-IV formulations exist?
- When can 2nd line agents be repeated and when should you move to 3rd line agents?
- What side effects should you be aware of?
1) Keppra-20-60mg/kg IV
2) Fosphenytoin-20mg/kg IV or IM
- draw up your 3rd line agent! 2nd line agents take 20 minutes to have effect, time is brain!
- 2nd loading dose of fosphenytoin can be given vs switching to keppra following 10 minutes.At least 2 doses of 2nd line agent should be given (Keppra x1+forpheny x1 vs fospheny x2) prior to switching to 3rd line agent
- fosphenytoin can cause hypotension
- What are 3rd line agents that can be given for status epilepticus?
- How are these dosed?
- What should have already happened prior to giving a 3rd line agent?
- Versed-continuous IV infusion of 0.05-2mg/kg/hr
- pentobarbital-5-15 mg/kg bolus followed by 0.5-5mg/kg/hr continuous infusion
- ketamine 0.5-2mg/kg/hr continuous infusion
- propofol 2mg/kg bolus followed by 1-15mg/kg/hr continuous infusion
- Before you give a 3rd line medication patient needs to be intubated
- What are potential etiologies of seizure?
- How are these treated?
1) Hypoglycemia-tx with rule of 50
2) Hyponatremia-tx with 5mL/kg of 3%NS over 20 minutes, do not correct more than 8 mEq in 24 hours to avoid central pontine myelinosis
3) hypocalcemia-tx with 10% calcium gluconate 0.3mL/kg over 5-10 minutes
4) Isoniazid toxicity-give pyridoxine (Vit B6) 70 mg/kg max 5g
5) Miscellaneous-NAT, toxin (B blocker), metabolic abnormality
- How do afebrile seizures in neonates present?
- How should these be managed?
- non-specific motor/neuro signs as their nervous system isn’t well developed yet-repetitive lip smacking, bicycling, eye twitching, abnormal vital signs
- perform a full sepsis workup, obtain a head CT and admit
Give some red flags that a headache may be 2/2 brain tumor.
- headache/vomiting in the middle of the night or morning
- papilledema
- ptosis
- focal neuro deficits
- torticollis
- occipital headache
- recent confusion or behavioral changes
- lack of photo/phonophobia consistent with migraine or lack of family hx of migraine
What are sxs of low level carbon monoxide exposure?
dyspnea on exertion, difficulty concentrating
What are sxs of moderate carbon monoxide exposure?
ataxia, confusion, PVCs, syncope
What are sxs of high carbon monoxide exposure?
seizure, coma, encephalopathy, HA
What are late findings of carbon monoxide poisoning?
retinal hemorrhages and cherry red skin
- Who will be most severely affected in a household by carbon monoxide poisoining?
- How should CO poisoning be managed?
- kids and pets! (the small ones)
- Give O2 immediately as it reduces the half life and consider hyperbaric O2 if patient has severe sxs, remove exposure!
- Give the 3 typical presentations of sinusitis
- What symptoms are common?
- How should this be treated?
1) URI sxs x10 days that aren’t resolving
2) severe URI sxs x3-4 days associated with high fever
3) Recurrence of URI sxs day 5-6 after initial improvement
- foul breath, pain with palpation, nocturnal cough
- Give augmentin and intranasal steroids
- Give the diagnostic criteria for migraine
- What other sxs are common?
- 5+ headaches w/out other explainable source lasting 1-72 hours with at least 2 of the following characteristics:
1) bifrontal, bitemporal, or unilateral
2) pulsating/throbbing quality
3) moderate-severe pain
4) aggravated by activity - N/V and photo/phonophobia also common
How should migraine be treated in the ER?
- 1st trail NSAID/tylenol
- 2nd give sumatriptan if not contraindicated
- 3rd trial compazine
- last measure discuss with neurology about inpatient admission for DHE
What are contraindications for giving sumatriptan for migraine?
- Triptan used more than once in past week
- Sickle cell disease
- CAD, dysrhythmia (WPW), or
- congenital heart disease
- CNS vasculitis/moya-moya
- Zofran within last 24 hours
- Recent MAO-I use
- What are sxs of infantile botulism?
- What complications can it lead to?
- How is it treated?
- Sxs-constipation, lethargy, decreased tone, poor feeding, eye paralysis, cranial nerve findings
- Complications-respiratory arrest
- Tx-patient to be admitted for ventilatory support and botulism IG
Give a ddx for pediatric stroke
-todd’s paralysis, demyelinating conditions, meningitis, meningococcemia, trauma, tumor, migraine, hypoglycemia, inborn error of metabolism, intoxication
- What are etiologies for hemorrhagic strokes?
- What modalities for treatment should be considered?
- ruptured AVM, trauma, coagulopathy, tumor, cavernous hemongioma
- treat the ICP with mannitol, hypertonic saline, treat coagulopathy and consider seizure prophylaxis
Describe risk factors for ischemic stroke
1) infection
2) arteriopathy (posterior palate trauma–>carotid dissection, moyamoya, lupus/rheumatologic)
3) cardiac dz-congenital malformation
4) hematologic disease-platelet disorder vs sickle cel disease
5) Drugs-meth, cocaine, chemotherapy, radiation
How should ischemic stroke be managed?
- discuss with a neurologist or stroke expert as data is limited.
- If arteriopathy consider heparin, aspirin, plavix (clopidogrel)
- Discuss tPA if clot demonstrated on an emergent MRI
- If patient has sickle cell obtain stat H/O consult for exchange transfusion
- What is transverse myelitis?
- What sxs does it present with?
- How should it be managed?
- post/parainfectious focal spinal cord demyelination usually following a VZV or EBV infection
- sxs of bilateral motor/sensory loss at a specific dermatome and urinary retention, back pain, loss of deep tendon reflexes
- mgmt by getting MRI and neuro consult. If focal spinal demyelination seen give high dose steroids and plasmapheresis
- What is Guillain-Barre Syndrome and how does the Miller Fischer variant differ?
- What are the sxs?
- How is it treated?
- typically ascending paralysis 2/2 an autoimmune response following a campylobacter, flu infection or rarely flu vaccine. The Miller-Fischer variant is descending paralysis
- Sxs-progressive weakness, sensory loss, or decreased deep tendon reflexes
- respiratory support, IVIG, plasmapheresis
At what age does modesty develop in children?
Modesty develops between 4 to 6 years of age
At what age do children gain a visual preference for the human face?
newborn period
At what age do children begin smiling responsively?
1 month
At what age do children begin climbing onto furniture?
2yo
At what age do children have the ability to balance on 1 foot?
6yo
At what age can children visually follow a moving object?
1mo
At what age can children stand momentarily on one foot?
3yo
When do most babies begin crawling by?
9mo
At what age do most babies have a pincher response by?
1 yo
At what maximum rate can fosphenytoin be given?
3mg/min
What are risk factors for febrile seizure recurrence?
Risk factors for febrile seizure recurrence include:
- age less than 12 months with onset of febrile seizures
- temperature less than 40C with febrile seizure
- family history of febrile seizures
What is the dosing of diazapam for status epilepticus?
- rectal: 0.5mg/kg
- IV:0.2-0.3mg/kg
What common pathogen for gastroenteritis is associated with seizures?
Shigella!
- What is the drug of choice for neonatal seizures?
- What is the dosing?
Phenobarbital-20 mg/kg; maximum dose: 1,000 mg/dose
When can children do tandem gait on a neurologic exam?
5 years
When is an upgoing plantar reflex normal?
Up to 1yo
What are some early signs of hypertonicity in a child who is fighting you?
Scissoring and truncal hypertonicity. Babies who are trying to kick you away can seem surprisingly strong. While they are resting, holding their legs crossed in a “scissors position” is frequently abnormal. Also, when you turn the baby from back to front by pulling on one arm, he/she should move in sections- chest first, then abdomen, then diaper area. If they roll over all at once, like a log, this is abnormal.
When should the moro reflex stop?
6 months
When do the palmar and plantar grasps stop?
4 months
