Peds enhancement neuro

Question 1

A seizure

Answer 1

abnormal, excessive, synchronous discharges of neurons residing primarily in the cerebral cortex.

Question 2

Epilepsy

Answer 2

two or more seizures not due to acute causes.

Etiologies:
Genetic
Structural
Metabolic
Idiopathic

Question 3

Metabolic and other causes of seizure

Answer 3

*** Hypoglycemia
Hypo or hypernatremia
Hypocalcemia
	PE: Chvostek’s and Trouseau’s
Intoxications/ toxins (lead)

• FEVER also can be a cause of provoked seizure
• Toxic- meds

Question 4

• Differences in pediatrics

Answer 4

• Generalized seizures are more common in children than adults.
• Generalized tonic–clonic seizures are rare before 2 yrs of age.

Children older than 6 years old will have seizures similar to that of adults.

Younger children have * less complex behaviors, especially with complex partial seizures.

Can be difficult to determine altered LOC in infants/young children

• • Newborns’ seizures can present in a variety of different ways, and are uncommonly generalized.
• Apnea, subtle eye deviations, or abnormal chewing movements
• Differentiating between a newborn who has a seizure and a ‘‘jittery baby’’
• – Seizures cannot be suppressed by passive restraint
• – Seizures are not elicited by motion or startling

Question 5

Seizures in the neonatal period: causes

Answer 5

* Hypoxic ischemic encephalopathy
Intracranial hemorrhage (intraventricular, subdural, subarachnoid)
Ischemic stroke
Infections 
- Bacterial meningitis (E. coli, Listeria, GBS)
- Viral (HSV
Hypoglycemia
Hypo or hypernatremia
Hypocalcemia
Hypomagnesemia
Inborn errors of metabolism
Genetic disorders with seizures

Question 6

Partial seizures

Answer 6

Simple partial seizure
= Focal seizure without impairment of consciousness

Complex partial seizure
= Focal seizure with impaired consciousness

Partial seizures with secondary generalization
= Focal seizure evolving to bilateral convulsive seizure

Question 7

** Automatisms

Answer 7

(stereotypical, repetitive behaviors) present in 50%-75% of cases of Complex partial seizures

Question 8

Simple partial seizure

Answer 8

Focal seizure without impairment of consciousness
Symptoms are referable to the area of the brain involved, no alteration of consciousness
EEG demonstrates unilateral spikes or sharp waves in anterior temporal region; can occasionally by bilateral or multifocal

Question 9

Complex partial seizure

Answer 9

= Focal seizure with impaired consciousness
Partial seizures with alteration of consciousness
Automatisms (stereotypical, repetitive behaviors) present in 50%-75% of cases
EEG with sharp waves or spike discharges in the anterior temporal or frontal lobe, occasionally with multifocal spikes

Question 10

Partial seizures with secondary generalization

Answer 10

= Focal seizure evolving to bilateral convulsive seizure

Partial seizure at onset followed by generalized convulsive activity

Question 11

Partial seizures (simple and complex): 
- signs

Answer 11

Partial seizures may begin with localized symptoms that the patient is aware of (aura)
May have asymmetric motor symptoms.
*** Postictal state is common, even without convulsive activity.

Question 12

Types of seizures: generalized (description)

Answer 12

Arise from both sides of the brain simultaneously

Quick onset, no aura or warning

Motor activity is symmetrical, whole body

Alteration of consciousness occurs
Primary generalized seizures (grand mal)
Postictal state is common for seizures with convulsions
Absence seizures (petit mal) and myoclonic seizures, atonic seizures, tonic clonic

Question 13

Neurofibromatosis types 1 and 2

Answer 13

café au lait spots
axillary freckling
Lisch nodules (brown spots on iris), optic gliomas
neurofibromas

Question 14

Tuberous sclerosis

Answer 14

Ash leaf macules
Shagreen patch
adenoma sebaceum

Question 15

Sturge Weber

Answer 15

• portwine stain (V1, V2)
  intellectual disability
  seizures
• glaucoma

Question 16

idiopathic seizures

Answer 16

in more than half of them we don’t figure out what’s going on

Question 17

Febrile seizures

Answer 17

Most common type of seizure in childhood

Seizure in association with a febrile illness in children between * 6 months and 5 years of age.

• Simple febrile seizure is single, brief (<15 minutes), and generalized

Complex febrile seizure is much less common (approximately 20%) and is recurrent in a single illness, prolonged (>15 minutes), and focal.

3-6% of those with febrile seizures will develop afebrile seizures or epilepsy

Question 18

Febrile seizures- LP indicated if:

Answer 18

Infant under 12 months
Prolonged complex febrile seizure
** Children who have been partially treated with antibiotics

Question 19

Absence seizures

Answer 19

Short (5-20 sec) lapses in consciousness, speech, or motor activity
Often daily or multiple times a day
No postictal drowsiness
EEG: 3 cycles per second generalized spike and wave activity
Tx: ethosuximide

Question 20

Myoclonic seizure

Answer 20

Spasm of a muscle or group of muscles

Brief, repetitive, symmetrical muscle contractions

• Juvenile myoclonic epilepsy (JME)
• Is an idiopathic generalized epileptic syndrome characterized by myoclonic jerks, generalized tonic-clonic seizures (GTCSs), and sometimes absence seizures
• Presents in adolescence
• Generalized polyspike and wave discharges at 4-6Hz
• Lifelong risk of seizures
• Tx: valproic acid

Question 21

Benign Rolandic Epilepsy

Answer 21

with centrotemporal spikes (BECTS)

Onset between 3-10, with seizures during sleep or at night
Facial twitching, salivation
Normal development
Low seizure frequency: ¼ of patients have only one seizure
* Spontaneously remits

Question 22

Atonic-akinetic seizure (drop attack)

Answer 22

Sudden loss of postural tone

Question 23

Infantile spasms

Answer 23

Seizure that involves * spasms of the muscles of the neck, trunk, and extremities

Unclear if focal or generalized, so categorized as unknown type

Any disorder that can produce brain damage can be associated with infantile spasms – tuberous sclerosis, HIE (=hypoxic ischemic encephalopathy)

2% of childhood epilepsies but 25% of epilepsy with onset in the first year of life.

EEG shows * hypsarrhythmia (high amplitude disorganized background, multifocal discharges)

• Long-term overall prognosis for patients with infantile spasms is poor. Associated with cognitive impairment.

Tx: ACTH, or for tuberous sclerosis: vigabatrin

West syndrome = severe epilepsy syndrome with

1. Infantile spasms
2. Hypsarrhythmia on EEG
3. Developmental regression/mental retardation

Question 24

asking about precipitating events

Answer 24

Start with open ended question
Precipitating events (pre-ictal)

• Position, activity, awake or asleep, * trigger: illness, medications, flashing lights, hyperventilation, being overtired/sleep deprivation (stress?)
  Was there any warning before the spell: abdominal discomfort, fear, other, any associated symptoms?

Question 25

Description of the episode (ictal)

Answer 25

LOC: was the child responsive during the episode Amnesia of episode? Repetitive behaviors: lip smacking, pulling at clothing Body movements * Loss of continence? Skin color, perioral * cyanosis? Prior episodes, frequency?

Question 26

Physical Examination-

Answer 26

* Fever or other abnormal vital signs Ht/wt/FOC (= head circumference) Head size, skin abnormalities (hypo/hyperpigmented areas), meningismus, asymmetry of the face or the extremities, enlarged organs, dysmorphic features Alteration of mental status, cranial nerve abnormalities, motor tone or strength or reflex changes, gait abnormalities, ataxia, sensory abnormalities. *** Evidence of trauma: Battle’s sign, raccoon eyes, clear rhinorrhea = basilar skull fracture Evidence of increased ICP * Brudzinski’s or Kernig’s would suggest meningitis

Question 27

Differential diagnosis

Answer 27

Syncope - Syncopal seizures may have tonic stiffening, clonic jerking and/or post-ictal confusion - Vasovagal (fear, heat, stress, noxious stimuli): nausea, pallor, diaphoresis - Orthostatic (dehydration, autonomic disease) - Cardiogenic (arrhythmia, structural) Parasomnias - Sleepwalking - Night terrors ``` Hyperventilation/ panic attack Benign sleep myoclonus Benign positional vertigo Complicated migraine Tics Narcolepsy Confusional migraine Staring spells, daydreaming * Breath holding spell Aspiration Decorticate posturing Sandifer’s syndrome (GERD related) ```

Question 28

Differential Diagnosis: Seizure versus syncope

Answer 28

Position- seizures may occur in any position, *syncope usually occurs when sitting or standing Eye movements- eyes are usually closed or partially open during a syncopal episode, more likely to be * open during a seizure. The presence of * deviation of the eyes to one side or another suggests a partial seizure. Seizures that affect one side of the body more than the other are likely to be focal in origin. Syncopal episodes are usually symmetrical. Precipitating factors Seizures may be precipitated by flashing lights, hyperventilation, illness or being overtired (stress?) Syncope is precipitated by standing up, being overheated, sight of blood, frightening event State of alertness- syncope doesn’t occur in sleep, seizures may occur in sleep or wakefulness. Parasomnias only occur in sleep.

Question 29

* Staring spells

Answer 29

Occur when the patient is passive, listening to a teacher, or parent or watching TV Indeterminate length Interruptible by voice or touch.

Question 30

* Absence seizures can

Answer 30

``` Occur in the midst of activity Last only 10-20 seconds May have eye blinking/fluttering or subtle head movements Recovery is quick Incontinence may occur. ```

Question 31

Acute stabilization

Answer 31

Airway, breathing, and circulation and stopping the seizure. The patient should be positioned to allow for an open airway, and if necessary, an oral or nasal airway should be inserted. Oxygen should be administered and further equipment for assisted ventilation should be at the bedside. Intravenous (IV) access should be established promptly. The actively convulsing patient should also be protected from self-inflicted trauma. *** A rapid glucose level determination should be performed at the bedside Naloxone for suspected drug exposure

Question 32

Todd’s paralysis

Answer 32

temporary paralysis after seizure Partial or complete but usually occurs on *just one side of the body Average of 15 hours, at which point it resolves completely. May also affect speech and vision.

Question 33

Stevens Johnson Syndrome

Answer 33

terrible allergic reaction to a drug, e.g. antibiotic and anti seizure drugs

Question 34

treatment vs not?

Answer 34

* If 1st seizure with lower risk of recurrence, consider no treatment. Use of rectal valium as a “rescue measure” If decision to treat, choose a medication based on seizure type, age of patient and side effect profile. Monotherapy is generally preferable, especially in first line treatment. Dietary treatment - Ketogenic diet - Modified Atkins diet Surgical treatment - Vagal nerve stimulator - Surgical removal of seizure focus

Question 35

Hertz

Answer 35

3 hertz- absence seizure 4-6 hz- Juvenile myoclonic epilepsy 2 Hz-Lennox-Gastaut Syndrome

Question 36

Pathophysiology of head injury

Answer 36

Primary injury: mechanical damage sustained immediately at the time of trauma Secondary injury: ongoing derangement of neuronal cells not initially injured during the traumatic event ** Hypoxia, hypoperfusion, e.g.

Question 37

Why kids are more at risk for head trauma

Answer 37

Developing brain is more sensitive to concussion injury than an adult athlete. * Developing brain is not able to recover as quickly as teen or adult brain. * Axons in pediatric brain are not as well myelinated – more vulnerable to injury. * Younger have less well-developed cervical and shoulder muscles, less stability to absorb impact. May not use proper techniques to reduce risk for injury. ** On the other hand, a recent study showed that younger kids may recover more quickly than adolescents with concussion.

Question 38

Emergent head CT is recommended if:

Answer 38

Penetrating injury * GCS under or = 14, or other evidence of altered mental status * Depressed or basilar skull fx * Worsening HA LOC prolonged Clinical deterioration or worsening symptoms Pre-existing risk factors (ex. - bleeding disorder) Also, for age under 2: ``` Concerns for abuse Irritability Bulging fontanel Persistent vomiting *** Large boggy nonfrontal scalp hematomas in children under 1 yr old Definite LOC ```

Question 39

Concussion

Answer 39

by immediate and transient post traumatic impairment of neural function due to CNS involvement ``` Approach to management: RECOGNITION RESPONSE REHABILITATION RETURN ```

Question 40

Colorado’s Senate Bill 40

Answer 40

Re: concussions 1. Required training for coaches 2. Removal from play (“when in doubt, sit them out”) 3. Notify parent 4. Medical clearance before return to play Special consideration: the pushy parent

Question 41

Management (cont’d) -When to send concussion patient to ED

Answer 41

Acute head trauma Seizures or focal neurological deficits History of prolonged LOC : > 30 seconds Suspicion of Skull Fracture Severe Headache (9-10/10) Slurred speech Significant drowsiness Repetitive Vomiting Altered mental status more than 30 minutes Subacute head trauma (1-5 days) Increasing severity of headache Sudden onset of vomiting, especially if headache is relieved by vomiting New severe symptoms

Question 42

Concussion Management

Answer 42

Day of Injury: * No same-day return to play! * No driving. Do not leave injured athlete unattended for first 24 - 48 hours. ** Emphasize physical and cognitive rest! Consider limiting… TEXTING * VIDEO GAMES * INTERNET * TV * LOUD MUSIC Educate parents that some symptoms may worsen over 1st 24 – 48 hours (but child should not have worsening LOC, 3-4 episodes of vomiting, etc) Second Impact Syndrome * Catastrophic event which may occur when a second concussion occurs while the athlete is still symptomatic and healing from a previous concussion. Can cause cerebral blood flow increase and rapid swelling around the brain, rarely resulting in severe neurological damage or death. Rare; All reported cases < 24 years old Imaging: * CT without contrast if neuro exam findings are abnormal* *** Premature return to play may confer increased risk to the athlete Physical and Cognitive Rest:  1st few days (* no "cocooning) * Step-wise Return To Play protocol Same for child & adolescent athletes. Individualized Additional management tools: neuropsychological (=NP) testing, balance assessment, neuroimaging Home management of mild concussions: observation No need to wake them frequently Pharmacotherapy Headache: Naproxen (Aleve) 110 lbs: Rx for 500mg tab po q AM & q PM <110 lbs: OTC 220mg tab po q AM & q PM Take with breakfast/dinner (food and drink) Limit use to 5 days on, 2 days off, repeat x 1.

Question 43

return to play

Answer 43

``` generally at least 24 hours for each step. no activity 1. Light exercise 2. sport specific exercie (no impact) 3. non contact training 4. full contact practice 5. Return to play ```

Question 44

***Concussion Management Summary**

Answer 44

Concussion prevention  Properly fitted helmet Cervical musculature strengthening Play clean (good sportsmanship) Appropriate recognition and diagnosis Educate players, parents, and coaching staff about signs and symptoms so they quickly recognize Close monitoring over initial hours to identify catastrophic response Proper healthcare evaluation prior to return sports Specialty follow-up when an athlete has not returned to normal within expected recovery times (i.e., 2-3 weeks) Management should be more conservative in younger patients!

Question 45

majority of concussion patients are better in

Answer 45

7-10 days important to refer when recovery is not proceeding as expected after concussion (ie, relatively quick 1-2 week symptom resolution) – if symptomatic after 3 wks