Lecture 10 - Neurology

Question 1

Epi of headaches

Answer 1

3% (age 3-7 years)
4-11% (Age 7 -11 years)
8-23% (age 11-15 years)

slightly more common in boys than girls <7 years
by adolescents MC in girls than boys

Question 2

What are the different classifications of HAs?

Answer 2

Acute
Acute recurrent
Chronic non-progressive
Chronic progressive

Question 3

Tension HA

Answer 3

one of the most common types in childhood
less debilitating than migraine
non-pulsating pressure/tightness
pain mild to moderate
not associated with N/V, photo/phonophobia

last for an hour to several days
may be episodic (<15 days per month) or chronic (>/=15 days per month)

Question 4

Migraines epi

Answer 4

1-3% in age 3-7 years
8-23% in adolescents
without aura > aura

Question 5

What makes dx migraines challenging in children?

Answer 5

vomiting and vertigo may be more prominent than HA
can be bilateral or unilateral in children
frontal or temporal

Question 6

Migraine withOUT aura criteria

Answer 6

at least 5 migraines with the following criteria:

• HA lasts 1-72 hours
• has at least 2 of the following characteristics:
• –unilateral (although may be bilateral or frontal in children)
• –pulsing quality
• –moderate or severe pain
• –aggravation by physical activity
• at least 1 of the following:
• –N and or V
• –photophobia
• not attributed to another disorder

Question 7

Migraine WITH aura criteria

Answer 7

at least 2 migraine HAs with the following criteria:

• Aura consisting of at least one of the following:
• –visual sxs or loss of vision
• –sensory sxs (pins and needles, numbness)
• –dysphasic speech disturbance
• migraine HA that beings during aura or follows aura within 60 min

Question 8

What are red flags for HA?

Answer 8

sleep-related HA
HA associated with cough, defection 
Explosive or sudden onset of HA
progressive pattern - increased severity or frequency 
neurologic signs/sxs 
-altered mental status 
-papilledema
-abnormal eye movements 

systemic sxs: fever, weight loss, rash, vomiting (vomiting&raquo_space;»>nausea)

Question 9

What are causes of intracranial HTN?

Answer 9

Traumatic brain injury/intracranial hemorrhage 
-subdural, epidural, or intraparenchymal hemorrhage 
-ruptured aneurysm
-diffuse axonal injury 
-arteriovenous malformation 
CNS infections 
Ischemic stroke
Neoplasm
Vasculitis
Hydrocephalus
Hypertensive encephalopathy 
Idiopathic intracranial HTN

Question 10

What are the indications for neuroimaging for a child with HA?

Answer 10

1) NOT indicated on routine basis in children with recurrent HA and normal neurological exam
2) should be considered in children with abnormal neurological exam, coexistence of seizures or both
3) should be considered in children with historical features to suggest recent onset of severe HA, change in HA type, or other associated features suggesting neurological dysfunction

Question 11

When is MRI an appropriate assessment in a child with HA?

Answer 11

r/o structural intracranial lesions, inflammation, ischemia

Question 12

When is a CT an appropriate assessment in a child with HA?

Answer 12

if concern for hemorrhage or fx

Question 13

When is LP an appropriate assessment in a child with HA?

Answer 13

meningitis, suspicion for increased ICP (measure opening pressures)

Question 14

What are lifestyle modifications used to manage HAs?

Answer 14

sleep, diet, hydration, caffeine, exercise

treat underlying depression/anxiety

Question 15

Acute HA management

Answer 15

early intervention
OTC tx effective for migraine
can add caffeine no more than 9 days a month

Question 16

Triptans in use for HA management?

Answer 16

children >6 y/o

NSAID use >2 to 3 days/week (<15 days/month)

acute treatment with triptans or caffeine <10 days/month)

Question 17

What preventative treatment do we have for HA?

Answer 17

antiepileptics 
beta blockers 
CCB 
antihistamines
antidepressants 
no FDA approved indication for HA in children 

considered for >/=4 days of debilitating HAs/month

Topiramate shown more effective than placebo in management of pediatric migraine

Question 18

Seizure epi

Answer 18

1% prevalence of epilepsy
3% prevalence of febrile seizures
generalized seizures are more common in children than adults

Question 19

How are seizures dx?

Answer 19

Mainly on HX

EEG - if normal: 
- does NOT r/o epilepsy 
if abnormal: 
-does not dx epilepsy unless seizure is recorded 
-helps classify type of epilepsy

Question 20

What are the different types of generalized seizures?

Answer 20

tonic clonic 
tonic 
clonic
absence
atonic
mytonic

Question 21

What are the different types of focal seizures?

Answer 21

simple partial
complex partial
secondary generalized

Question 22

Febrile Seizure

Answer 22

convulsion associated with an elevated temperature greater than 38C
3 months - 6 years

MC neuro disorder of infants and young children

peak incidence 12-18 months

Question 23

What is the MC neuro disorder or infants and young children?

Answer 23

febrile seizure

Question 24

What are the risk factors of febrile seizures?

Answer 24

peak temperature during illness
1st degree relative with febrile seizures
neurodevelopmental delays
increased exposure to herpesvirus 6
vaccinations with DTaP, influenza may be associated

almost 50% have NO identifiable risk factor

Question 25

What are the two types of febrile seizures?

Answer 25

Simple febrile seizure (MC) - generalized - duration less than 15 minutes - single seizure in a 24h period Complex febrile seizure - focal clinical manifestation - duration longer than 15 minutes - more than one in 24 hour

Question 26

When is an LP appropriate for febrile seizures?

Answer 26

infants <12 months | meningeal signs or sxs or other clinical features that suggest a possible meningitis or intracranial/CNS infection

Question 27

What is the treatment for febrile seizures?

Answer 27

antipyretics do NOT help rectal diazepam can be used in short term for children with recurrent or prolonged febrile seizures

Question 28

What is the prognosis of febrile seizures?

Answer 28

education, reassurance, and counseling risk of recurrence ~30-50% no increased risk of developmental or scholastic problems risk of epilepsy increases from 1% - 2.5% -family history of epilepsy -complex febrile seizures -neurodevelopmental abnormalities

Question 29

Status epilepticus

Answer 29

at least 30 minutes of continuous seizure activity or intermittent convulsive activity without regaining consciousness 1/3 - initial event 1/3 established epilepsy 1/3 other (trauma, stroke, meningitis, ingestion)

Question 30

Broselow tape

Answer 30

color coded tape each color corresponds to estimated weight class often paired with pediatric color coded crash cart obesity should be taken into account

Question 31

What is the management of status epilepticus?

Answer 31

ABC IV access check blood glucose Benzodiazepines - first line -Lorazepam (ativan) preferred choice in status epilepticus because rapid (3-5 min) onset and long (12-24 hour) half life - diazepam (valium) - rectal - midazolam (versed) - IM Benzos may be repeated every 5 minutes for a max of 3 doses if still seizing after 3 doses of Benzos --alternative treatment Phenytoin (Dilantin) is next drug of choice -given slowly to avoid cardiac dysrhythmia and hypotension Phenobarbital added if third medication is needed (risk of respiratory depression - be prepared to intubate)

Question 32

What do you do after giving 3 doses of ativan over 15 minutes to a child having a seizure?

Answer 32

given phenytoin -given slowly to avoid cardiac dysrhythmia and hypotension Phenobarbital added if third medication is needed (risk of respiratory depression - be prepared to intubate)

Question 33

Epilepsy definition

Answer 33

2 or more unprovoked afebrile seizures

Question 34

What is the treatment of epilepsy treatment?

Answer 34

antiepileptic drugs recommended after 2 or more afebrile seizures partial complex: Oxcarbamexpine, levetiracetam generalized: - tonic clonic - lamotrigine, valproate, topiramate - absence - valproate antiepileptic therapy continued for at least 2 years after the last seizure

Question 35

Concussion

Answer 35

a brain injury defined as a complex pathophysioloigcal process affecting the brain, induced by traumatic biomechanical forces often referred to as a "mild TBI"

Question 36

Who is at highest risk of concussion?

Answer 36

middle and high school age children

Question 37

What are the signs and sxs of concussions?

Answer 37

+/- preceding loss of consciousness min to hours: HA, dizziness (vertigo or imbalance), lack of awareness, N/V hours to days: mood and cognitive disturbances sensitivity to light and noise sleep disturbances

Question 38

SAC Tool

Answer 38

standardized assessment of concussion tool - orientation - immediate memory - concentration - delayed recall - neurologic screening - exertional maneuvers - includes a graded sxs checklist, a brief neurologic examination, and records the presence of post-traumatic and retrograde amnesia

Question 39

PECARN rule

Answer 39

findings associated with very low risk of significant traumatic brain injury in children

Question 40

Return to school rule for TBI?

Answer 40

may return after they can concentrate on a task and tolerate visual and auditory stimulation fro 30-45 minutes

Question 41

Return to play rule for TBI?

Answer 41

Zurich guidelines for return to play following concussion the following are requirements for return to play protocol: - successful return to school - sxs free and off any medications prescribed to treat the concussion - normal neurologic examination - back to baseline balance and cognitive performance measures

Question 42

Zurich guideline for return to play after TBI

Answer 42

0 - no activity 1 - light exercise 5 - normal game play