Lecture 10: Neurology

Question 1

4 classifications of headaches

which is most often benign and which is most worrisome

Answer 1

1. Acute = mostly benign
2. Acute Recurrent (Episodic)
3. Chronic non-progressive
4. Chronic progressive = most worrisome

Question 2

What is the definition of Acute Recurrent (Episodic) HA

Answer 2

chronic daily headache > 15 days/month for 3 mo

Question 3

What is a/w tension HA?

What is NOT a/w tension HA?

Answer 3

mild-mod pulsating press/tightness

NOT a/w: N/V or photo/phonophobia

Question 4

2 challenges about Dx Migraines?

Answer 4

1. Vomiting and vertigo more prominent Sxs (dont report HA)

2. Bilateral = more in kids but can be unilateral

Question 5

Migraine w/OUT aura criteria:
How many migraines needed?

1. how long do HA last:
2. Two of following (4):
3. one of following (2):

Answer 5

At least 5 migraines

1. Lasts 1-72 hrs
2. need at least 2:
   - unilateral
   - pulsing
   - mod-severe pain
   - aggravated by activity
3. need at least 1:
   - Photophobia
   - N/V

Question 6

Migraine w/aura criteria:
How many migraines needed?

1. Aura w/one of following:
2. when does migraine start:

Answer 6

least 2 migraines

1. Aura w/one of following:
   - Visual Sxs or vision loss
   - Sensory Sxs (pins/needles, numb)
   - dyphasic speech disturbance
2. Migragine = dura aura or w/in 60 min after

Question 7

6 Red flags of HAs that are concerning for intracranial pressure

Answer 7

1. Sleep related HA
2. A/w cough/defecation
3. Explosive/sudden onset
4. Progessive
5. Neuro Sxs
6. Systemic sxs
   * Vomiting&raquo_space;»>nausea

Question 8

What is the imaging modality of choice for eval HAs?

Answer 8

MRI (diffusion weighted)

Question 9

When is eval NOT indicated for HAs?

When should it be considered (2)?

Answer 9

1. NOT indicated if recurrent HA + normal PE
2. Consider if abn exam, have seizures or both
3. consider if recent onset of severe HA, change in HA type, neuro dysfxn

Question 10

if suspect child has ICP what is imaging study done? what also must be done 1st?

Answer 10

ICP –> LP

• MUST DO MRI first to r/o mass
• if dont –> herniation w/LP

Question 11

Nemonic for lifestyle management of HAs

Answer 11

"SMART"
Sleep 
Meals (diet)
Activity
Relaxation 
Trigger avoidance

Question 12

2 Tx options for Acute HA

When do you consider Triptans?

Answer 12

1. OTC Tx
2. add caffeine < 9 days/mo

Triptans if > 6 y/o

• if NSAID use > 2-3x/wk
• Acute Tx of Triptans or caffeine < 10 days/mo

Question 13

When is preventative therapy considered for HAs?

Med?

Answer 13

when > 4 debilitating HAs/month

Topiramate

Question 14

What types of seizures are more common in kids than adults

Answer 14

generalized seizures

vs focal - affects 1 side

Question 15

Can a norm EEG r/o seizures?

When is the only time an abn EEG can Dx seizure?
- how are they useful?

(Main method of Dx seizures)

Answer 15

Norm EEG CANT r/o seizures

Abn EEG –> Dx of seizure if actual seizures recorded
- help classify type of epilespy

main method = Hx

Question 16

1. Weird baby movements
2. Sleep myoclonus
3. Syncope
4. Breath holding spells
5. Movement d/o
6. Behavioral - daydream, temper tantrum, night terror
7. Parasomnias
8. Pseudo-seizures

Answer 16

Paroxysymal Non-epileptic Events (not seizures)

Question 17

What is a febrile seizure?

• age range & peak?
• 3 RFs (1/2 = no RFs)

Note: MC neuro d/o of infants + young kids

Answer 17

convulsion a/w temp > 38 C

• age range: 3 mo - 6 yrs
• peak = 12-18 mo

RFs

1. FHx (1st deg relative)
2. Neurodevelopmental delays
3. incr exp to HSV-6

Question 18

3 differences b/t simple and focal febrile seizures

which is MC?

Answer 18

Simple = MC

1. generalized
2. shorter duration ( < 15 min)
3. 1 in 24 hrs

Complex

1. focal (one side of body)
2. longer duration > 15 min
3. 1+ in 24hrs

Question 19

Two abn things on PE for seizure that require further workup?

non-focal exam –> no Dx testing

Answer 19

1. Meningmus

2. Bulging fontanelles

Question 20

3 reasons to do LP in workup of seizures? 3 for Neuroimaging?

What type of testing usu NOT recommended

Answer 20

LP

1. < 12 mo
2. meningitis or CNS infxn
3. on ABX

Neuro-imaging

1. macrocephayl
2. persistent abn neuro exam
3. incr ICP

EEG usu not recommended

Question 21

What is the Tx for recurrent or prolonged febrile seizure?

What does NOT help?

Why are daily ppx anti-epiletics NOT recommended

Answer 21

1. Rectal Diazepam (short term)

Anti-pyretics NOT helpful

ppx anti-epiletics dont decr likelihood of progression (epilepsy, non-febrile)

Question 22

When is there a slightly higher risk of seizures progressing to epilepsy? (3)

Answer 22

1. Complex febrile seizures
2. FHx of epilepsy
3. Neurodev abn

Question 23

Definition of status epilepticus (SE)?

How long til worry about long term damage?

What is the purpose of Broselow tape in SE

Answer 23

5+ min of continous seizure activity or intermittent convulsions w/out regaining consciousness

30+ min –> long term damage

Broselow tape = determine ht/wt –> dose meds

Question 24

Pt in ER has been having continous seizures that have gone on for 7 min. What 3 initial steps in managing this pt (3)?

Answer 24

1. ABCs
2. obtain IV access (can give meds IM, rectally too)
3. check BG

Question 25

If pt in SE is HYPOglycemia what should be done?

Answer 25

give IV dextrose--> likely stops the seizure

Question 26

What type of meds are 1st line for SE? what drug specifically used MC? Pt still seizing after 5 min what should be done? max dosing? What if pt still seizing after max dosing?

Answer 26

BZs = 1st line tx - Lorazepam Give repeat dose of BZs --> max = 3 doses give other meds 1. phenytoin 2. phenobarbital

Question 27

Definition of epilepsy

Answer 27

>2 unprovoked Afebrile seizures note: most kids w/ 1 unprovoked abef seizure never have another

Question 28

When give anti-epileptic drugs? for how long? When is the greatest risk of recurrence?

Answer 28

Anti-epileptic drugs - Give after 2+ afebrile seizures - for least 2yrs after last seizure greatest risk of recurrence = first 2 yrs after stop meds

Question 29

What should peds pts w/SE avoid? Edu for teens/adults?

Answer 29

peds pts w/SE avoid: - contact sports - ride bike w/out helmet - swimming unsupervised EtoH/drugs lower seizure threshold

Question 30

Med for tachy rhythms Meds for brady rhythms

Answer 30

Tachy --> adenosine, vagal manuevers Brady --> atropine, IV epi

Question 31

S/s of concussion/TBI 1. main 2. w/in mins - hrs: 3. w/in hrs - days:

Answer 31

1. main: - confusion + amnesia (+/- LOC before it) 2. w/in mins - hrs: - HA, dizzy, lack awareness, N/V 3. w/in hrs - days: - mood/cognitive/sleep disturbances - light/noise sensitivity

Question 32

1. Orientation 2. Immed memory 3. Concentration 4. Delayed recall 5. Neuro screening 6. Exertional Manuever are components of:

Answer 32

SAC | - standardized assessment of concussion tool

Question 33

What is the PECARN rule in concussion assessment? What type of imaging used in kids for TBI?

Answer 33

Findings a/w LOW risk of signif TBI --> no imaging recommended CT

Question 34

Falls of what height in < 2 y/o = severe MOA? For > 2 y/o?

Answer 34

< 2 y/o = falls > 3 ft | > 2/o = falls > 5 ft

Question 35

Early vs late signs of basilar skull fractures?

Answer 35

Early signs - CSF rhino/otorrhea - Hemotypanum Late signs - raccoon eyes - battle sign

Question 36

What is return to school protocol for concussion/TBI

Answer 36

must be able conc & tolerate visual/auditory stim for 30-45 min

Question 37

4 requirements for return to play protocol?

Answer 37

1. return to school 2. no meds 3. normal neuro exam 4. back at baseline fxning

Question 38

How do Zurich guidelines for return to play work?

Answer 38

Stages 0 - 5 | - must pass all before returning to play