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Neurological Disorders Flashcards

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1
Q

Migraine hx to ask in children

A

Assess;
- severity, frequency, impact on life
- quality of attacks: intensity and site of pain, ass. Sx?
- Timing: associations? duration,
- ?cause (triggers or emotional problems)
- general health between attacks
consider 8wk headache diary

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2
Q

Acute migraine Mx (12-17)

A
  1. P/I for pn
  2. Nasal sumatriptain (PO not licensed <18), consider aspirin if >16 (Reye’s)
  3. Combination nasal sumatriptan + NSAID/paracetamol (consider anti-emetic)
    Arrange 1m FU ask to return if worsening Sx
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3
Q

Migraine Prophylaxis in children

A

Topiramate or propranolol

(topiramate risks foetal malformation)`

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4
Q

Headaches in children

A

Exclude red flags
Rescue Mx:
- P/I, antiemetics, nasal triptans, physical eg cold compress
Prophylaxis:
- Na channel blockers, beta blockers, tricyclics, acupuncture
Psychosocial:
- identify stressors, relaxation techniques

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5
Q

Na channel blockers for headache

A

topiramate and valproate

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6
Q

Febrile Convulsions During seizure Mx

A

Protect from injury (cushion head)
Remove harmful objects nearby
do NOT restrain or put anything in mouth
When seizure stops check airway and put in recovery position
If Seizure >5m:
- rectal diazepam, repeat at another 5m OR one dose buccal midazolam
Call 999 if:
10 mins after first dose seizure has not stopped or there is ongoing twitching, another seizure before child regained consciousness
Measure blood glucose if non-rousable/convulsing

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7
Q

Doses of rectal diazepam for febrile seizure

A

<1m 1.25-2/5mg
1m-1y= 5mg
2-11y= 5-10mg

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8
Q

Dose of buccal midazolam for febrile seizure

A 
<6m = 300ug/kg (max 2.5mg)
6m-11m = 2,5mg
1-4y = 5mg
5-9y = 7.5mg
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9
Q

After febrile seizure

A

Identify and manage cause (?meningococcus/traffic lights)
Arrange immediate hospital assessment if:
- first febrile seizure/second seizure if not assessed before
- diagnostic uncertainty
- seizure >15m
- focal features persisting
- seizure recurred within same febrile illness or within 24hr
- incomplete recovery by 1hr
- <18m old
- currently taking Abx
- parents anxious
- suspected cause eg pneumonia

If no apparent focus of infection consider admission and monitoring

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10
Q

If febrile seizures can be Mx at home

A 
Tell Parents:
NOT epilepsy, risk of epilepsy in future only slightly elevated, NOT harmful if short, 1/3 will have them
Advise Parents:
Make area safe, leave alone, check airway, medical help/ambulance (>5m)
Managing fever:
does NOT prevent recurrence, P/I, fluids
NO prescription to cover seizures,
Arrange FU
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11
Q

PACES counselling febrile seizure

A 
explain dx, seizures but not epilepsy 
1/3 risk of recurrence
explain Mx of seizure
Ambulance >5mins
2% increased risk of epilepsy 
Don't try and cool the child
P/I if distressed but not at -anti-pyrexial
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12
Q

Epilepsy first seizure

A 
All patients suspected of first epileptic seizure to see neurologist (first fit clinic)
Advice:
recognition
record
avoid dangerous activities
seek help if another one
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13
Q

Rx NOT usually given for which epilepsy?

A

childhood rolandic

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14
Q

AED therapy considerations

A

NOT all children w/seizures need AED
Base choice on: seizure/epilepsy type, frequency, side effects
Monotherapy at minimum dose
ALL AEDs have potential SE
AED levels not checked regularly but may be measured to check adherence
Children w/>5m seizures given rescue meds (bucccal midaz)

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15
Q

Choice of anti-epileptic:

Generalised tonic-clonic

A

1L; Valproate
Alt: lamotrigine, carbamezapine, oxcarbazepine)

Adjunct: clobazam, lamotrigine, levetiracetam, valproate, topirmate

NB can exacerbate myclonic (lamotirigine), absence (carbamazepine + oxcarbazepine)

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16
Q

Choice of anti-epileptic:

Generalised absence

A

1L: ethosuxamide/valproate
Alt: lamotrigine
adjunct: combination of 2 of the 3

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17
Q

Choice of anti-epileptic:

Generalised myoclinic

A

1L: valproate
Alt: levetaricatem, topiramate

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18
Q

Choice of anti-epileptic:

focal

A

Carbamazepine, lamotrigine
Alt: levetiracetam, oxcarbazepine, valproate
Adjunct: clobzam, gabapentin, carbamazepine

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19
Q

SE of AEDs

A 
Valproate: wt gain, hair loss, rare liver failure
-azapine: rash , neutropenia, ataxia
Lamotrigine: rash
Ethosuxamide: N+V
Topiramate: drowsiness, weight loss
Gabapentin: insomnia
Levetiracetam: sedation rare
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20
Q

Other Mx of intractable epilepsy

A

Ketogenic diet
Vagal nerve stim
surgery (only if well localised structural cause)

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21
Q

PACES counselling of epilepsy

A 
Tendency to unprovoked seizure
Aim to promote independence and confidence
make school aware
Avoid baths/swimming unsupervised
Driving after 1yr seizure free
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22
Q

Status epilepticus

A 
Secure airway
Oxygen and pulse ox
if IV access: 
- glucose, FBC, U+E, LFT, Ca
- AED levels/tox screen if necessary
if NO IV access: 
- rectal diaz/buccal midaz
Step 1: IV loraz
2: if no response in 10m second dose IV loraz
3. if persistent start phenytoin infusion (monitor ECG/BP)
4. GA if refractory
Consider dex if vasculitis/cerebral oedema possible
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23
Q

Guillain-Barre syndrome

A

Supportive
Respiratory support
IVIG
Plasma exchange

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24
Q

Myasthenia Gravis

A

Anti-cholinesterase: pyridosigmine/neostigmine
Immunosupressive therapy
Immune-modulation drugs (pred, azt, mycophenolate)
Thymectomy if thymoma present
Plasma exchange in crisis

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25
Duchenne Muscular Dystrophy
Ix: serum CK, genetic, EMG, biopsy PT to prevent contractures Exercise/psych support ?Tendoachilles lengthening/scoliosis surgery Noctural hypoxia ?CPAP Glucocorticoids may delay wheelchair dependence If LV ejection fraction drops give cardioprotective (carvedilol)
26
Noctural hypoxia
occurs in DMD | presents w/ daytime headache, irritability, loss of apetite
27
Myositis in children
PT to prevent contractures Steroids for 2y Immunosuppressants
28
Extradural haemorrage in children
Correct hypovol urgent evacuation of haematoma arrest bleed
29
Subarachnoid haemorrhage in children
Neurosurgical or interventional readiology
30
Neural tube defects in children
``` Back lesion closed soon after birth PT early ?walking aids Good skin care to avoid sensory loss Neuropathic bladder: indwelling/intermittent catheter Regular checks for htn, renal function, urinary function Proph. abx Ehedrine/oxybutinin may help bladder Bowel denervation: regular toileting, laxatives, suppositories Scoliosis - ?surgery Hydropcephalus - VP shunt MOST disabled = lesion above L3 at birth ```
31
Hydrocephalus
Sx relief Reduce ICP to prevent damage VP shunt is mainstay (can malfunction if blocked or infected) Overdrainage can cause low pressure headche
32
Breath holding attacks
self resolve | behaviour modification with distraction
33
West syndrome (infantile spasm)
Vigabatrin or corticosteroids | POOR prognosis
34
Tension headache in children
not concerning | P/I
35
Raised ICP
CT/MRI | cerebral odema can be Mx w/mannitol IV
36
Idiopathic intracranial HTN
Eliminate causes eg drugs Weight loss if overweight Low Na diet, mild fluid restriction Mx: acetazolamide (2L: furosemide, topiramate) Analgesia: amitriptyline/naproxen for persistent headache VP shunt for intractable
37
Cerebral Palsy RF/causes
AN: preterm, chorioamonitis, maternal resp or GU infection Perinatal: LBW, neonatal encephaolpathy, sepsis Postnatal: meningitis Causes: MRI: White matter damage (45%), BG/deep grey matter (13%), after neonatal period: meningitis (20%), other infection (30%), head injury (12%)
38
Signs of cerebral palsy
``` Possible early motor: - unusual fidget, asymmetry of movement - abnormal tone - late development (not sitting by 8m, not walking by 18m, hand preference <1y) Refer all with persistent toe walking For those at risk: clinical and developmental FU by MDT ```
39
Red flags for other disorder than CP
``` Absence of risk factors FHx of progressive dx Loss of previously attained unexpected FNS MRI not consistent ```
40
MDT for CP
Main heroes: paediatrician, nurse, PT, OT, SALT, dietetics, psych Side dishes: ortho, visual and hearing
41
Prognosis of CP
Walking: if sitting by 2, likely to be walking unaided by 6 Speech: 1/2 struggle with communication, 1/3 SALT difficulties Life expectancy: depends on serverity
42
Eating, drinking, swallowing in CP
assessed by SALT trained in dysphagia ?video fluoroscopy Create individualised plan
43
Speech language and communication
comms difficulty doesnt equal learning difficulty Interventions: posture, breath control, rate of speech Consider augmentative/alternative systems eg pictures/signs
44
Other Factors in CP
``` Optimise nutritional status Manage saliva control (?glycopyrronium) Low bone density (assess diet and offer calcium/vit D) Pain, discomfort, distress: paracetamol ?baclofen Sleep: optimise hygiene, ?melatonin Mental health Visual impairment Heating impairment Behavioural GORD Constipation Epilepsy (1/3) ```
45
Sumary of CP
``` PT; encourage movement, improve strength, prevent ROM loss Speech OT Meds: - stiffness: baclofen, diazepam - sleep: melatonin - constipation: laxatives - saliva anticholinergic ```
46
PACES of CP
dx: damage to brain that occured early during development damage wont get worse but ways it manifests will change Refer to specialist in devlopment will see many people: Dr, OT/PT, nurses, SALT, dietician Meds available to help w/Sx
47
Autism spectrum disorders Ix
Hearing, speech and language assessment Cognitive assessment (WISC, WPPSI) Autism assessment (ADOS, 3Di) Childhood autism rating scale
48
ASD psychosocial interventions
Aim to increase attention, engagement, reciprocal communication Aim to increase understanding of childs pattern of communucation Expand communication, interactive play, social routines
49
Factors that increase risk of difficult behaviour in ASD
``` Impairment in communication Physical dx mental health dx Environment (light, noise) Routine change Developmental change (puberty) Exploitation/abuse ```
50
Pharmacological intervention in ASD
consider antipsychotic if psychosocial interventions fail r/v at 3-4wks, stop at 6w if no indication ?melatonin for sleep ?methylphenidate for attention difficulty
51
PACES ASD
Explain is a spectrum hard to give prognosis Is characterised by difficulty in social interaction, language impairment, ritualistic behaviours Mx: psychosocial interventions, SALT w/focus on behaviour, education assessment and plan - some symptomatic drugs National Autistic society
52
ADHD Ix
``` Rating scale (Conners) refer to CAMHS ```
53
ADHD MDT members
Paediatrician, psychiatrist, ADHD nurse, mental health and learning disability trust, CAMHS, parent groups, school
54
Risk groups for ADHD
``` Preterm Oppositional defiant disorder conduct disorder Mood disorder Epilepsy ASD Learning difficulty ```
55
Children having behaviour/attention problems that adversely impact on their development or family life
Consider watchful waiting for 10w Offer referral to group based ADHD support for parents Refer if severe
56
Criteria for ADHD
Meet DSM5/ICD10 (impaired attention, over activity, onsey <6y, impairment in 2+ settings, other dx excluded) Cause at least moderate impairment (bio, psycho, social)
57
Children <5 w ADHD
1st line: ADHD focussed group parent training programme (10-16 meetings, groups of 10) If fails seek specialist NOT medication unless specialist advice remember dietary advice
58
Children >5 w/ADHD
Recommend ADHD focussed group parent training programme Offer individualised programmes if complex Offer meds if sx persistent and causing significant impairment despite environmental modification Consider CBT if social sx Sx relief: clonidine, antipsych remember diet
59
Medication in ADHD
Methylphenidate 6 week trial, if unsuccessful consider lisdexamphetamine If responding but SE too much Offer atomoxetine or gaunfacine if both MP and (lis)dexamphetamine fail Establish baseline medical state and perform ECG before meds Meds require monitoring
60
Medication monitoring in ADHD
Use Sx rating scale (Conners) Measure height every 6m and weight every 3m (consider treatment holiday if necessary) HR and BP every 6m Monitor for development of tics after starting stimulant meds Monitor sexual dysfunction, seizure, sleep disturbance, worsening behaviour
61
SE of ADHD meds
anorexia mood change palpitations tics

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