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Flashcards in Altered level of consciousness Deck (53):
1

Febrile convulsion

Defined - brief, generalised seizures associated with a febrile illness, in the absence of any CNS infection or past hx of febrile seizure
Occurs in 3-4% of children from 6 m to 5yrs
Recurs in 1/3
In otherwise health children, FC are not accompanied by an increase risk of intellectual disability, cerebral palsy, other neurological disorder or death.
Modest increase in risk of epilepsy.

2

Types of febrile convulsion

Simple - brief generalised tonic clonic and single one per illness
Complex - Either focal, greater then 15 min, or multiple in a 24 HR period. Incomplete recovery within an hour or recurrence in same illness

3

Mx for Febrile convulsions

Underlying cause
- Search for cause of fever - commonest is viral
- General temperature control eg remove excess clothing. Only paracetamol if child is uncomfortable.
Seizure - If duration greater than 10 mins. IV or rectal diazepam 0.2-0.4mg/Kg.
Reassurance - only 3% go on to develop epilepsy compared to 0.5%.
Education - low risk of neurological complication and excellent prognosis for eventual remission. 1:3 risk of recurrence. She will outgrow them. Advise on how to mx.
Management of Seizure at home: lay on side, don't force her month open, remove any danger, call an ambulance, undo tight clothing around neck, time the seizure, stay with patient and try to reassure.
Follow up visit to help explain things afterwards.

4

What are the risk factors that make the development of epilepsy in a child with febrile convulsion more likely.

Previous abnormal neurological development
A hx of epilepsy in first degree relatives.
Prolonged Febrile convulsion greater then 10min
Focal features present during or after the febrile convulsion
Multiple convulsions during a single febrile episode

5

DDX for fits

Non paradoxall?
Syncope
TICS
Breath holding spells

6

Types of breath bonding spell

Cyanosis - cry and then turn blue
Pallor - sml bump makes then pass out vagal vagus.

7

Triad of hypoglycaemia

Lethargy - coma
Confusion and agitation
Seizure

8

Triad of hyperglycaemia

Polyuria
Polydipsia
Blurred vision

9

Driving restrictions for diabetic

HbA1c less than 9
Knows how to recognise high and low
Test regularly
If BSL higher than 15 or lower then 4
Stop, treat, wait 2 hrs and retest.

10

Resus of a child

Airway - check secretions or strider, foreign body or unprotected airway
Breathing - RR, Recession and accessory muscle use, O2 stats, auscultation
Circulation - colour, HR, CRT peripheral and central, temp of hands and feet and BP
Disability - Pupils, limb tone and movement, AVPU and GCS
ENT assessment
Temperature assessment
Tummy assessment
Blood glucose assessment

11

Cause of ALOC

V - aneurysm or AV malformation, embolus
I - Meningitis, Encephilitis, abscess, Malaria, Rabies
T - trauma
A
M - metabolic, dehydration, glucose, Na, Ca, Liver failure
I - Drug
N - primary tutor
C
O - Seizure

12

Tx for raised Intracranial pressure

Raised head of bed
Fluid balance - avoid over hydration
Manitol if serum is less than 325mOsm/L
BP maintained in range
Maintain PCO2
May need dexamethasone
IDC
Maintain glucose and temp
NGT to prevent aspiration
SKID to avoid bed sores

13

Triad of hypoglycaemia

Lethargy - coma
Confusion and agitation
Seizure

14

Triad of hyperglycaemia

Polyuria
Polydipsia
Blurred vision

15

Driving restrictions for diabetic

HbA1c less than 9
Knows how to recognise high and low
Test regularly
If BSL higher than 15 or lower then 4
Stop, treat, wait 2 hrs and retest.

16

Resus of a child

Airway - check secretions or strider, foreign body or unprotected airway
Breathing - RR, Recession and accessory muscle use, O2 stats, auscultation
Circulation - colour, HR, CRT peripheral and central, temp of hands and feet and BP
Disability - Pupils, limb tone and movement, AVPU and GCS
ENT assessment
Temperature assessment
Tummy assessment
Blood glucose assessment

17

Cause of ALOC

V - aneurysm or AV malformation, embolus
I - Meningitis, Encephilitis, abscess, Malaria, Rabies
T - trauma
A
M - metabolic, dehydration, glucose, Na, Ca, Liver failure
I - Drug
N - primary tutor
C
O - Seizure

18

Tx for raised Intracranial pressure

Raised head of bed
Fluid balance - avoid over hydration
Manitol if serum is less than 325mOsm/L
BP maintained in range
Maintain PCO2
May need dexamethasone
IDC
Maintain glucose and temp
NGT to prevent aspiration
SKID to avoid bed sores

19

Hx Q to ask for suspected febrile convulsion

I'd if seizure or rigor
Febrile vs a febrile
CNS infect
Simple vs complex
ID cause
Hx fever

20

Ex for febrile convulsion

Neurological exam
Check for source of fever

21

Ix for febrile convulsion

Only if complex seizure

22

Paediatric GCS

For less then 4yr
Eyes
- spontaneous 4
- verbal 3
- pain 2
- None 1
Verbal
- Appropriate words or social smile, fixes, follows 5
- Cries but consolable; less than usual words 4
- Persistently irritable 3
- Moans to pain 2
- none 1
Motor
- Spontaneous or obeys verbal command 6
- Localises to stimuli 5
- withdraws to stimuli 4
- Abnormal flex ion to pain - decorticate - 3
- Abnormal extension to pain - decerebrate - 2
- None 1

23

AVPU

Alert
V - response to voice
P - response to pain - purposefully or not (withdrawal/flexor response or extensor you response) same at GCS 8 needs to protect airways by intubation to prevent aspiration.
U - unresponsive

Assess pupil size, equality and reactivity.

24

Causes of coma

head injury
Meningitis/encephalitis
Seizure
Toxin ingestion
Cerebrovascular accident
Major organ failure
Metabolic causes
Anaphylaxis
Shock

25

Causes of fits, faints, funny turns

Infants and toddlers
- Apnoea and acute life threatening event
- Febrile convulsion
- Breathing hold spells
- Reflex anoxic spells
- Infantile spasm
- Hypoglycaemia and metabolic conditions
School aged children
- Seizure/Epilepsy
- Syncope
- Hyperventilation
- Cardiac arrhythmia
- Hypoglycaemia

26

Hx Q for a child in a coma

Possible drug ingestion
Prodromal illness or so tact with serious illness
Possibility of non accidentally injury
Hx of convulsion and details about them
Child neurodevelopmental Hx normal prior.

27

Ex of a child in a coma

Vital signs
- bradycardia in raised ICP
- tachyarrythmia - drug ingestion
- Deep, sighing (Kussmaul) - DKA Ketones on breath
Focus of infection - check rashes, neck stiffness, pneumonia and UTI
Check pupils - symmetrical and constrict?
Check for abnormal posture eg decorticate or decerebrate
Assess LOC with GSC or AVPU
Blood pressure

28

Ix for a child in a coma.

Blood glucose - hypo-hyperglucaemia
FBC - infection or blood loss
Blood culture - infective
U and E - urea if dehydrated. Na high or low
Blood gases - Metabolic or Resp acidosis
CXR - infection or cardia failure, trauma eg rib fracture
CT or MRI - focal pathology - tumour, haemorrhage, abscess
LP - infection (meningitis, encephalitis) or bleeding (SAH)
Metabolic screen - ammonia in urea cycle defect or Reye's syndrome. need to exclude raise ICP
LFT - hepatic encephalopathy
URine - toxicology screen for poisoning or overdose. Ketones and culture.

29

Meningitis
Cause

Viral
- Mumps virus
- Coxsackie virus
- Echovirus
- Herpes simplex
- Poliomyelitis
Bacterial
- Neisseria meningitis
- Streptococcus pneumoniae
- Haemophilus influenza epidemic type B
- Group B streptococcus - newborn
- Escherichia coli and listeria - newborn

30

Symptoms and signs of viral meningitis vs bacterial

Viral
Preceded by pharyngitis or GI upset
Develops fever, headache, neck stiffness
Bacteria
Drowsy and may be vacant
Irritability is common
High pitched cry
Convulsion
Examination
Ill child with stiff neck and positive Kernig's sign (pain on extending leg). Bulging fontanelle. Petechiae or purpuric rash.
DDX - tonsillitis and otitis media and mimic neck stiffness

31

Ix of meningitis

Confirmed by LP showing leucocytosis, high protein count, low glucose and may show organism. Appears cloudy.

32

Tx of meningitis

?

33

Causes of encephalitis

Herpes simplex virus
Mycoplasma pneumoniae

34

Symptoms and signs and IX of encephalitis

Onset is mor insidious then meningitis
Personality may change
Confused or clumsy before coma
LP - lymphocytesis, culture and PCR for virus

35

Tx of encephalitis

Acyclovir
Erythromycin
Cefotaxime
Used until organism is known
EEG and MRI show temporal lobe involvement.

36

Metabolic causes of coma

Hypoglycaemia - due to reduced carbohydrate intake or excess insulin in children with DM or inborn error of metabolism or adrenal insufficiency
Hyperglycaemia - uncontrolled diabetes can lead to DKA and coma. Onset is gradual.
Severe uraemia from renal failure
High ammonia from inborn errors of metabolism such as urea cycle
Sever hypernatraemia or hypo atresia
Severe dehydration

37

Reye's syndrome

Preceded by viral illness eg influenza or chickenpox
Commoner in winter
Triggered by aspirin during viral illness
Symptoms - initial phase of vomiting, and lethargy followed by a non inflammatory encephalopathy illness with personality changes, irritability and then coma with ICP
Fatty changes n liver may lead to acute hepatic failure
Tx - mainly supportive aggressive intensive care Tx to trest ICP.

38

Non accidentally injury

CT brain scan and skeletal survey
Retinal haemorrhages
Urine toxicology screen
Drugs that affect CNS - opiate analgesics, alcohol and antidepressents

39

Acute asphyxiation event

Birth asphyxia
Near miss cot death
Post cardiac arrest

40

Shock

Capillary refill greater then 2 sec
Cool, mottled peripheries
Thready pulse

41

Encephalitis

Fever
Hx of changes in personality or ability

42

Raised intracranial pressure

Symptoms
Headache, vomiting and visual disturbances
Depressed consciousness
Photophobia
Tinnitus
retrobulbar pain
Papilloedema
decreased visual acuity
Extra ocular movement problems
Diplopia
relative afferent pupillary defect
Signs
Cushing’s triad: Hypertension, bradycardia, Irregular breathing
Signs of Herniation
Subfalcine = common: Headache, contralateral leg weakness
Transtentorial - central: Small but reactive pupil, drowsiness
Transtentorial - temporal uncle: CN III - ipsilateral dilated pupil
Tonsillar: Obtundation, decerebrate posture
Cardiorespiratory arrest.

43

Head injury DDX

Subdural haematoma
Extramural haematoma
Diffuse axonal injury
Non accidentally injury

44

Cerebrovascular accident DDX

Vasculitis disorder
HTN
Thrombotic disorder
malformation

45

Metabolic disorders DDX

Hypoglycaemia
DKA
Inborn errors of metabolism
Renal failure - uraemia
Liver failure - hepatic encephalopathy
Reye's syndrome

46

Convulsion

Status epileptic us
Hx of epilepsy

47

Breath holding spells

Primarily in babies and toddlers
Resolves by 18m
Symptoms - crying due to pain or temper. Cries once or twice and then takes a deep breath become deeply cyanosis and limbs extend. May loose consciousness and have convulsive Jerks. After becoming limp resumes breathing and after a few seconds become alert. 1 min in total.
Dx clinically due to Hx and no postictal.
Tx educating the parent and reassureiing them to treat the child as normal.

48

Reflex anoxic seizure/Breath holding attacks

White breath holding attacks
Peak at in 6m to 2 yr
Occur after a bump on the head or other minor injury which trigger a excessive vagal reflex results in bradycardia, and circulatory impairment.
May or may not cry, turns pale and collapses.
Transient apnoea and lumpiness followed by recovery after 30-60mins
May have eye rolling and incontinence and sometime clonic stiffening of the limbs but no tongue bitting.
Afterwards may be tired and emotional
DDX for epilepsy by Hx and absence of postictal drowsiness.
Tx
Educate that they are benign and disappear before school.
In episodes : put child in recovery position and await recovery.
Reassurance.

49

Infantile spasm

Form of generalised myoclonus epilepsy
Onset in infancy, peaking between 4-8m
Symptoms - sudden tonic flexor spasm of the head and trunk causing the child to bend forward
Relaxation after a few seconds and episode may occur in cluster up to 10 to 20 times, Common on awakening, or just before sleep.
Sometime extensor spasm
Dx EEG - Chaotic hips arrhythmia pattern
Ass with tuberous sclerosis so examine with a Wood's light
MX
Vigabatrin may be beneficial
Ass with severe learning disability.

50

Syncope

Cause - Hypotension and decrease cerebral perfusion
Particularly - Teenage girl reacting to painful or emotional stimuli or prolonged standing.
Symptoms - blurred vision, light headedness, sweating and nausea precede loss of consciousness. Regain consciousness after lying flat.
In childhood it is rarely a symptom of cardiac arrhythmia a or poor cardiac output in childhood.
Mx
- cardiovascular examination
- standing and lying BP
- ECG if cause is doubted
- Tilt table test in unusually severe cases.

51

Cardiac arrhythmias

If clear Hx of palpitations or FmHx of cardiac tachyarrythmia said or sudden death.
Cause
- Hypertrophic cardiomyopathy - autosomal dominant condition. Due to episodes ventricular tachycardia with syncope.
- Wolff- Parkinson White syndrome - SVT - recently rhythms and Characteristics ECG wth short PR, Delta wave upstroke to R wave, markedly increase QT interval on ECG
Need 24hr ECG recording.

52

Hyperventilation

causes
- excitement in teenagers leads to hyperventilation and LOC particularly in teenage girls
- Hypervention - drop in CO2 - triggering apnoea
Dx based on Hx of breathing excessive and deep and tetany may occur.
Tx - rebreathe into a paper bag to allow CO2
- if recurrent episode then psychological therapy is needed.

53

Hypoglycaemia and other metabolic conditions

Cause LOC with seizures of ALOC
Suspect underlying metabolic problem if following as present
- developmental delay
- Dysmorphism
- Hepatosplenomegaly
- Micro or macrocephaly