Paeds Neurology Flashcards
What are febrile seizures?
Simple self limiting tonic-clonic seizures associated with mild infections (particularly gastro)
1/30 kids will have one, 30-40% will have a second and 10% will have a 3rd
Typically occurs between the ages of 6 months to 6 years
1st febrile convulsaion <18months of age and FHx of epilepsy or febrile convulsions predicts recurrence
What are features suggesting a febrile seizure is not a febrile seizure?
Lasts > 15mins
Recurrence within 24hrs
Any focal neurology or seizure activity
Toxic appearing
What is status epilepticus in kids?
Seizure lasting >5mins
Or
recurrent seizures with no return to baseline in between
Which anti-epileptic levels should routinely be check in patients taking them who have seizures?
Phenytoin
Carbamezapine
Phenobarbitone
These drugs can have variability in their pharmacokinetics, only test other anti-epileptic drug levels if adherence is thought to be an issue
What is the difference in acute dosing of Keppra between adults and children?
Adults Keppra is 60mg/kg IV
Kids Keppra is 40mg/kg IV
What ages should Phenytoin vs Phenobarbitone be used?
Phenytoin 20mg/kg is 2nd/3rd line in children >1yr of age
Phenobarbitone 20mg/kg is in liew of phenytoin in kids <1yrs old, or other contraindication to phenytoin (Dravet syndrome, allergy, already on pheyntoin)
What is the maximum lifetime dose of Paraldehyde? What is its toxic breakdown product?
Maximum 30mls over a lifetime, increased used has progressive cancer risk
Toxic breakdown product is Crotonaldehyde
Why is Valproate generally not use in children?
Valproate IV 30mg/kg over 5mins
Risk of hepatotoxicity in children <2yo and in those with metabolic disorders
What are some other identifiable and potentially treatable causes of seizures?
Pyridoxine dependent epilepsy (give IV pyridoxine)
Thiamine deficiency
Hypomagnesaemia
Hyponatraemia
Hyperammonaemia
Local anaesthetic toxicity
How does a ketogenic diet affect active seizure management?
Ketogenic diets take weeks to months to become effective
Giving glucose may negate this, so only give glucose to the patient if they are actively hypolycaemic
What are episodic issues that mimic seizures in neonates?
Jitteriness/cold
Benign neonatal sleep myoclonus
Non-epileptic apnoea
Opisthotonus (back arching, spasticity, hyperextension)
Sometimes just normal movement
What are episodic issues that mimic seizures in kids older than neonates?
Syncope
BRUE
Breath holding spells
Migraine with aura
Sydenhams Chorea (GAS and rheumatic fever)
Narcolepsy/Catoplexy
Tics
Panic attacks
PNES
What is the most common cause of paediatric ataxia?
Acute cerebellar ataxia (40%)
Usually boys 2-4yo
An autimmune disorder causing cerebellar demyelination
Usually a recent acute infection, most common being VZV (26%)
What are the differentials for paediatric ataxia?
Differentiate true ataxia from refusal to walk due to pain
Acute cerebellar ataxia
Drug ingestion
Illicit substance ingestion (ie alcohol in adolescents)
Seizure
Stroke/Bleed
Head trauma
Metabolic disorders
Meningoencephalitis
brain tumour
Genetic/congenital ataxias
What is the most common cause of vertigo in childhood?
Migraine with vertiginous aura
What are the most common causes of stroke in paediatrics?
Thrombus
- Sickle cell disease (the most common cause, also causes haemorrhage)
- Cardiac disease with embolisation
- Moyamoya disease
Haemorrhage
- Sickle cell disease
- AVM rupture
- coagulopathies (ITP, haemophilia etc)
What is infantile botulism?
Occurs in infants <1yo, but more often <8months old
Infants stomach pH is less acidic (higher) than older children and cant breakdown the toxin
Presents with constipation, dry mouth, hypotonia/reflexia, poor head control, weak cry and poor suck
What are the risk factors for infantile botulism?
Most commonly caused by honey ingestion
Exclusive breastfeeding is actually a risk factor
Treated with supportive management and BabyBIG, a monoclonal antibody against the Clostridium botulinum toxin
What is the normal range of ICP in paediatrics? What is the normal CPP?
12 - 28cmH20
or
9 - 21mmHg
Normal CPP 40-60mmHg
What are the clinical signs of raised ICP in infants <12months?
Bulging fontanelle
- Macrocephaly if chronic process
Unequal pupils
Cushings triad
- >BP, <Hr, Cheyne-Stokes breathing
Paradoxical tachycardia
N/V
Visual disturbances
Low GCS, altered gait/neurology
What are the common and serious causes of Torticollis?
Serious
- Retropharyngeal abscess
- CNS tumour
- C-spines injury
- Suppurative Jugular thrombophlebitis (Lemierre syndrome)
Common
- Minor/Mod infection (URTI, upper lobe pneumonia, pharyngitis etc)
- Muscular sprain
- Dystonic reaction
- congenital torticollis
- Ocular torticollis
- Sandifer syndrome
- Benign paroxysmal torticollis
Which children are at risk of atlantoaxial instability
Acute trauma to neck
Infection to upper C-spine
JRA and Ank Spond
Downs syndrome
Cerebral palsy
Morquio’s syndrome
Other important
- Klippel-Feil Syndrome
- Larsen Syndrome
- Osteogenesis imperfecta
- Marfans, Ehlers Danlos
- Steroid use
- Rickets
- Achondroplasia
What are the causes of status epilepticus in children?
Febrile status epilepticus
- Most common cause
CNS infection
Head trauma
CNS malignancy
Congenital seizure disorders
- Withdrawal from meds
Hypoglycaemia
Metabolic abnormalities
- ie Hyperammonaemia, uraemia, hepatic encephalopathy
Electrolyte disturbance
Substance withdrawal (ie ETOH)
Toxicological
- TCA’s, theophylline, local anaesthetic, Lithium, metronidazole, cyclosporines etc
What are the contraindications to lumbar puncture?
- GCS <8 or fluctuating
- Signs of raised ICP
- Bulging fontanelles
- New altered focal neurology
- septic shock or haemodynamic compromise
- Significant resp compromise
- Seizures <30mins ago
- INR >1.5 or platelts <50
