Neurosurgery/Abuse Flashcards
1
Q
neurosurgery consult indications
A
- Too much brain (Brain Tumor, abscess, swollen brain)
- Too much blood (Bleeding such as subdural hematoma, epidural hematoma)
- Too much CSF (hydrocephalus)
2
Q
hydrocephalus
A
- Disorder in which there is an excessive amount of cerebrospinal fluid (CSF).
- Disorder may arise from one of three conditions or combination of the following
- CSF overproduction
- CSF circulation/flow
- CSF absorption
- Why do we worry about Hydrocephalus?
- Unfused Sutures- head enlargement, ventricles enlarge and poor brain development (common scenario of infancy)
- Fused Sutures- increased intracranial pressure, rapid destruction of brain tissue, herniation
- Causes of Hydrocephalus in infants/children
- Defective Reabsorption
- Hypoplasia of arachnoid villa
- Post-infectious destruction of arachnoid villi
- Overproduction of CSF
- Choroid Plexus papilloma
- Obstruction of CSF pathways
- Brain Mass/Brain Tumor
- Aqueductal Stenosis
- Post-infectious/Post-inflammatory
- Arnold Chiari Malformation
- Dandy Walker Malformation
3
Q
Risk factors and signs of hydrocephalus
A
- Risk Factors for Infantile Hydrocephalus
- Birth Weight < 1500 gms
- Prematurity
- Maternal Diabetes
- Male sex
- Race/ethnicity (Asians at decreased risk)
- Hydrocephalus Signs
- Vital Signs- bradycardia, hypertension, altered respiratory rate - CUSHINGS TRIAD
- Head Circumference/Head Shape
- Macrocephaly (off the growth curve, or significantly increasing)
- Frontal bossing
- Prominent scalp veins
- Cranial nerve- paresis of 3rd or 6th cranial nerve
- 3rd nerve carries info for eyes and pupils - what you see is big pupils that arent responsive to light reflex (sometimes assymetrically)
- Fundoscopic Exam- papilledema
- Spine- Neural Tube Defect
- Motor Function- spasticity
- Growth and pubertal development- maybe altered
4
Q
diagnosis and management of hydrocephalus
A
- Diagnosis
- Imaging
- CT scan
- MRI
- Ultrasound can be of some utility in patients who have an open fontanelle
- Imaging
- Management
- Surgical Placement of Shunt
- Ventriculo-Peritoneal Shunt
- Catheter placed into one of the lateral ventricles
- Catheter is connected to right atrium or peritoneal cavity
- Ventriculo-Peritoneal Shunt
- Medical Therapy
- Acute: hyperventillation, mannitol, 3% saline, positioning
- Serial Lumbar Punctures (temporizing for non-acute hydrocephalus)
- Considerations in Management
- Infection of the VP Shunt
- difficult to manage
- emergent neurosurgery consult
- Mechanical Failure of the shunt
- emergent neurosurgery consult
- Overdrainage
- Infection of the VP Shunt
- Surgical Placement of Shunt
5
Q
child abuse
A
- Physical Abuse
- Sexual Abuse
- Shaken Baby Syndrome
- Neglect
- Child Abuse and the Social System/Foster Care
6
Q
physical abuse
A
- any non-accidental injury inflicted by a caretaker
- estimated 1-2% are physically abused in childhood
- physical abuse accounts for ~2000 deaths/year
- mothers are most frequently reported, but fathers or mother’s boyfriend are more likely to inflict serious injury
- approximately 1/3 of patients with inflicted head trauma are misdiagnosed on their first presentation to medical care
- risk factors for misdiagnosis include mild injury, age under 6 months
- screening for physical abuse includes ruling out unusual diseases that have previously been mistaken for abuse
- coagulopathies
- diseases that increase risk of fracture
- glutaric aciduria type I (subdural hemorrhages)
- Osteogenesis Imperfecta
- Rickets - even in cases where child abuse is highly likely, defense will say low vitamin D level caused the fracture
7
Q
red flags for physical abuse
A
- red flag: history inconsistent with injury
- a parent unable to explain an injury (its extent, location, timing, etc.) prevents ruling out a non-accidental cause
- bruise red flags
- patterned bruises
- bruises isolated to the trunk, neck, or not over bony prominences
- bruises in non-ambulatory infants
- burn red flags
- immersion injury, particularly around buttocks and heels during toilet training
- fracture red flags
- unexplained fractures
- fractures in non-ambulatory children
- fractures of multiple bones
- fractures of different ages
- abdominal injury red flags
- bruises over soft areas
- injury to hollow or solid organs without explanation
8
Q
non-accidental burns
A
- unusual burn patterns raise concern for non-accidental trauma
- water immersion produces full thickness burns
9
Q
workup of suspected abuse
A
- history
- consistent with the injury?
- consistent with development abilities?
- past history of injury or unexplained illness?
- social evaluation
- dysfunctional family
- substance abuse
- medically fragile child (premature, impaired, etc.)
- complete physical examination
- may include photographs and measurements of suspicious areas
- care for chain of evidence in forensic photography is essential
- laboratory
- platelets, coagulation studies, liver function tests
- radiologic studies have much greater value in small children
- skeletal survey
- +/- bone scan
- head imaging
- ophthalmologic examination
- evaluate for abdominal or other injuries
- social service and police referral/report
10
Q
non-abusive causes of fractures
A
- birth trauma: clavicle, humerus, skull, rib, femur-w/neuromuscular disease
- prematurity: higher risk for osteopenia, rickets
- neuromuscular defects, osteoporosis, contractures, decreased or absent pain perception
- hypophosphatasia
- neoplasm
- Osteogenesis imperfecta (OI)
- 1 in 50,000 live births
- deficiency of type I collagen, results in increased bone fragility
- +/- blue sclera
- family history
- osteopenia
- Wormian Bones
- biochemical collagen test positive in 80% of OI
- Menkes syndrome
- defect in copper metabolism
- metaphyseal-epiphyseal fractures, wormian bones, periosteal reaction, sparse & kinky hair, FTT, developmental delay
11
Q
conditions mistaken for fractures
A
- congenital syphilis and osteomyelitis
- metaphyseal irregularities & periosteal new bone growth
- drug toxicity
- methotrexate - periosteal reaction, metaphyseal fx
- prostaglandin E - diaphyseal periostitis
- hypervitaminosis A - diaphyseal periostitis
- scurvy
- painful swollen limbs, metaphyseal irregularity,
extensive periosteal new bone formation,
thin cortices, demineralized bones
- painful swollen limbs, metaphyseal irregularity,
- rickets
- generalized and symmetric skeletal changes,
metaphyseal irregularity and widening
- generalized and symmetric skeletal changes,
12
Q
A
13
Q
normal radiographic variants
A
- 2-8 month old infants
- periosteal new bone along the shafts of long bones
- spurring and cupping of the metaphyses
- other variants can appear as fractures
14
Q
non-accidental head trauma
A
- 80% of deaths of children < 2 years of age from non-accidental head trauma
- Abusive head trauma results in estimated 1,500 hospitalizations each year.
- most often in first 6 months
15
Q
shaken baby syndrome
A
- consider SBS in infants with:
- intracranial injury after minor trauma
- scan infants with symptoms indicative of head injury
- neurologic deterioration in an infant is always indication for cranial imaging
- retinal hemorrhages
- intracranial injury after minor trauma
- does the history explain the injuries?
- common presenting findings
- apnea
- bulging fontanelle
- fever
- history of minor head trauma
- irritability
- lethargy
- poor feeding
- seizures
- staring episodes
- vomiting
- mechanism of injury
- head is relatively large and heavy
- infant 10-15% of body weight
- adult 2-3% of body weight
- weak neck muscles
- brain is underdeveloped in infant
- acceleration-deceleration injury
- relative lack of myelination
- shear of neurons and vast variations in intracranial pressure during shaking
- impact injuries cause even greater focal injury to brain
- head is relatively large and heavy
- injuries from shaken baby syndrome
- subdural and/or subarachnoid hemorrhage
- diffuse axonal injury
- intracranial hypertension
- retinal hemorrhages
- usually documented by ophthalmologist
- always screen on admission, particularly if CPR is to start
- do not delay CPR to do a funduscopic exam, however
- intervention
- maintain a high suspicion in young infants with mental status changes or other signs of abuse
- key to early diagnosis
- mandated reporting for cases of suspected child abuse
- maintain a high suspicion in young infants with mental status changes or other signs of abuse
- prognosis - poor for most infants
- preventive education for parents to safeguard against stressful periods of parenting
- happens with anticipatory guidance
- the parental “time-out”
