Neurology/Sedation/Analgesia Flashcards
Lab tests for febrile seizure?
None needed
Lab tests for seizure diagnosis
CBC, electrolytes, toxicology screen, glucose, calcium, magnesium
When does a child with a seizure and a fever need an LP? (3 things)
- When they also have signs of meningitis including neck stiffness and +Kernig and/or Brudzinski signs
- In an infant 6-12 months w/o immunizations to Hib or Strept pneumo or if immunization status can’t be determined
- If they have been pretreated w/ antibiotics, b/c antibiotics can mask the s/s of meningitis but may not be sufficient to eradicate it
Kernig sign
One of the physically demonstrable symptoms of meningitis is Kernig’s sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Brudzinski sign
One of the physically demonstrable symptoms of meningitis is Brudzinski’s sign. Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.
Simple Partial Seizures
Motor signs, somatosensory or special sensory, autonomic symptoms and signs, psychic signs
Complex partial seizures
Simple partial onset followed by or w/ impairment of consciousness
Febrile seizures
Occur on rise of fever, usually between ages 6 months and 5 years, short, resolve spontaneously
Status Epilepticus
A single seizure lasting longer than 30 minutes or two or more consecutive seizures w/o returning to baseline LOC
Referral to the ED
1st line therapy:
- ABC, then benzodiazepines PR, IM, IV
- Secondary therapy w/ Dilantin or Phenobarbital load
Infants and spinal cord injury
Poorly developed cervical musculature, head is disproportionately large
Children less than age 9 and spinal cord injury
Wedge shaped vertebral bodies, angled horizontally
Who is more prone to SCIWORA
Spinal cord injury without radiological abnormality
Young children have cartilaginous endplates w/ lax interspinous ligaments, so they are more prone to SCIWORA
Who is more prone to atlantoaxial subluxation?
Children w/ Down syndrome are more prone to atlantoaxial subluxation as a result of acute flexion injury.
Atlantoaxial instability (AAI) is characterized by excessive movement at the junction between the atlas (C1) and axis (C2) as a result of either a bony or ligamentous abnormality. Neurologic symptoms can occur when the spinal cord or adjacent nerve roots are involved.
SCIWORA
Spinal cord injury without radiographic abnormality (SCIWORA) refers to spinal injuries, typically located in the cervical region, in the absence of identifiable bony or ligamentous injury on complete, technically adequate plain radiographs or computed tomography. The majority of children with SCIWORA do have demonstrable injury of the spinal cord, spinal ligaments, or vertebral body end plate on magnetic resonance imaging (MRI). SCIWORA should be suspected in patients subjected to blunt trauma who report early (immediate) or transient symptoms of neurologic deficit or who have existing findings upon initial assessment. Treatment and prognosis are based upon neurologic presentation and MRI findings.
Spinal Cord Injury Impairment Scale
A- Complete- No sensory or motor function preserved below S4-S5
B-Incomplete- Sensory function present, no motor function preserved below the neurologic level extending through S4-S5
C-Incomplete- Motor function preserved below the neurologic level w/ muscle grade less than 3
D- Incomplete- Motor function preserved below the neurologic level w/ muscle grade of 3 or greater
E- Normal- Sensory and motor function preserved
Management of Spinal Cord Injury
- Manage airway
- Immobilize C-Spine
- High dose IV steroids (30mg/kg)
- Manage neurogenic shock w/ fluids, alpha-adrenergic agents, continuous monitoring
- Spinal shock can last several days, causing paralysis and loss of tone w/ hypovolemia
Primary TBI - Injury/Results
Injury:
Intracranial contusion, Extra-axial hemorrhage: epidural, subdural and subarachnoid, Diffuse Axonal Injury
Results:
Epidural hemorrhage: injury to the middle meningeal artery or vein
Subdural hemorrhage: Bridging vein rupture
Subarachnoid hemorrhage: Tearing of small vessels in the pia mater
Secondary TBI - Injury/Results
Injury: Sequelae of local and systemic events
Results: Ischemia, Energy failure, cell death and secondary brain injury, axonal injury and death, cerebral edema, intracranial pressure increases or changes
Epidural bleed/hematoma
Does not cross suture line, typically on side of direct impact, rapid accumulation of blood, often w/ fracture
Subdural bleed/hematoma
Crescent shape, may cross suture line, but not midline, countercoup injury
Contrecoup injury: an injury, usually involving the brain, in which the tissue damage is on the side opposite the trauma site, as when a blow to the left side of the head results in brain damage on the right side.
Intraparenchymal hemorrhage
Bleeding within brain tissue
Intraventricular hemorrhage
Bleeding inside or around the ventricles of the brain
Hypoxic-ischemic injury
Initial CT may be normal, occurs and progresses over 24-48 hours, CT appears hyperdense
Short term Management of TBI
Rapid Sequence Intubation, minimize increased intracranial pressure
Follow critical pathway for treatment of established Intracranial hypertension in pediatric trauma
Continued evaluation of symptoms is extremely important in children with moderate to severe brain injuries, but children w/ mild injury should also be monitored for changes in status and sequelae
Long Term Management of TBI
- Multi-system problems
- Complex care/medically fragile needs
- Rehabilitaiton and medical home management
- Chronic care of child with TBI or CP includes collaboration with services such as physical therapy, speech and language, school services, neurology and other sub speciality services
Cushing’s Triad
Sign of increasing ICP
- Bradycardia
- Hypertension
- Irregular breathing
Cerebral Palsy
- Motor impairment resulting from neurological insult, typically classified by type of movement problem
- Spasticity- failure of muscle to relax
- Athetoid- inability to control movement of the muscle
- Hemiplegic- involves one arm and one leg on the same side of the body
- Diplegia- both legs
- Quadriplegia- all 4 extremities
Encephalitis
Acute inflammatory process of the brain parenchyma, often caused by a viral process, bacterial, autoimmune, or fungal
- Herpes simplex encephalitis (HSE), occurs in neonates infected at birth and in other young infants and is potentially lethal if not treated
- Varicella-zoster virus encephalitis (VZVE) is life threatening in immunocompromised patients
Symptoms: HA, aphasia, ataxia, visual disturbances, seizures. Diffuse and/or focal neuropsychological dysfunction
Management: Treatment of known cause and neurology consult with recommended diagnostic w/u. Therapy should be initiated w/ acyclovir in any young infant or child who is suspected of having viral encephalitis, especially those who appear ill
Botulism
Progressive neuromuscular weakness as a result of presence of C. botulinum
- Infants less than 6 months of age
- Hypotonia, constipation, listlessness, poor feeding, weak cry and decreased gag reflex
- Dx is through identification of C.botulinum spores in feces and clinical findings
- Tx is botulism specific IVIG (BIG-IV) obtained only through the California Department of Health
Guillain-Barre Syndrome
Progressive Neuromusuclar weakness
- Follows 4-6 weeks after a viral illness or prior infection
- Symptoms are progressive and symmetrical w/ ascending paralysis (feet to head)
- Pain, numbness, tinging of the extremities and sensory loss w/ gait disturbances
- Management: Dx is through CSF protein measurement and clinical findings, Tx is IVIG and supportive care.
Musucular Dystrophy
Typically diagnosed by age 2.
The limb girdle muscular dystrophies=diseases w/ progressive, symmetrical proximal weakness w/ genetic link
Concern for children w/ MD is the progressive neuromuscular weakness which will eventually involve respiratory center and require ventilation assistance
Spinal Muscular Atrophy (SMA)
Neuromuscular disease of childhood. Symptoms include weakness at birth or within the first year of life, feeding, breathing difficulties.
Type 1=Werdnig Hoffman- never sit, usually dx by 6 months
Type 2=Intermediate. Usually can sit, but not stand or ambulate
Type 3=Kugelberg Welander- presents after age 18 months and children have learned to walk
Mitochondrial Disorders
As metabolic disease- acidemia, respiratory chain disorders and fatty acid oxidation deficits
Acute traumatic head injury- Blown Pupil…
Elevate HOB, Hyperventilate, maintain BP, administer hypertonic saline and/or mannitol
Hyperventilate - blow off CO2- CO2 goes down
Midazolam
Benzodiazepine
Procedural sedation, sedation for ventilation, etc
Lorazepam
Acute Seizure management
Agitation
Diazepam
Sedation
Sedation weaning, muscle tremors
Haloperidol
Agitation, irritability, adjunct for longer term sedation w/ other agents
Proprofol
Anesthetic agent, short acting
Neuromuscular Blockade
Reserved for critically ill children usually for the purpose of controlled ventilation
Must administer w/ sedatives and analgesics
Know total time of action prior to administration, especially w/ intubation
