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
