Week 3 Neuro Flashcards
In peds, must r/o these severe head injury before dx of minor head injury or mild TBI (concussion):
- skull fracture
- spinal cord injury
- brain bleeds
- moderate-severe TBI
What guideline is used if a CT scan is needed?
PECARN calculator
Glasgow coma scale score 13-15 means
- mild
- no focal deficits
- < 30 minutes LOC
- may have linear skull fractures
Glasgow coma scale score 9-12 means
- moderate
- focal signs
- variable loss LOC
- may have depressed skull fracture or intracranial hematoma
Glasgow coma scale of < 8 means
- severe
- focal signs
- prolonged loss LOC
- depressed skull fractures and intracranial hematoma
Pedi head injury management
- If worried caregiver is not reliable = admit
- Discharge home with close observation:
- Minor head trauma and no LOC
- Brief LOC (< 5 mins) with:
- Normal neuro exam
- No s/sx IICP (vomiting, h/a)
- No s/s basilar skull fracture (raccoon eyes, battle sign)
- With or w/o a head CT
- Wake child every 2-4 hours at night for first 24-48 hrs
- Educating parent s/sx of deterioration
- Not responding to q’s
- Vomiting
- Horrible headache
- Slurring speech
highest risk sport for boys and girls for concussion/mild traumatic brain injury?
boys: football and hockey
girls: soccer and basketball
concussion red flags, bring to ED!
- Weakness, numbness, decreased coordination
- Worsening headaches
- Repeated vomiting or nausea
- Slurred speech
- Anisocoria (unequal pupils)
- Seizures
- very drowsy
- Increasing confusion, agitation, restlessness
- Focal neurological signs
- Problem with nerve, spinal cord, left side face numb / arm numb, paralysis of leg
- Can’t recognize people or places
- Neck pain
- Unusual behavior changes
- Any loss of consciousness, especially if for 30 seconds or more
retrograde amnesia vs anterograde amnesia
retrograde amnesia: very brief, can’t recall events before injury
anterograde amnesia: seconds-minutes, can’t make new memories and can’t recall
which imaging preferred for concussions? and what are the indications?
CT scan
indications:
- Focal neurological findings
- Signs of IICP
- GCS < 15 after 2 hrs OR < 13 at any time
- Seizures r/t to trauma
- Age > 60
- Anticoagulation or coagulopathy
- Intoxication
- Recurrent vomiting
- s/sx skull fracture
- LOC (excessive irritability or lethargy)
- LOC >1 min
- Amnesia
simple concussion
sx’s resolve (brain healed) in 7-10 days without complications
complex concussion
- prolonged healing that is persistent for over 10 days
- may develop post concussive syndrome
- prolonged impaired cognitive function
- repeated concussions
concussion monitoring
repeat neuro exam q 15 mins
if sent home, monitor next 24 hrs:
- Inc drowsiness
- Vomiting > 2x
- Neck pain
- Drainage from ear / nose
- Seizure , fainting
- Unu irritability, personality changes
- h/a getting worse or lasts > 1 day
- Unequal pupils, blurred vision
- Gait abnormalities
When can the child return to play after a concussion?
not until all symptoms have cleared, both at rest and with exertion and without meds
Return to play guidelines after a concussion
- Physical & cognitive rest for the first 24-48 hrs before return to play, 24 hrs or longer each step
- Need to communicate with coach, teachers
- Advance activity slowly (includes screen use, reading, homework, physical activity) with lots of breaks
- 1 - sx limited activity (no sx)
- 2 - light aerobic - no weights
- 3 - sport specific
- 4 - non contacting drills - yes weights
- 5 - full contact practice
- 6 - return to play
- If symptoms return, cannot attempt that activity again for 24 hours
concussion prevention
- Wear helmets when appropriate and properly fitted
- Avoid re-injury before first concussion resolves
What is second impact syndrome?
- Patient sustains a 2nd head injury before the symptoms from the first head injury have resolved
- Days to weeks after the first injury
- LOC is not a requirement; impact may be mild and athlete may appear only dazed initially
- Can cause cerebral edema and herniation, leading to death
*Stress importance with patients that ALL concussion symptoms must be resolved prior to return to activity*
What is post concussive syndrome?
- Sequela of minor head injury
- poorly understood
- at least 3 of these:
- h/a, dizziness, fatigue, irritability, impaired memory/concentration, insomnia, lowered tolerance for noise and lights
- no imaging needed unless red flags
What is Bell’s palsy?
- Acute, isolated peripheral facial paralysis of the 7th cranial nerve
- most common cause: HSV activation
- Other associated viruses are: cytomegalovirus, Epstein–Barr virus, adenovirus, rubella virus, influenza B, coxsackie virus
- Pregnancy
- most spontaneously resolve
What is Bell’s palsy?
- Acute, isolated unilateral peripheral facial paralysis of the 7th cranial nerve
- most common cause: HSV activation
- Other associated viruses are: cytomegalovirus, Epstein–Barr virus, adenovirus, rubella virus, influenza B, coxsackie virus
- Pregnancy
- most spontaneously resolve
Bell’s palsy sx’s
- Sx’s can persist up to 3 months
- Acute onset (w/in 48 hrs) of unilateral of upper and lower facial paralysis
- Weakness of facial muscles
- flattening of the nasolabial fold
- drooping mouth/asymmetrical smile
- Hyperacusis (sounds too loud)
- Posterior auricular pain
- Decreased tearing
- can’t close eyelid = irritation
- Taste disturbances
Bell’s palsy sx’s
- Acute onset (w/in 48 hrs) of unilateral of upper and lower facial paralysis
- Weakness of facial muscles (flattening of the nasolabial fold and drooping of the affected corner of the mouth)
- Hyperacusis (sounds too loud)
- Posterior auricular pain
- Decreased tearing
- Poor eyelid closure
- Taste disturbances
- Otalgia
when are you worried if it’s a central cause/stroke or if it’s Bell’s palsy?
a stroke/central cause would have only 1 area affected (mouth drooping) and other parts of face are still movable like wrinkling forehead and eyes
paralysis from stroke spares forehead
What grading system used for Bell’s palsy?
house and brackmann system
1 = normal
6 = severe paralysis
bells palsy diagnostic criteria
paralysis or paresis of *all* facial nerve muscle groups unilaterally, sudden onset and absence of CNS disease
What other testing to consider in dx for Bell’s Palsy?
Lyme titer (if tick exposure) MRI (if don't recover in 3 months) EEG/EMG (if fail to improve)
Bell Palsy treatment/management
- Corticosteriods/Prednisone w/in 72 hrs of sx onset
- or Acyclovir or valacyclovir in conjunction
- Eye care
- risk for corneal abrasions/ ulcers
- Artificial tears during the day and lubricating ointment at night
- risk for corneal abrasions/ ulcers
- tape or an eye patch for 24–48 hours to help heal a corneal abrasion
Ramsay hunt syndrome
- Peripheral facial nerve weakness caused by varicella zoster
- Same symptoms as Bell’s palsy but:
- rash/vesicles
- Paralysis more severe
- Anterior tongue numbness, ear pain, vertigo, hearing impairment
- Less likely to have a complete recover
Treat early with oral glucocorticoids and antivirals:
- Prednisone and acyclovir
what is the SCAT5?
sport concussion assessment tool 5
- No screen time, no reading, no strenuous activity
- No aspirin or NSAIDs
- Worsening sx’s to seek help
- Enough rest /sleep
- Return in 7-10 days and repeat SCAT test to see
Is imaging indicated with recurring, stable headache with normal neurological exam?
NO
indications for imaging for headache include
- Abnormal neuro exam findings
- History suggestive of ICP
- seizures
- Recent onset of severe HA
- Change in type or pattern of HA
- Severe HA with underlying disease that predisposes them to intracranial process (sickle cell anemia, HTN, coagulopathy, history of neoplasm, neurofibromatosis
what is SNOOP and what is it for?
headache warning signs
- systemic symptoms
- fever, muscle pain, weightless
- neoplasm or neurologic sx’s
- onset
- How fast h/a sets in, severely
- older age
- 50+
- pattern, position change, pregnancy, progressive, painful eye
tension headache sx’s
at least 2 of:
- bilateral, band like
- pressing/tighening quality
- mild to moderate intensity
- no aggravation from routine physical activity
both of these:
- NO n/v
- NO photophobia or photophobia
