Paediatrics - Neurology and CAMHS Flashcards
KEY BIG CARD
Epilepsy is an umbrella term for a condition where there is a tendency to have seizures.
Seizures are transient episodes of abnormal electrical activity in the brain.
Define tonic and clonic?
There are many different types of seizure. The types generally seen in adults and children include:
Generalised tonic-clonic seizures
Partial seizures (or focal seizures)
Myoclonic seizures
Tonic
Atonic seizures
The types more common in children include:
Absence seizures
Infantile spasms
Febrile convulsions
What are the different features of these types of seizures?
Management - what is the management for each type of seizsure
T-onic - muscle T-ensing
Clonic/clonus - muscle jerking (clonus - huntington jerks)
Generalised tonic-clonic seizures:
- involve tonic (muscle tensing) and clonic (muscle jerking) movements associated with a complete loss of consciousness. Typically, the tonic phase comes before the clonic phase. They are also called grand mal seizures.
- Before the seizure, patients might experience aura, an abnormal sensation that gives a warning that a seizure will occur.
- There may be tongue biting, incontinence, groaning and irregular breathing.
- After the seizure, there is a prolonged post-ictal period, where the person is confused, tired, and irritable or low.
- Management is lamotrigine or carbamazepine.
Partial seizures (or focal seizures) occur in an isolated brain area, often in the temporal lobes. They affect hearing, speech, memory and emotions. Patients remain awake during partial seizures. They remain aware during simple partial seizures but lose awareness during complex partial seizures. There are various symptoms associated with partial seizures, depending on the location of the abnormal electrical activity:
Déjà vu
Strange smells, tastes, sight or sound sensations
Unusual emotions
Abnormal behaviours
**- Management is with lamotrigine or cabemazepine - KEY **
Myoclonic seizures present with sudden, brief muscle contractions, like an abrupt jump or jolt. They remain awake. Myoclonic seizures can occur as part of juvenile myoclonic epilepsy in children.
ME - I think the seizures are seocnds long, just a brief jerk.
Tonic seizures involve a sudden onset of increased muscle tone, where the entire body stiffens. This results in a fall if the patient is standing, usually backwards. They last only a few seconds, or at most a few minutes.
Atonic seizures (causing “drop attacks”) involve a sudden loss of muscle tone, often resulting in a fall. They last only briefly, and patients are usually aware during the episodes. They often begin in childhood. They may be indicative of Lennox-Gastaut syndrome.
- Management for myoclonic, tonic and atonic is lamotrigine
Absence seizures are usually seen in children. The patient becomes blank, stares into space, and then abruptly returns to normal. During the episode, they are unaware of their surroundings and do not respond. These typically last 10 to 20 seconds. Most patients stop having absence seizures as they get older.
Treatment: ethosuximide
Infantile spasms are also known as West syndrome. It is a rare (1 in 4,000) disorder starting at around six months of age. It presents with clusters of full-body spasms. Hypsarrhythmia is the characteristic EEG finding. It is associated with developmental regression and has a poor prognosis.
It can be difficult to treat but first line treatments are:
Prednisolone
Vigabatrin
Febrile convulsions are tonic-clonic seizures that occur in children during a high fever - more detail on another card
Investigations in epilepsy/seizure
requirements for each
Remeber non neuro Ix
A good history is the key to a diagnosis of epilepsy. It is important to establish that any episodes were seizures, as opposed to vasovagal episodes or febrile convulsions. Try to identify the type of seizure. Patients with a clear history of a febrile convulsion or vasovagal episode do not require further investigations.
An electroencephalogram (EEG) can show typical patterns in different forms of epilepsy and support the diagnosis. Perform an EEG after the second simple tonic-clonic seizure. Children are allowed one simple seizure before being investigated for epilepsy.
An MRI brain can be used to visualise the structure of the brain. It is used to diagnose structural problems that may be associated with seizures and other pathology such as tumours. It should be considered when:
The first seizure is in children under 2 years
Focal seizures
There is no response to first line anti-epileptic medications
Additional investigations can be considered to exclude other pathology that may cause seizures:
ECG to exclude problems in the heart.
Blood electrolytes including sodium, potassium, calcium and magnesium
Blood glucose for hypoglycaemia and diabetes
Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected
Mangement of acute seizures
Management of Seizures
Put the patient in a safe position (e.g. on a carpeted floor)
Place in the recovery position if possible
Put something soft under their head to protect against head injury
Remove obstacles that could lead to injury
Make a note of the time at the start and end of the seizure
Call an ambulance if lasting more than 5 minutes or this is their first seizure OR treat them at this point if in hospital!
What is status epilepticus and how is it manged?
3 key drugs?
Status epilepticus is a medical emergency defined as either:
A seizure lasting more than 5 minutes
Multiple seizures without regaining consciousness in the interim
me - i think brain damage doesnt occur until about 30 minutes though
Management of status epilepticus involves an ABCDE approach, including:
**Securing the airway
**Giving high-concentration oxygen
**Checking blood glucose levels
Gaining intravenous access (inserting a cannula)
Medical treatment
IV lorazepam, repeated after 10 minutes if the seizure continues
If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin. At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.
What is syncope?
What is a vasovagal episode?
What are some of the common triggers of a primary syncope/simple fainting?
Ix for syncope
Syncope is the term used to describe the event of temporarily losing consciousness due to a disruption of blood flow to the brain, often leading to a fall. Syncopal episodes are also known as vasovagal episodes, or simply fainting.
A vasovagal episode (or attack) is caused by a problem with the autonomic nervous system regulating blood flow to the brain. When the vagus nerve receives a strong stimulus, such as an emotional event, painful sensation or change in temperature it can stimulate the parasympathetic nervous system. Parasympathetic activation counteracts the sympathetic nervous system, which keeps the smooth muscles in blood vessels constricted. As the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of brain tissue. This causes the patient to lose consciousness and “faint”.
Primary syncope (simple fainting):
Dehydration
Missed meals
Extended standing in a warm environment, such as a school assembly
A vasovagal response to a stimuli, such as sudden surprise, pain or the sight of blood
Secondary causes:
Hypoglycaemia
Dehydration
Anaemia
Infection
Anaphylaxis
Arrhythmias
Valvular heart disease
Hypertrophic obstructive cardiomyopathy
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Investigations
- ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome. 24 hour ECG if paroxysmal arrhythmias are suspected
- Echocardiogram if structural heart disease is suspected
- Bloods, including a **full blood count **(anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)
Once a simple vasovagal episode is diagnosed, reassurance and simple advice can be given to avoid triggers.
What are febrile convulsions?
simple vs complex?
Management?
Febrile convulsions are a type of seizure that occurs in children with a high fever. They are not caused by epilepsy or other underlying neurological pathology, such as meningitis or tumours. By definition, febrile convulsions occur only in children between the ages of 6 months and 5 years.
Simple febrile convulsions are generalised, tonic clonic seizures. They last less than 15 minutes and only occur once during a single febrile illness.
Febrile convulsions can be described as complex when they consist of:
- partial or focal seizures
- last more than 15 minutes or occur multiple times during the same febrile illness.
Diagnosis
In order the make a diagnosis of a febrile convulsion, other neurological pathology must be excluded - i am ignoring this for now
Management
- control the fever with simple analgesia
- simple febrile convulsion do not require further investigation -KEY, complex febrile convulsions may do
- give paretns advice on managing seizusres- safe place, pillow behind head, recovery position if possible
Meningitis - key symptoms?
vs migraine?
vs febrile convulsions?
- fever
- neckstiffness
- seizure or altered conciousness
- headache
- vommitng
- photophobia
Vs febrile convulsions - neck stiffness! petichiaea, ongoing drowsiness/altered conciouness
Vs migraine - Fever, neck stiffness and seizure
Basically learn NECK STIFFNESS AS A PATHOGNOMONIC SIGN OF MENINGITIS
All children with suspected mengitis should have a lumbar puncture
Is cerebral palsy a progressive condition?
Causes?
Types of cerebral palsy - 4?
Presentation?
Cerebral palsy (CP) is the name given to the permanent neurological problems resulting from damage to the brain around the time of birth. It is not a progressive condition, however the nature of the symptoms and problems may change over time during growth and development.
Huge variation of severities from wheelchair bound to subtle problems with co-ordination and mobility.
Causes of Cerebral Palsy
Antenatal:
Maternal infections
Trauma during pregnancy
Perinatal:
Birth asphyxia
Pre-term birth
Postnatal:
Meningitis
Severe neonatal jaundice
Head injury
Type of Cerebral Palsy:
Spastic/ pyramidal: hypertonia (increased tone) and reduced function resulting from damage to upper motor neurones
Dyskinetic/athetoid : problems controlling muscle tone, with hypertonia and hypotonia, causing athetoid movements (involvuntary) and oro-motor problems. This is the result of damage to the basal ganglia.
Ataxic: problems with coordinated movement resulting from damage to the cerebellum
Mixed: a mix of spastic, dyskinetic and/or ataxic features
Patterns of Spastic Cerebral Palsy - monoplegic, deplegic, hemiplegic, tetraplegic
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Presentation:
- Failure to meet milestones
- Increased or decreased tone, generally or in specific limbs
- Hand preference below 18 months is a key sign to remember for exams
- Problems with coordination, speech or walking
- Feeding or swallowing problems
- Learning difficulties
Management of cerebral palsy?
MDT:
- Physiotherapy is used to stretch and strengthen muscles, maximise function and prevent muscle contractures (shortening of muscles)
- Occupational therapy
- SALT for dwallowing difficulty (may require NG or PEG feeding).
- Orthopedic surgeons can perform procedures to release contraction or legnthen tendon
- Medications : Muscle relaxants (e.g. baclofen) for muscle spasticity and contractures; Anti-epileptic drugs for seizures; Glycopyrronium bromide for excessive drooling
What do different types of gate indicate?
You can gain a lot of information about a child from their gait:
Hemiplegic / diplegic gait: indicates an upper motor neurone lesion
Broad based gait / ataxic gait: indicates a cerebellar lesion
High stepping gait: indicates foot drop or a lower motor neurone lesion
Waddling gait: indicates pelvic muscle weakness due to myopathy
Antalgic gait (limp): indicates localised pain
What is juvenile myoclonic epilepsy
Also known as Janz Syndrome, Juvenile myoclonic epilepsy is a largely genetic condition that begins in adolescence. It is a common epilepsy syndrome. Its main seizure type is myoclonic, which present with sudden, brief muscle contractions, like an abrupt jump or jolt. They remain awake. As well as myoclonic seizure, people may experience tonic-clonic siezures or absence seizures.
Diagnosis is made usually with an EEG and clinical history of myoclonic seizsures (i think otherwise rare?).
Management for myoclonic, tonic and atonic is lamotrigine
What is ADHD?
Features?
Management? 3 medications
monitoring requirments
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopment disorder featuring the core features of difficulty maintaining attention, excessive energy and activity, and impulsivity. It is more than twice as common in males.
It is thought to result from a combination of factors:
Genetic (there is significant heritability)
Pregnancy-related factors (e.g., maternal smoking, premature birth and low birth weight)
Environmental factors
The symptoms start in childhood and should be consistent across settings. When a person displays symptoms only at work or school but is calm and focused at home, this is suggestive of an environmental effect rather than an underlying diagnosis.
Features
All the features of ADHD can be part of a normal spectrum of behaviour. When many of these features are present, and they are adversely affecting the person, ADHD may be considered. Symptoms include:
Short attention span
Easily distracted
Quickly moving from one activity to another
Quickly losing interest in a task
Inability to persist with and complete tasks
Constantly moving or fidgeting
Impulsive behaviour
Disruptive behaviour
Difficulty managing time
Management
A specialist will make the diagnosis after a detailed assessment, including a history dating back to childhood.
Managing strategies for parents include:
A positive approach
Structured routines
Clear boundaries
Plenty of physical activity
A healthy diet (certain foods may exacerbate the symptoms)- e numbers
Medication is an option after conservative management has failed, or in severe cases. This should be coordinated by a specialist. The medication are central nervous system stimulants. Examples are:
Methylphenidate
Lisdexamfetamine
Dexamfetamine
Atomoxetine
lol they all sound like meth
Monitoring requirements whilst taking medications include heart rate, blood pressure, weight and mood changes.
What is ASD- 3 things?
Features? just list some for each of the 3
Management?
Autistic spectrum disorder (ASD) includes a range of impairments in social interaction, communication and behaviour.
On one end of the autistic spectrum, patients have normal intelligence and the ability to function in everyday life but display difficulties with reading emotions and responding to others. This was previously known as Asperger’s disorder. On the other end, patients can be severely affected and unable to function in typical environments.
Features
The features of ASD vary significantly between individuals along the spectrum. They can be categorised as deficits in social interaction, communication and behaviour. Features are usually observable before the age of 3 years.
Deficits in social interaction include:
Lack of eye contact
Delay in smiling
Avoiding physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not displaying a desire to share attention (e.g., not playing with others)
Deficits in communication include:
Delay, absence or regression in language development
Lack of appropriate non-verbal communication (e.g., smiling, eye contact, responding to others and sharing interest)
Difficulty with imaginative or imitative behaviour
Repetitive use of words or phrases
Deficits in behaviour include:
Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements (e.g., self-stimulating movements, such as hand-flapping or rocking)
Intense and deep interests that are persistent and rigid
Repetitive behaviour and fixed routines
Anxiety and distress with experiences outside their regular routine
Extremely restricted food preferences
Diagnosis usually involves assessment by psychiatrists and clinical psychologists. It involves a detailed evaluation of the patient’s current and historical behaviour and communication.
Management
Patients with mild impairments may be highly functioning and not require any formal support.
A multidisciplinary team can help support patients and carers (e.g., parents) with greater impairments. For example:
- CAMHS
- specialist education
- occupational therapy
- speech therapy
NICE recomends against using any drugs for the management of autism, including the use of antipsychotics for challanging behavoir. However, patients with symptoms of depression and/or anxiety may benefit from behavioural and pharmacological intervention (e.g. SSRIs).
In addition, children with sleep difficulties which may benefit from a trial of melatonin if behavioural management/sleep hygiene proved to be unsuccessful.
When doing a developmental assessment of a child it is important to appreciate that children develop at different rates, and there is flexibility in the milestones. However, a child who is very slow to achieve all milestones or lags behind on a specific developmental domain may have underlying pathology.
List 4 causes of global developmental delay?
List 2 causes of each of the specific developmetal domains? - 8 marks
Global developmental delay refers to a child displaying slow development in all developmental domains. This could indicate an underlying diagnosis such as:
Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
Metabolic disorders
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Gross Motor Delay
A delay that is specific to the gross motor domain may indicate underlying:
Cerebral palsy
Ataxia
Myopathy
Spina bifida
Visual impairment
Fine Motor Delay
A delay that is specific to the fine motor domain may indicate underlying:
Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (rare)
Language Delay
A delay that is specific to the speech and language domain may indicate underlying:
Specific social circumstances, for example exposure to multiple languages or siblings that do all the talking
Hearing impairment
Learning disability
Neglect
Autism
Cerebral palsy
Management of language delay involves a referral to speech and language, audiology and the health visitor. Referral to safeguarding is required if neglect is a concern.
Personal and Social Delay
A delay that is specific to the personal and social domain may indicate underlying:
Emotional and social neglect
Parenting issues
Autism
What is oppositional defiant disorder?
It is characterized by a consistent pattern of angry, irritable moods, defiant behavior, and vindictiveness that goes beyond the typical behavior expected for a child’s age or developmental level.
Oppositional Defiant Disorder (ODD) is a condition that is commonly seen in up to 50% of
children and young people with ADHD.
The child is stubborn, hostile and often:
- loses their temper and argues with adults
- defies or refuses to comply with instructions - says NO alot
- annoys people and blames others for his or her mistakes
- easily annoyed with themselves
- angry and resentful
- spiteful or vindictive
Management includes a behavioural approach by parents/carers who can learn additional
strategies by attending group-based parenting programmes. With appropirate intervention children can improve dramatically, without intervention ODD can lead to anti-social behavoir as adults.
