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PedsSpring2020 > Case 19: 16mo - Seizure > Flashcards

Case 19: 16mo - Seizure Flashcards

1
Q

diffdx of unresponsiveness in children

A

COMMON

  • toxic ingestion
  • seizure
  • syncope
  • closed head injury
  • infection

LESS COMMON

  • intracranial process
  • intussusception
  • SEVERE dehydration
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2
Q

unresponsiveness: Toxic ingestion in kids
- age group
- etiology
- management

A
  • age group = 9mo-3yo
  • etiology = altered mental status (opiates, benzos, clonidine), metabolic disturbance (hypoglycemia)
  • management = careful hx of all meds in the home and where the child spends his time
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3
Q

unresponsiveness: seizure
- age group
- etiology
- timing
- management

A

“paroxysmal neurologic events” == generalized/seizures

  • age group = common in children (esp.
  • etiology = metabolic disturbance, head trauma, developmental / genetic abnormalities of the brain; post-traumatic seizure; idiopathic
  • timing: some will have only 1, some ongoing (epilepsy)
  • management = antipyretics
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4
Q

unresponsiveness: syncope
- age group
- etiology
- timing
- management

A

age group: 1-3yo

Etiology: BREATH-HOLDING: CYANOTIC
- timing = precipitating event ==> vigorous crying + hyperventilation ==> prolonged expiratory apnea ==> transient hypoxia ==>child becomes pale/cyanotic ==> brief LOC, limpness
+/- brief generalized seizure due to hypoxia
+/- asystole
- management = self resolve, no associated post-ictal state; symptomatic as needed

Etiology: Cardiac
- supraventricular arrhythmia (tachycardia), ventricular arrhythmia (d/t prolonged QT syndrome) ==> decreased cerebral blood flow ==> Syncope

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5
Q

unresponsiveness: closed head injury
- age group
- etiology
- timing
- management

A
  • age group = any
  • etiology = fall, ran into something, INFLICTED
    +/- intracranial injury
    +/- witnessed traumatic event
  • timing
  • management = CT without contrast ==> concerns of bleeding
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6
Q

unresponsiveness: infection
- age group
- etiology
- timing
- management

A

initial sxs = fever, irritability
==> no return to baseline; remain impaired

ETIOLOGY = meningitis
- 30-40% of meningitis present with seizure

ETIOLOGY = encephalitis
- fever, seizure == Enteroviral, herpes simplex

ETIOLOGY = sinus infection ==> abscess
- hx of URI.

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7
Q

unresponsiveness: intracranial process
- age group
- etiology
- timing
- management

A

sxs = seizures, global alterations in mental status
prodrome: HA, behavioral change, vomiting

  • etiology = brain tumor
  • timing = brain tumors = most common solid tumors in childhood
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8
Q

unresponsiveness: intussusception

- sxs

A

= telescoping / prolapsing of a portion of the intestine within an adjacent portion (usual terminal ileum into the colon)

sxs = repeated episodes of colicky pain ==> intervening lethargy with near unresponsive state
+/- intravascular volume depletion d/t vomiting & third-spacing of fluids ==> leading to further mental status changes

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9
Q

distinguishing seizure v. seizure-like activity

A

SEIZURE = excessive neuronal activity in the brain

  • hx of alteration of consciousness / LOC
  • incontinence
  • deviation of the eyes
  • post-ictal state
  • rhythmic motor movements that cannot be stopped by touching/holding the child
  • Prodrome = unusual behavior; aura / “premonition” prior to onset

NOT SEIZURES =
==> “seizure” is distractible; the event couldbe interrupted
- motor tics
- myoclonus
- GERD (Sandifer’s syndrome)
- pseudoseizures/ psychogenic seizures = physical manifesetation of a psychological disturbance

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10
Q

define: epilepsy

A

> /= 2 unprovoked seizures

prevalence = 1% throughout childhood

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11
Q

what is the most common solid tumors in childhood

A

brain tumors (1200 cases / year), esp in posterior fossa

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12
Q

where does intussusception usually happen?

A

usual terminal ileum into the colon

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13
Q

what is the most common type of seizure seen in children?

A

generalized tonic clonic seizure

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14
Q

types of seizures

A
  • generalized tonic clonic seizure
  • simple partial seizure
  • complex partial seizure
  • childhood absence epilepsy (petit mal seizure)
  • atonic (akinetic) seizure
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15
Q

describe the seizure: generalized tonic clonic seizure

A
  • most common type in children
    1) tonic (rigid) stiffening of all extremities and upward deviation of the eyes
    2) clonic jerks of all extremities
    3) flaccid +/- urinary incontinence
    4) post-ictal phase
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16
Q

describe the seizure: simple partial seizure

A

motor signs in a single extremity or on one side of the body

==> can spread to become more generalized

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17
Q

describe the seizure: childhood absence epilepsy (petit mal seizure)

A

timing: ANY age
sxs ==> last 30s - 2 min
*** altered consciousness
- localized eyes =
glassy eyed
- localized mouth = lip-smacking, drooling, gurgling
- localized abdomen = N/V
- automatisms = quasi-purposeful motor / verbal behaviors that are repeated inappropriately and commonly accompany complex partial seizures
2)post-ictal phase = confusion, sleepiness, headache

==> 30% secondary generalization

EEG = 3-Hz spike and wave pattern

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18
Q

describe the seizure: atonic (akinetic) seizure

A

loss of motor tone

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19
Q

when a parent says “my child is lethargic” should you be worried?

A

if the parent uses medical lethargy = serious alteration of mental status, suggesting diagnoses of meningitis / toxic ingestion

layman’s lethargy = more tired / less active than usual

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20
Q

how accurate is a tactile temperature?

A

80% of cases == subjective meets objective definition of fever >38 C, 100.4 F

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21
Q

describe the seizure: febrile seizure

A

more common with temp > 100.4F

Age: 6mo-5yo

  • most are developmentally normal ==> viral infection (benign, prodrome, self-limited); meningitis and encephalitis (severe)
  • if febrile seizure + abnormalities in neurodevelopmental maturation ==> serious underlying illness
  • if febrile seizure + pre-existing developmental abnormalities ==> risk factor for subsequent epilepsy
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22
Q

what would make a child with a febrile seizure more at risk for developing epilepsy later?

A

1) + pre-existing developmental abnormalities
2) one febrile seizure ==> 0.5-1% above baseline population risk
3) esp. with early, recurrent febrile seizures
4) family hx of epilepsy
5) complex febrile seizures

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23
Q

are febrile seizure hereditary?

A

yes, according to twin studies
- Genetic loci= 8q13-21 (often called FEB1),
19p (FEB2), 2q 23-24 (FEB3)
- different modes of inheritance == autosomal dominant, polygenic, multifactorial

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24
Q

a child comes in with a severe fever. to what degree should you consider whether he has a serious bacterial illness (SBI)?

A

un/under-immunized = 1-5% risk of SBI (less than expected d/t to herd immunity; higher prevalence of viral illnesses)

Mgmt:

1) CBC with WBC, differential
2) blood culture == when risk of disease is low, but burden of disease is high ==> to help r/out badness (e.g. bacterial meningitis)

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25
Q

what is a childhood example of an illness where risk of disease is low, but burden of disease is high?

  • etiology
  • signs & sxs
  • dx
  • mgmt
  • complications
A

bacterial meningitis

  • increasingly uncommon d/t immunization; herd immunity
    ==> potentially serious ==> should be included in differential diagnosis of all febrile children with altered mental status (lethargy, irritability, seizure).
  • etiology = <2yo (E. coli, GBS, Listeria); 2-12yo (S. pneumoniae, N. meningitidis)
  • signs & sxs = increasing lethargy, irritability, meningeal irritation (nuchal rigidity, meningismus), systemic (fever, anorexia, poor feeding, sxs of URI, myalgias, tachycardia)
  • dx =
  • mgmt
    1) empiric high dose IV antibiotics == 3rd gen cephalosporin + vanco for 7-14d [then narrow as needed]
    2) CSF culture

Complications

  • stroke
  • subdural effusions
  • SIADH secretion
  • developmental delays
  • seizures
  • hearing loss
  • (RARE) death
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26
Q

infant with meningeal signs

- mgmt

A

lethargic

bulging fontanelle

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27
Q

child with meningeal signs

- mgmt

A

bending neck / knees ==> pain [Kernig]
[Brudinski] - bend neck ==> hips and knees bend

1) if older = CT

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28
Q

NMDA encephalitis

A

Sxs= subacute onset of seizures, confusion, memory loss, and/or behavioral change

Etiology = autoimmune, paraneoplastic,

Mgmt = steroids

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29
Q

when to do a lumbar puncture

A
  • tumor = for antineoplastic antibodies (esp. ALL, lymphoma), for which you can’t get a tissue
  • infectious
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30
Q

what is the risk of recurrence of febrile seizures?

A

if first febrile seizure <12mo = 50% recurrence risk

if first febrile seizure >12mo = 30% recurrence risk

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31
Q

what is the long-term risk of recurrent simple febrile seizures

A

none

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32
Q

differentiate simple and complex febrile seizures

A 
SIMPLE FEBRILE SEIZURE
incidence = more common
duration = <15min
freq = q24h
type = generalized
COMPLEX FEBRILE SEIZURE
incidence = less common
duration = >15min
freq = >1x q24h
type = focal
33
Q

what the critical pieces to determining the etiology of a seizure?

A

1) detailed description of the event = first thing noticed? (lip smacking, facial twitching); typical movements of arms / legs; eyes deviating
2) detailed timeline of events = leading up to and through episode, how child recovered (cranky, etc.)
3) any precipitating events = fever, medical & developmental hx, ? recurrent seizure
4) possibility of toxic ingestion (meds)
5) recent hx of injury (esp. head)
6) pertinent medical & family hx = past hx seizures, developmental delay, premature birth, FHx of seizure disorders or neurologic problems.

34
Q

Child presents with fever of 101F and a seizure. is this a febrile seizure?

A 
NOT NECESSARILY
diffdx:
- febrile seizure
- meningitis
- encephalitis
35
Q

describe the etiology of febrile seizure

A

usually infectious

MILD/MODERATE (seizure on first day of febrile illness), >38C
==> viral infection (benign, self-limited): infection –> fever –> trigger seizure
- developmentally normal; FHx of febrile seizures as kids
- usually generalized

SEVERE
==> meningitis, encephalitis: infection –> fever and triggered seizure (b/c CNS infections involving directly adjacent brain / meninges)
- sxs = prolonged fever prior to event (+ irritability, inconsolability)

36
Q

Risks of a lumbar puncture

A
  • Bleeding or bruising at the site of the needle insertion
  • Temporary leakage of spinal fluid from the site
  • Temporary headache after the procedure is done.
  • traumatic spinal tap = introduction of blood into spinal fluid, making interpretation difficult (for RBC count, WBC count) == must admit pt for assumption of infection b/c can’t rule it out.
37
Q

describe: spinal headache

A
  • Improves with lying down
  • worsens with sitting up
    + photophobia
    + vomiting

Improved with

  • caffeine
  • blood patch
38
Q

diffdx seizure (and timing):

A
  • CNS infection (viral / bacterial) = esp. tactile fever. If infection ==> causing seizure == meningitis / encephalitis
  • Febrile seizure (first day of fever)
  • head injury / post traumatic seizure (1-2h after)
  • ingestion/poisoning = insulin overdose; EtOH/long-standing lead poisoning (generalized seizures)
  • idiopathic seizure / epilepsy = for which fever is often the trigger for first seizure in those with epilepsy
  • hypoglycemia == longer recovery time; low blood sugar
  • brain tumor (partial seizure +/- secondary generalized)
  • breath-holding spell (+/- hypoxic seizure) - very brief
39
Q

what is this in a young child? irritability, fever for 2-3d, then seizure

A

meningitis / encephalitis

infection is causing the seizure directly

30% of infants with meningitis present with seizures

40
Q

signs and sxs of meningitis

A

30% - seizures

vomiting, lethargy, behavioral changes

41
Q

what types of poisonings lead to more generalized seizures?

A

EtOH

long-standing lead

42
Q

differentiate symptomatic epilepsy v. idiopathic epilepsy

A

symptomatic epilepsy = d/t developmental delay from genetic / congenital / acquired disorders

idiopathic epilepsy = developmentally normal

43
Q

risks of very prolonged seizures

A

sustained motor activity +/- release of inflammatory mediators ==> fever

44
Q

diffdx fever in young child (+ timing)

A

VIRUS
- enterovirus, adenovirus +/- sxs of congestion, cough, diarrhea, rash

SERIOUS BACTERIAL INFECTION

  • occult bacteremia (3-36mo)= Strep pneumoniae (<1% risk d/t vaccine); temp >39C, no other sxs ==> risk for bacterial seeding ==> meningitis, osteomyelitis
  • meningitis (young children) = fever, irritability, seizure (esp. is prolonged impaired)
  • UTI = even if no other classical sxs b/c children’ can’t complain,

POSSIBLE

  • gastroenteritis
  • pneumonia
  • septic arthritis
  • osteomyelitis = swollen, tender joint; diminished / painful ROM; overlying erythema
  • otitis media
  • Kawasaki = persistent fever for >5d and conjunctival injection; rash; erythema / cracked lips / strawberry tongue / UL cervical lymphadenopathy / swollen hands and feet
45
Q

define: serious bacterial infection in a young child

A

occult bacteremia, meningitis, UTI

+/- gastroenteritis, pneumonia, septic arthritis, osteomyelitis

46
Q

when is a UA / urine culture indicated in a child.

what are the concerns?

A

==> for a child with fever and no other obvious source of infection (via straight cath)

  • males < 6mo circumcised; <12mo uncircumcised
  • females < 12mo

Concerns: low likelihood of UTI in circumcised older male; trauma to child of catheterization.

47
Q

when is a lumbar puncture indicated in a child.

what are the concerns?

A

1) younger children have more subtle signs of meningitis (esp. <3-6mo - showing no signs of nuchal rigidity)==> persistent irritability
2) unclear / incomplete vaccination hx (6-12mo)

Concerns: overall risk of meningitis is low in children with simple febrile seizure

48
Q

CSF findings in bacterial meningitis

A

CSF hypoglycoracchia

  • decreased CSF glucose; decreased CSF glucose:blood glucose ratio
  • elevated protein
  • elevated WBCs (predominantneutrophils)
  • Gram stain of organisms
49
Q

treatment of febrile seizures

A

1) comfort: acetaminophen, ibuprofen ==> but DO NOT help prevent recurrence
2) place child on side to prevent aspiration and hurting himself. DO NOT PLACE ANYTHING IN MOUTH; DO NOT RESTRAIN
3) Time the seizure (usually minute)
4) Call 911 if seizure >5min
5) NO anti-seizure meds in children with simple febrile seizures b/c are maintenance and potential s/e

50
Q

what types of perinatal complications can lead to neurologic disorders?

A
  • intrauterine congenital infections (CMV, toxo) ==> microcephaly, developmental delay, seizures
  • teratogens
  • aspyxia ==> neurologic abnormalities, subsequent seizure d/o
  • prematurity ==> intracranial hemorrhage, subsequent seizure d/o
  • medical complications in neonatal (neonatal meningitis, prolonged hypoglycemia, kernicterus) ==> seizures
51
Q

in the perinatal period, what complications can intrauterine congenital infections (CMV, toxo) cause?

A

microcephaly, developmental delay, seizures

52
Q

in the perinatal period, what complications can asphyxia cause?

A

neurologic abnormalities, subsequent seizure d/o

53
Q

in the perinatal period, what complications can prematurity cause?

A

intracranial hemorrhage, subsequent seizure d/o

54
Q

in the perinatal period, what complications can medical complications in neonatal life (neonatal meningitis, prolonged hypoglycemia, kernicterus) cause?

A

seizures

55
Q

At the age of 16 months, which of the following developmental milestones should Ian have reached?
A Uses 4-6 words consistently.
B Uses a spoon and cup, spilling occasionally.
C Follows simple commands.
D Stoops and recovers.

A

All of the above

most children with febrile seizures are developmentally normal

pre-existing developmental abnormalities = risk factor for subsequent epilepsy

56
Q

relationship between developmental maturation and seizures

A

Most children with febrile seizures are developmentally normal.

Abnormalities in neurodevelopmental maturation ==> serious underlying disease in a child with seizures.

Pre-existing developmental abnormalities are a risk factor for subsequent epilepsy.

57
Q

define: a “toxic-appearing” child

A
  • poor or absent eye contact.
  • Fails to recognize caregivers.
  • Is very irritable and cannot be consoled or distracted.
  • Has a minimal response to painful procedures, such as an IV placement or blood draw.
  • Has signs of poor perfusion or respiratory distress.

==> febrile child who requires immediate diagnostic and therapeutic intervention, usually for a serious bacterial infection such as meningitis or sepsis

58
Q

16mo boy comes in with febrile seizure of unknown origin. should you get a UA? why?

A

if circumcised == NO

if uncircumcised == MAYBE.

febrile seizure could be due to UTI in:
[BOYS]
- babies <6mo circumcised,
- babies 6-12mo and uncircumcised

[GIRLS] <12MO

59
Q

evaluation of first febrile seizure

A

if the child’s clinical history is consistent with the classic pattern of a simple febrile seizure and if his past medical history and physical examination are normal, then he likely has a febrile seizure and no further workup is necessary.

IF he continues to be fussy ==> LUMBAR PUNCTURE

60
Q

evaluation of first non-febrile seizure

A

1) EEG == only useful if can catch seizures/epilepsy
(3Hz spike and wave == absence; hypsarrhythmia == infantile spasm)
2) MRI == esp. in focal seizures; parenchymal malformations, vascular malformations, temporal sclerosis
3) CT == for trauma, calcifications (CMV, tuberous sclerosis)

61
Q

CSF findings in viral meningitis

A
  • nml CSF glucose; nml CSF glucose:blood glucose ratio
  • nml protein
  • elevated WBCs (predominant neutrophils ==> lymphocytes)
62
Q

CSF findings in viral meningitis d/t herpes virus

A
  • nml CSF glucose; nml CSF glucose:blood glucose ratio
  • nml protein
  • elevated WBCs (predominant neutrophils ==> lymphocytes)
  • elevated RBCs
63
Q

should anti-seizure meds be used in kids with simple febrile seizures?

A

NOT usually recommended

  • Phenobarbital (prevent) == poor adherence to therapy and serious s/e in at least 20% of patients.
  • Primidone (prevent) = high s/e profile.
  • Valproic acid (prevent) = hepatotoxicity.
  • Carbamazepine = NOT help prevent
    febrile seizure recurrence.
  • Phenytoin = NOT help prevent
    febrile seizure recurrence
  • Diazepam (prevent when given at the start of the febrile illness) = BUT seizure in many cases may be the first sign of a febrile illness; s/e of sedation, possible masking of a serious CNS infection
64
Q

which commonly used anti-seizure meds have NOT been shown to prevent recurrence of febrile seizures?

A

carbamazepine

phenytoin

65
Q

which commonly used anti-seizure meds HAVE been shown to prevent recurrence of febrile seizures?

A

phenobarbital
primidone
valproic acid
diazepam (at start of febrile illness).

66
Q

for a child with first febrile seizure, what conditions would satisfy him going home?

A

non-focal examination, his normal CBC and lumbar puncture results, as well as his rapid improvement in the emergency department with only IV fluid treatment ==> presumed viral illness as the cause for Ian’s fever.

blood culture, CSF culture pending

esp. if fully immunized

67
Q

A previously healthy and developmentally normal 16-month-old male comes to the urgent care clinic with his father with a chief complaint of his first reported seizure. The child was reported to have dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. The child has had URI symptoms for the past two days, with a fever to 103 degrees F without any changes in mental status. Neither parent has a seizure disorder, but the child’s mother reports having a single seizure as a young girl once after developing a high fever after a cold. What is the most likely diagnosis?

A		Epilepsy	
B		Simple febrile seizure	
C		Complex febrile seizure	
D		Absence seizure	
E		Cyanotic breath-holding spell
A

B.
generalized tonic clonic

febrile illness d/t URI
Fhx of febrile seizure
<15min; once in 24h; generalized.

68
Q

During the middle of dinner on your day off, you receive a call from one of your neighbors who remembers that you are a medical student. He is concerned about his 15-year-old daughter who had previously been in her usual state of health and has no significant past medical history. However, over the past 24 hours, his daughter suddenly spiked a fever of 103 F and has “not been herself,” acting very lethargic and dazed at times. He also notes that she has been breathing heavily, not been able to eat or drink, and has not urinated over the past 12 hours. He wants your advice about whether she should be taken to the ED. Although you are fairly certain that the best course of action would be to take her to the ED, you contemplate the differential diagnosis of her presentation. Given the limited history, which of the following is highest on your differential?

A		Acute cystitis	
B		Diabetic ketoacidosis	
C		CNS tumor	
D		Meningitis	
E		Hypoglycemia
A

D

lethargic
deep breathing (? respiratory obtundation)
anorexia
low UOP

hoice D is correct because meningitis is the most likely etiology in our differential given the fever, altered mental status, decreased PO intake, and decreased urine output. While the incidence of meningitis has decreased in this patient’s age range due to increased vaccinations against the most common causative organisms of meningitis, it still remains high on our differential given the presentation of this patient. In the ED, we would likely need to obtain a more thorough history and physical exam as well as blood cultures and lumbar puncture to establish the diagnosis of meningitis.

69
Q

You see a 6-year-old male in the ED who presents with a history of a 10-second episode of jerking movements of his extremities with unresponsiveness, observed by both of his parents. His parents claim he has had abdominal pain and small quantities of bloody diarrhea for two days. The child has no significant past medical history, has taken no medications recently, has no pets, and has not traveled outside of California in the past year. He attends kindergarten. Which organism is the most likely cause of the child’s symptoms?

A		Shigella sonnei	
B		Rotavirus	
C		Clostridium difficile	
D		Enterotoxigenic E. coli (ETEC)	
E		Vibrio cholerae
A

A. Shigella sonnei causes bloody diarrhea and WBCs in the stool on Wright stain. Rarely, children infected with Shigella can suffer from seizures due to neurotoxin release.

abd pain, bloody diarrhea

Shigella, EHEC == bloody diarrhea

ETEC = more likely from Mexico (traveler’s diarrhea) == noninvasive without WBCs in stool. watery.

70
Q

A woman brings her 8-year-old son to the pediatrician after witnessing him stare blankly into the distance at dinner the previous week. He was unresponsive to her calling his name or any other stimuli, and it lasted for about 10 or 20 seconds. His teacher reports he does seem to daydream often in class but is able to keep up with schoolwork and excels in his studies. She doesn’t note him being disruptive or impulsive in class. His mother is concerned about these blank stares and unresponsive episodes. Which of the following is the most likely diagnosis?

A		Generalized tonic-clonic seizure	
B		Atonic seizure	
C		Absence seizure	
D		Simple partial seizure	
E		Complex partial seizure
A

C

absence seizure –> still able to do well in school

The patient is having absence seizures. Absence seizures are characterized by loss of awareness of surroundings (“blank stare” or “in another world”) and automatisms (e.g., eye-fluttering or lip-smacking). These patients do not lose consciousness or have loss of tone. Absence seizures should also be differentiated from ADHD, since children with ADHD also can be inattentive or seem to be daydreaming. However, since the patient in the vignette still does well in school and does not have other signs of ADHD, it is most likely an absence seizure. An EEG will confirm the diagnosis.

71
Q

You are working overnight call in the ED when Charlie, a 3-year-old male infant, arrives after his parents witnessed an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management?

A		Workup for source of fever	
B		EEG	
C		MRI brain	
D		Abdominal ultrasound	
E		Administration of valproic acid
A

A

likely ebrile seizure in the setting of an infection. These are relatively common occurrences in Charlie’s age range (6 months to 5 years), and the first priority would be to identify the source of fever and treat it.

No anticonvulsants b/c the majority of patients with febrile seizures do not require treatment with anticonvulsants. This is especially true if this is Charlie’s first febrile seizure. Anticonvulsants such as phenobarbital or valproic acid may rarely be indicated, but generally these drugs are not recommended in the setting of febrile seizures because they are associated with serious side effects.

72
Q

Mgmt?

Patient in ED: 12 d/o previously healthy male with new seizure activity

After breastfeeding mom holding infant in her arms, noticed that he developed arm and leg shaking and looked to one side
Mom not sure how long it lasted, “felt like forever,” lips seemed to turn a bit blue
Mom called 911, movement had stopped before they arrived

A

Vitals, monitoring, IV

ABCs!!!
Get the baby on monitors
Assess for respiratory effort 
Provide supplemental O2/PPV as needed
Assess circulatory status, chest compressions for HR <50

Obtain IV access
Administer medications
Labs = glucose, all electrolytes , VBG, ABG, CBC (infectious)
Consider further workup (MRI/CT/ US, EEG, LP)

73
Q

what anti-seizure meds do you give to babies (<6mo)

A

NO BENZOS

  • fosphenytoin
  • phenobarbital
  • pyridoxine (2nd line)
74
Q

what is involved in the baby neuro exam

A 
General: Activity level (irritable v. somnolent)
Anterior fontanelle
Pupils (open eyes!)
Fixing/tracking
Tone
Reflexes = palmar, plantar, moro
75
Q

diffdx of nonfebrile seizures in newborn - 2w old

A
  • Infection (but NOT febrile seizure!)
  • Hypoxic-ischemic-encephalopathy (HIE) = newborn
  • Hemorrhage (consider NAT)
  • Electrolyte disturbance
  • Metabolic disorder
  • Congenital malformation
  • Toxins
76
Q

2-3w old baby has seizure, found on CT to have a subdural hematoma

what further workup?

A

likely due to abuse

Eye exam
Skeletal survey
MRI (crescent shaped)

77
Q

what causes of nonfebrile seizures are common in term infants?

in preterm infants?

uncommon in either?

A

TERM

  • Hypoxic-ischemic encephalopathy (more in term)
  • subarachnoid hemorrhage
  • hypoglycemia
  • intracranial infection
  • cerebral dysgenesis == poor outcome
  • drug withdrawal

PRETERM

  • Hypoxic-ischemic encephalopathy (more in term)
  • intraventricular hemorrhage (severe) == poor outcome
  • hypoglycemia
  • intracranial infection
  • cerebral dysgenesis == poor outcome

UNCOMMON
- hypocalcemia

78
Q

abnormal movements in young infants (newborns)

A

newborns rarely have organized, generalized, tonic-clonic seizures

  • seizures = jerking / horizontal deviation of the eyes; blinking / fluttering of the eyelids; drooling, sucking, lips-smacking; tonic posturing of a limb; apnea
  • jitteriness = stimulius-sensitive, generalized / symmetric, decreased with gentle, passive flexion of the limbs
  • myoclonic jerks = common when just falling asleep
  • clonus (normally disappears rapidly) = spasmotic alternation of muscular contractions b/w antagonistic muscle groups d/t hyperactive stretch reflex of an UMN
  • newborn = nml <10 beats
  • child <1-2mo = nml <3 beats

PedsSpring2020 (37 decks)

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