neurological conditions and diseases (during development)

Neurological conditions and Neurological conditions and diseasesdiseases

Post Basic PaediatricsPost Basic Paediatrics

18 April 201218 April 2012


Part IPart I– At birth (Congenital, acquired)At birth (Congenital, acquired)

MacrocephalyMacrocephalyMicrocephalyMicrocephalySpine defectSpine defectOther developmental defectOther developmental defectBirth trauma/HIEBirth trauma/HIE

Part IIPart II– During development (Congenital, acquired)During development (Congenital, acquired)

MeningitisMeningitisSeizureSeizureHeadacheHeadacheStroke/VascularStroke/VascularNeoplasm/TumourNeoplasm/TumourTraumaTraumaComaComa


Part IIPart IIDuring development During development

(Congenital, acquired)(Congenital, acquired)

During development (Congenital, During development (Congenital, acquired)acquired)

– MeningitisMeningitis– SeizureSeizure– HeadacheHeadache– Stroke/VascularStroke/Vascular– Neoplasm/TumourNeoplasm/Tumour– TraumaTrauma– ComaComa

MeningitisMeningitisInflammation of the meningesInflammation of the meningesMost common infection of the CNSMost common infection of the CNSMost cases (70%) occur in children <5 years oldMost cases (70%) occur in children <5 years oldMay be secondary to other localized or systemic infections May be secondary to other localized or systemic infections (e.g., otitis media).(e.g., otitis media).Two primary classificationsTwo primary classifications– ViralViral– BacterialBacterial– Others: fungi and (rarely) parasitesOthers: fungi and (rarely) parasites

Morbidity is also high. Morbidity is also high. About 30% of survivors have some sequelae of their About 30% of survivors have some sequelae of their diseasediseaseHowever, these complications can be reduced if meningitis However, these complications can be reduced if meningitis is treated early.is treated early.

AssessmentAssessment

Viral meningitisViral meningitis– Infants and toddlersInfants and toddlers

Irritability, lethargy, vomitingIrritability, lethargy, vomiting

Change in appetiteChange in appetite

– Older childrenOlder childrenUsually preceded by a nonspecific febrile Usually preceded by a nonspecific febrile illnessillness

Headache, malaise, muscle aches, nausea/ Headache, malaise, muscle aches, nausea/ vomiting, photophobia, nuchal/spinal rigidityvomiting, photophobia, nuchal/spinal rigidity

AssessmentAssessment

Bacterial meningitisBacterial meningitis– Infants and toddlersInfants and toddlers

Poor feeding/suck, vomiting, high-pitched Poor feeding/suck, vomiting, high-pitched cry, bulging fontanel, fever or hypothermia, cry, bulging fontanel, fever or hypothermia, poor muscle tonepoor muscle tone

– Children and adolescentsChildren and adolescentsAbrupt onsetAbrupt onset

Fever, chills, headache, nuchal rigidity, Fever, chills, headache, nuchal rigidity, vomiting, changes in LOC, photophobia, vomiting, changes in LOC, photophobia, extreme irritabilityextreme irritability

AssessmentAssessmentIn children <1 month oldIn children <1 month old: : – group B Streptococcus, Escherichia coligroup B Streptococcus, Escherichia coliIn children 4-12 weeks oldIn children 4-12 weeks old: : – E. coli, Hemophilus influenzae type B, E. coli, Hemophilus influenzae type B,

Streptococcus pneumoniae, group B Streptococcus pneumoniae, group B Streptococcus, Neisseria meningitidis Streptococcus, Neisseria meningitidis (meningococcal) (meningococcal)

In children 3 months to 18 years old:In children 3 months to 18 years old:– Streptococcus pneumoniae (most common Streptococcus pneumoniae (most common

cause), N. meningitidis, H. influenza type B cause), N. meningitidis, H. influenza type B (rare)(rare)

– Mycobacterium tuberculosisMycobacterium tuberculosis

AssessmentAssessmentPHYSICAL EXAMPHYSICAL EXAM- Temperature- elevatedTemperature- elevated- Tachycardia or bradycardia with increased intracranial Tachycardia or bradycardia with increased intracranial

pressurepressure- Blood pressure normal (low if septic shock has occurred)Blood pressure normal (low if septic shock has occurred)- Child in moderate-to-acute distressChild in moderate-to-acute distress- FlushedFlushed- Level of consciousness variableLevel of consciousness variable- Possible enlargement of the cervical nodesPossible enlargement of the cervical nodes- Focal neurologic signs: Focal neurologic signs:

-- photophobiaphotophobia-- nuchal rigidity (in children >12 months old)nuchal rigidity (in children >12 months old)-- positive Brudzinski's sign ( in children >12 positive Brudzinski's sign ( in children >12 months)months)

-- positive Kernig's sign (in children >12 months )positive Kernig's sign (in children >12 months )

Differential DiagnosisDifferential DiagnosisBacteremiaBacteremia

SepsisSepsis

Septic shockSeptic shock

Brain abscessBrain abscess

ComplicationComplication

SeizuresSeizures

ComaComa

Blindness Blindness

DeafnessDeafness

Death Death

Palsies of cranial nerves III, VI, VII, Palsies of cranial nerves III, VI, VII, VIIIVIII

Lumbar punctureLumbar puncturePatients at greatest risk for meningitisPatients at greatest risk for meningitis– under 18 months of ageunder 18 months of age– seizure in the EDseizure in the ED– focal or prolonged seizurefocal or prolonged seizure– seen a physician within the past 48 hoursseen a physician within the past 48 hours

Other indicationsOther indications– concern about follow-upconcern about follow-up– prior treatment with antibioticsprior treatment with antibiotics

The American Academy of PediatricsThe American Academy of Pediatrics““strongly consider” in infants under 12 strongly consider” in infants under 12 months of age with a first febrile seizuremonths of age with a first febrile seizure

Management: Nursing Interventions Management: Nursing Interventions Place child in isolation until 24 hours of antibiotic Place child in isolation until 24 hours of antibiotic therapy has completedtherapy has completed

Administer antibiotics (7-14 days)Administer antibiotics (7-14 days)

Fever controlFever control

Monitor for signs of ICPMonitor for signs of ICP

Monitor for fluid overloadMonitor for fluid overload

Viral meningitis is treated symptomaticallyViral meningitis is treated symptomatically

Prevention and ControlPrevention and ControlMeningitis Caused by Hemophilus influenzae Meningitis Caused by Hemophilus influenzae – A vaccine is now routinely given to infants as A vaccine is now routinely given to infants as

part of the usual childhood immunizations.part of the usual childhood immunizations.

SeizureSeizureFebrile seizureFebrile seizure

Epilepsy - two or more seizures not Epilepsy - two or more seizures not provoked by a specific event such as fever, provoked by a specific event such as fever, trauma, infection, or chemical changetrauma, infection, or chemical change

Neonatal seizuresNeonatal seizures

Status epilepticusStatus epilepticus

Febrile seizureFebrile seizureDefinition: Definition: Convulsions occurring in association Convulsions occurring in association with fever in children between 3 months and 6 with fever in children between 3 months and 6 years of age, in whom there is no evidence of years of age, in whom there is no evidence of intracranial pathology or metabolic derangement.intracranial pathology or metabolic derangement.

- - No signs or history of underlying seizure disorderNo signs or history of underlying seizure disorder- - Often familialOften familial- - Uncomplicated and benign if seizure is of short Uncomplicated and benign if seizure is of short

duration (<15 minutes), only 1 in 24 hours, and duration (<15 minutes), only 1 in 24 hours, and normal CNS exam after seizurenormal CNS exam after seizure

- Involves tonic-clonic movements, bilaterallyInvolves tonic-clonic movements, bilaterally- Associated with temperature >38°CAssociated with temperature >38°C

EpidemiologyEpidemiologyAge 3mo – 5yrsAge 3mo – 5yrsPeak age 9-20 monthsPeak age 9-20 months2-5% children will have before age 52-5% children will have before age 525-40% will have family history25-40% will have family history80 – 97% simple80 – 97% simple3 - 20% complex3 - 20% complex

ManagementManagementControl feverControl fever– take off clothing and tepid sponging.take off clothing and tepid sponging.– antipyretic e.g. syrup or rectal Paracetamol 15 antipyretic e.g. syrup or rectal Paracetamol 15

mg/kg 6 hourly.mg/kg 6 hourly.– antipyretic is indicated for parent’s comfort, antipyretic is indicated for parent’s comfort,

but has not been shown to reduce the but has not been shown to reduce the recurrence rate of febrile convulsion.recurrence rate of febrile convulsion.

EpilepsyEpilepsyDefinition: Definition: a neurological condition a neurological condition characterised by recurrent unprovoked characterised by recurrent unprovoked epileptic seizuresepileptic seizuresILAE Classification of seizure types:ILAE Classification of seizure types:– generalized generalized

LOCLOCtonic, clonic, tonic-clonic, myoclonic, atonic, absencetonic, clonic, tonic-clonic, myoclonic, atonic, absence

– partial – focal onsetpartial – focal onsetsimple partial – no LOCsimple partial – no LOCcomplex partial – LOCcomplex partial – LOCpartial secondarily generalizedpartial secondarily generalized

– unclassifiedunclassified

Epilepsy: EtiologyEpilepsy: Etiology

infectiousinfectious

metabolicmetabolic

traumatictraumatic

toxictoxic

neoplasticneoplastic

Epilepsy: Differential diagnosisEpilepsy: Differential diagnosis

Neonatal seizureNeonatal seizurebrief and subtlebrief and subtle– eye blinkingeye blinking– mouth/tongue movementsmouth/tongue movements– ““bicycling” motion to limbsbicycling” motion to limbs

typically seizure’s can’t be provoked/ consoledtypically seizure’s can’t be provoked/ consoled

autonomic changesautonomic changes

EEG less predictableEEG less predictable

Neonatal seizureNeonatal seizureEtiologyEtiology– hypoxic-ischemic encephalopathyhypoxic-ischemic encephalopathy

Presents within first dayPresents within first day

– congenital CNS anomaliescongenital CNS anomalies– intracranial hemorrhageintracranial hemorrhage– electrolyte abnormalities – hypoglycemia and electrolyte abnormalities – hypoglycemia and

hypocalcemiahypocalcemia– infectionsinfections– drug withdrawaldrug withdrawal– pyrodoxine deficiencypyrodoxine deficiency

Status EpilepticusStatus EpilepticusDefinitionDefinition– Seizure lasting >30 minsSeizure lasting >30 mins– sequential seizures without regain LOC >30minsequential seizures without regain LOC >30min

Mortality in pediatric status epilepticus 4%Mortality in pediatric status epilepticus 4%

Morbidity may be as high as 30%Morbidity may be as high as 30%

TreatmentTreatmentCorrect underlying pathology, if anyCorrect underlying pathology, if anyAntipyretics ineffective in febrile seizureAntipyretics ineffective in febrile seizureAnti-epileptic choice often trial and errorAnti-epileptic choice often trial and error

no anti-epileptic 100% effective no anti-epileptic 100% effective febrile seizure – diazepam, phenobarbital, valproic acidfebrile seizure – diazepam, phenobarbital, valproic acid

– Currently AAP does not recommendCurrently AAP does not recommend

neonatal - phenobarbitalneonatal - phenobarbitalgeneralized TC – phenytoin, phenobarbital, carbamazepine, generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid, primidonevalproic acid, primidoneabsence – ethosuximide, valproic acidabsence – ethosuximide, valproic acidnew anti-epileptics – felbamate, gabapentin, lamotrigine, new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate, tiagabine, vigabatrinetopiramate, tiagabine, vigabatrine

in consultation with neurologistin consultation with neurologist

NeuroimagingNeuroimagingNeuroimaging (preferably MRI) is indicated for Neuroimaging (preferably MRI) is indicated for any child withany child with– epilepsy occurring in the first year of life, epilepsy occurring in the first year of life,

except febrile seizuresexcept febrile seizures– partial epilepsy except benign rolandic partial epilepsy except benign rolandic

epilepsyepilepsy– developmental delay or regressiondevelopmental delay or regression

EEGEEGEEG is important to support the:EEG is important to support the:– clinical diagnosis of epileptic seizures, clinical diagnosis of epileptic seizures, – Classify the epileptic syndrome, Classify the epileptic syndrome, – selection of anti-epileptic drug and prognosisselection of anti-epileptic drug and prognosis– helps in localization of seizure foci in helps in localization of seizure foci in

intractable epilepsyintractable epilepsy

Consider in:Consider in:– persistent altered mental status (?non persistent altered mental status (?non

convulsive status epilepticus)convulsive status epilepticus)– paralyzed patientsparalyzed patients– pharmacologic comapharmacologic coma

DispositionDisposition

can be discharged home ifcan be discharged home if– single seizuresingle seizure– stable, returning to baseline neuro stable, returning to baseline neuro

statusstatus– no underlying condition/cause requiring no underlying condition/cause requiring

treatment in hospitaltreatment in hospital– arranged follow-uparranged follow-up

HeadachesHeadachesOccurs in 20% of school-age children. Onset may Occurs in 20% of school-age children. Onset may occur at any ageoccur at any age

The most common causes of headache in The most common causes of headache in children:children:

-- benign vascular headaches (leading to benign vascular headaches (leading to migraine)migraine)

-- muscle contraction (leading to tension muscle contraction (leading to tension headaches) headaches)

HeadachesHeadaches: classification: classificationClassify based on temporal patternClassify based on temporal pattern– acute headachesacute headaches

any febrile illness, sinus/dental infection, any febrile illness, sinus/dental infection, intracranial infection/bleed intracranial infection/bleed (AVM,SAH,trauma)(AVM,SAH,trauma)

– acute recurrentacute recurrent– chronic progressivechronic progressive– chronic non-progressivechronic non-progressive

tension, psychogenic, post-traumatic, ocular tension, psychogenic, post-traumatic, ocular refractive errorrefractive error

HeadachesHeadaches: Etiologies: EtiologiesVascular / Organic CausesVascular / Organic Causes- - Arteriovenous malformation Arteriovenous malformation - - Berry aneurysm Berry aneurysm - - Cererbral infarction Cererbral infarction - Intracranial hemorrhageIntracranial hemorrhage

Other causesOther causes – InfectionInfection– TraumaTrauma– Toxic EffectsToxic Effects– PsychogenicPsychogenic– Organic -Traction Organic -Traction – Food allergy or sensitivityFood allergy or sensitivity– Refractive errorRefractive error– Ocular muscle imbalance Ocular muscle imbalance – Temporomandibular joint (TMJ) dysfunction Temporomandibular joint (TMJ) dysfunction – HypertensionHypertension

Acute Recurrent HeadacheAcute Recurrent Headache

migrainemigraine

otherother– cluster headache – typically >10 yocluster headache – typically >10 yo– sinusitissinusitis– vascular malformationvascular malformation

Organic –TractionOrganic –TractionResult of an abnormality in the brain or skullResult of an abnormality in the brain or skull

- - Headaches increase rapidly in frequency and Headaches increase rapidly in frequency and severityseverity

- - Headache is worst upon awakening in the Headache is worst upon awakening in the morning, diminishes during the daymorning, diminishes during the day

- - Headache wakens child from sleepHeadache wakens child from sleep- - Aggravated by coughing or valsalva maneuverAggravated by coughing or valsalva maneuver- - May be relieved by vomitingMay be relieved by vomiting- - Associated symptoms: focal neurological findings; Associated symptoms: focal neurological findings;

altered gait; changes in behavior, personality, altered gait; changes in behavior, personality, cognition or learning abilitycognition or learning ability

MigraineMigraine-- Headache -pulsatile (throbbing)Headache -pulsatile (throbbing)-- Headaches are periodic, separated by symptom-Headaches are periodic, separated by symptom-

free intervals free intervals -- Associated with at least three of the following Associated with at least three of the following

symptoms: abdominal pain and nausea or symptoms: abdominal pain and nausea or vomiting, aura (motor, sensory, visual), family vomiting, aura (motor, sensory, visual), family history of migrainehistory of migraine

-- Unilateral or bilateralUnilateral or bilateral-- Headache relieved by sleepHeadache relieved by sleep

Tension HeadacheTension Headache-- Band-like tightness or pressure in the Band-like tightness or pressure in the

bifrontal, occipital or posterior cervical bifrontal, occipital or posterior cervical regions regions

- Seen at any age- Seen at any age-- Lasting for days or weeks but not Lasting for days or weeks but not

disrupting regular activitiesdisrupting regular activities-- Not associated with a prodromeNot associated with a prodrome-- Associated symptoms: tight neck muscles, Associated symptoms: tight neck muscles,

sore scalp, nausea, vomiting and aura are sore scalp, nausea, vomiting and aura are uncommonuncommon

Refractive ErrorRefractive Error-- Persistent frontal headache, which is worse while Persistent frontal headache, which is worse while

reading or doing schoolworkreading or doing schoolwork

TMJ DysfunctionTMJ Dysfunction-- Temporal headacheTemporal headache

-- Associated symptoms: local jaw discomfort, Associated symptoms: local jaw discomfort, malocclusion (crossbite), decreased range of malocclusion (crossbite), decreased range of motion of mouth, click with jaw movement, motion of mouth, click with jaw movement, bruxism (grinding of teeth)bruxism (grinding of teeth)

Chronic SinusitisChronic Sinusitis-- Frontal headacheFrontal headache

-- Tenderness to percussion over the frontal, Tenderness to percussion over the frontal, maxillary or nasal sinuses maxillary or nasal sinuses

- Associated symptoms: prolonged rhinorrhea and Associated symptoms: prolonged rhinorrhea and congestion, chronic cough and postnasal drip, congestion, chronic cough and postnasal drip, anorexia, low-grade fever, malaiseanorexia, low-grade fever, malaise

- It is unusual for children <10 years old to have It is unusual for children <10 years old to have recurrent headaches secondary to chronic recurrent headaches secondary to chronic sinusitissinusitis

Chronic Progressive HeadacheChronic Progressive Headacheleast common presentationleast common presentationclassically based on historical and physicalclassically based on historical and physical– sudden severe headachesudden severe headache– rapid increase over days - weeksrapid increase over days - weeks– suggestive of increased ICPsuggestive of increased ICP

severe nocturnal headache (wakes or upon severe nocturnal headache (wakes or upon waking), changes in pain with position, waking), changes in pain with position, coughingcoughing

– pseudotumor cerebripseudotumor cerebri– space occupying lesionspace occupying lesion

– following head traumafollowing head traumaImagingImaging– CTCT– MRI preferred in non-urgent indicationMRI preferred in non-urgent indication

Stroke/VascularStroke/Vascular

Arteriovenous malformationArteriovenous malformation

Cerebrovascular accident, or strokeCerebrovascular accident, or stroke

Arteriovenous malformationsArteriovenous malformationsCerebral arteriovenous malformations occur in about 1 in 100, 000 of the population They are the most common cerebrovascular lesions in children. AVMs are congenital lesions which occur as a result of a malfunction in the normal separation of arteries and veins during embryonic development. AVMs in the CNS are more common above the tentorium, particularly around the middle cerebral artery.

Arteriovenous malformationsArteriovenous malformationsThe majority of AVMs are asymptomatic. Often these malformations are only discovered incidentally, usually during treatment for an unrelated disorder.AVMs that are symptomatic usually present in AVMs that are symptomatic usually present in young adulthood; the average age of young adulthood; the average age of presentation in children is about 10 years of age.presentation in children is about 10 years of age.

Arteriovenous malformationsArteriovenous malformationsGeneralized symptoms include seizures and Generalized symptoms include seizures and headaches, additionally, children with an AVMs headaches, additionally, children with an AVMs may present with a range of specific focal may present with a range of specific focal neurological signs depending on the location of neurological signs depending on the location of the lesion, such as the lesion, such as – muscle weakness or hemiplegia, muscle weakness or hemiplegia, – loss of coordination,loss of coordination,– visual disturbances, visual disturbances, – abnormal sensations or abnormal sensations or – alterations in cognitive functioning. alterations in cognitive functioning.

Approximately 50 to 80 per cent of AVMs present Approximately 50 to 80 per cent of AVMs present with signs and symptoms of raised intracranial with signs and symptoms of raised intracranial pressure as a result of intracranial haemorrhagepressure as a result of intracranial haemorrhage

Arteriovenous malformationsArteriovenous malformationsTreatment options:Treatment options:– MicrosurgeryMicrosurgery– Endovascular embolizationEndovascular embolization– RadiotherapyRadiotherapy

Cerebrovascular Accident (stroke)Cerebrovascular Accident (stroke)Defined as a clinical syndrome characterized by focal Defined as a clinical syndrome characterized by focal neurological deficits caused by a sudden disruption of the neurological deficits caused by a sudden disruption of the blood supply to the brain, lasting more than 24 hoursblood supply to the brain, lasting more than 24 hoursStroke is much less common in children than in adults. Stroke is much less common in children than in adults. The estimated incidence of stroke in children is The estimated incidence of stroke in children is approximately 3 in every 100,000 childrenapproximately 3 in every 100,000 childrenStroke in children is more likely to occur in the presence of Stroke in children is more likely to occur in the presence of underlying diseases, such as metabolic disorders, underlying diseases, such as metabolic disorders, haematological disorders (particularly sickle cell anaemia), haematological disorders (particularly sickle cell anaemia), congenital cardiac disease and moyamoya diseasecongenital cardiac disease and moyamoya disease

Cerebrovascular Accident (stroke)Cerebrovascular Accident (stroke)General care of a child who has had a stroke includes maintaining normal temperature, ensuring adequate oxygenation and consideration of aspirin in ischaemic stroke In the case of moyamoya disease improvements to cerebral blood flow, as a result of intracranial internal carotid occlusion, can be made by performing vasoreconstructive surgery (bypass surgery).The outcome following stroke in children is variable but survival is thought to be better than in adults The survival rate following stroke in children has been estimated to be about 85 per cent

Childhood MalignanciesChildhood MalignanciesCancer is the most common cause of disease Cancer is the most common cause of disease related deaths in children 1-19 yearsrelated deaths in children 1-19 years

Incidence has increased slowly, but mortality Incidence has increased slowly, but mortality rates have declined significantlyrates have declined significantly

Brain TumoursBrain TumoursPrimarily infratentorial involving cerebellum, Primarily infratentorial involving cerebellum, midbrain, brainstemmidbrain, brainstemGlial( cerebellar astrocytomas most common)Glial( cerebellar astrocytomas most common)PresentationPresentation-- Poor feeding, Vomiting , FTT( failure to thrive)Poor feeding, Vomiting , FTT( failure to thrive)-- Arrest or regression of developmental Arrest or regression of developmental

milestonesmilestones-- Morning headache, increased head Morning headache, increased head

circumferencecircumference( hydrocephalus)( hydrocephalus)

-- Diplopia, nystagmus, papilloedemaDiplopia, nystagmus, papilloedema-- Focal neuro deficits (+Cranial nerves), Focal neuro deficits (+Cranial nerves),

seizures, ataxiaseizures, ataxia

Brain Tumours: Diagnosis and MxBrain Tumours: Diagnosis and MxComprehensive history and complete PEComprehensive history and complete PE

Careful CNS examCareful CNS exam

Rule out other causes - Rule out other causes - infection/trauma/metabolicinfection/trauma/metabolic

CT head and/or MRICT head and/or MRI

Referral to neurosurgeryReferral to neurosurgery

Head InjuriesHead InjuriesHISTORY-HISTORY-Ascertain the following:Ascertain the following:-- Mechanism of injuryMechanism of injury-- Time of injuryTime of injury-- Loss of consciousness (a brief seizure at the time of Loss of consciousness (a brief seizure at the time of

injury) may not be clinically significantinjury) may not be clinically significant-- Loss of memory , amnesiaLoss of memory , amnesia- IrritabilityIrritability- Visual disturbanceVisual disturbance-- DisorientationDisorientation-- Abnormal gaitAbnormal gait-- Lethargy, pallor or agitation may indicate severe injuryLethargy, pallor or agitation may indicate severe injury-- Vomiting Vomiting -- Symptoms of increased intracranial pressure (vomiting, Symptoms of increased intracranial pressure (vomiting,

headache, irritability)headache, irritability)

Head InjuriesHead InjuriesPhysical ExaminationPhysical Examination

-- Vital SignsVital Signs

-- Tachypnea: Tachypnea:

-- Bradycardia (with hypertension - Cushing Bradycardia (with hypertension - Cushing response):response):

-- HypertensionHypertension

-- HypotensionHypotension

Head InjuriesHead InjuriesSigns of Skull FractureSigns of Skull Fracture

-- HemotympanumHemotympanum

-- Periorbital or post-auricular ecchymosisPeriorbital or post-auricular ecchymosis

-- Cerebrospinal fluid otorrhea or rhinorrhea Cerebrospinal fluid otorrhea or rhinorrhea

-- Depressed fracture or penetrating injuryDepressed fracture or penetrating injury

-- Palpate scalp for hematomas and contusions, Palpate scalp for hematomas and contusions, underlying depressions, which may signify underlying depressions, which may signify depressed skull fracturedepressed skull fracture

Head InjuriesHead InjuriesNeurologic ExaminationNeurologic Examination

-- Pediatric Glasgow coma scalePediatric Glasgow coma scale

-- Papilloedema Papilloedema

-- Pupillary light reflexesPupillary light reflexes

-- Cranial nerve examinationCranial nerve examination

-- Movement of extremities Movement of extremities

-- Abnormal posture (decorticate or decerebrate)Abnormal posture (decorticate or decerebrate)

-- Muscle flaccidity, spasticityMuscle flaccidity, spasticity

-- Plantar responsesPlantar responses

Head InjuriesHead Injuries

Mild Mild GCS >12GCS >12

Moderate Moderate GCS 9-12GCS 9-12

SevereSevere GCS <9GCS <9

Management Mild InjuryManagement Mild InjuryChildren with mild intracranial injury may be Children with mild intracranial injury may be discharged homedischarged home

An instruction sheet should be given to the An instruction sheet should be given to the parents or caregiver concerning observation and parents or caregiver concerning observation and precautions precautions

T a b l e 1 5 - 3 : I n s t r u c t i o n s t o P a r e n t s o r C a r e g i v e r s f o rO b s e r v a t i o n a t H o m e o f C h i l d r e n w i t h H e a d T r a u m a

B r i n g c h i l d b a c k t o c l i n i c i m m e d i a t e l y i f a n y o f t h ef o l l o w i n g s i g n s a n d s y m p t o m s a p p e a r w i t h i n t h e f i r s t7 2 h o u r s a f t e r d i s c h a r g e :

A n y u n u s u a l b e h a v i o r

D i s o r i e n t a t i o n a s t o n a m e a n d p l a c e

I n a b i l i t y t o w a k e c h i l d f r o m s l e e p

I n c r e a s i n g h e a d a c h e

S e i z u r e s

U n s t e a d i n e s s o n f e e t

U n u s u a l d r o w s i n e s s a n d s l e e p i n e s s

V o m i t i n g m o r e t h a n t w o o r t h r e e t i m e s

Moderate To Severe InjuryModerate To Severe Injury-- ABC’s ABC’s first priorityfirst priority-- C-spine controlC-spine control-- Suture scalp lacerations, as major blood loss can Suture scalp lacerations, as major blood loss can

occuroccur-- Start IV therapy with normal saline to keep vein Start IV therapy with normal saline to keep vein

open (unless the child is in shock from other open (unless the child is in shock from other injuries)injuries)

-- Restrict fluids to 60% of normal intake (except in Restrict fluids to 60% of normal intake (except in cases of shock)cases of shock)

-- Oxygen Oxygen -- Elevate head of bed by 30° to 45°Elevate head of bed by 30° to 45°-- Place head and neck in midline positionPlace head and neck in midline position

Moderate To Severe InjuryModerate To Severe Injury -- Minimize stimuli (e.g., suctioning and movement)Minimize stimuli (e.g., suctioning and movement)-- To control increased intracranial pressure: above To control increased intracranial pressure: above

measures measures plus establish controlled hyperventilationplus establish controlled hyperventilation

-- CT scan of headCT scan of head- C-spine x-rayC-spine x-ray- Diuretics if intracranial pressure is increased (and Diuretics if intracranial pressure is increased (and

there is documented deterioration) despite there is documented deterioration) despite measures outlined above:mannitol, 0.5-1 g/kg IV measures outlined above:mannitol, 0.5-1 g/kg IV

-- Monitor ABCs, vital signs, pulse oximetry, level of Monitor ABCs, vital signs, pulse oximetry, level of consciousness (with serial pediatric Glasgow consciousness (with serial pediatric Glasgow coma scores), intake and outputcoma scores), intake and output

Pediatric Glasgow Coma ScalePediatric Glasgow Coma Scale

Pediatric ComaPediatric ComaMost common pattern in children is diffuse Most common pattern in children is diffuse impairment of cerebral hemispheresimpairment of cerebral hemispheresLess commonly results from brainstem dysfunctionLess commonly results from brainstem dysfunctionDifferential Dx of causes:Differential Dx of causes:– TTraumarauma– IInsulin/hypoglycemia/inborn errors of nsulin/hypoglycemia/inborn errors of

metabolism/intususceptionmetabolism/intususception– PPsychiatricsychiatric– SSeizures, stroke, shock, shunt malfunctioneizures, stroke, shock, shunt malfunction– AAlcohol abuselcohol abuse– EElectrolytes, encephalopathy, endocrinopathy lectrolytes, encephalopathy, endocrinopathy – IInfectionnfection– OOverdose/ingestionverdose/ingestion– UUremiaremia

Pediatric Coma-Initial Pediatric Coma-Initial ApproachApproach

Primary SurveyPrimary Survey-- ABC;s - C-spine precautionsABC;s - C-spine precautions-- Pediatric Glasgow Coma ScalePediatric Glasgow Coma Scale-- Vital signs including rectal temperatureVital signs including rectal temperature-- Check for signs of obvious traumaCheck for signs of obvious trauma-- Check for S&S of raided ICPCheck for S&S of raided ICP-- Hypoglycemia- give glucose 0.5 g/kg( D50W, 1-2 Hypoglycemia- give glucose 0.5 g/kg( D50W, 1-2

ml/kg IV empirically - chemstrip sugar lowml/kg IV empirically - chemstrip sugar low-- Narcan empirically 0.1 mg/kg if pupils Narcan empirically 0.1 mg/kg if pupils

small/pinpointsmall/pinpoint


Secondary surveySecondary survey-- History - known underlying cause, acute fever, History - known underlying cause, acute fever,

trauma, ingestion, PMH, Medications, allergies, trauma, ingestion, PMH, Medications, allergies, last meallast meal

-- General CPX including CNS examGeneral CPX including CNS exam-- Look for evidence of infection, intoxication, Look for evidence of infection, intoxication,

traumatic and metabolic causestraumatic and metabolic causes-- Fontanelle, neck stiffness, neck bruits, Fontanelle, neck stiffness, neck bruits,

fundi( retinal hemorrhages), oculomotor fundi( retinal hemorrhages), oculomotor movementsmovements

-- Breathing patterns Breathing patterns- - Motor responses ( focalizing/lateralizing signs)Motor responses ( focalizing/lateralizing signs)


Investigations - depends on potential etiology and Investigations - depends on potential etiology and clinical conditionclinical condition– Blood work may include:Blood work may include:

-- CBC, cultures, glucose, electrolytes, BUN, creatinine, Calcium, CBC, cultures, glucose, electrolytes, BUN, creatinine, Calcium, magnesium, LFT’s, ammonium, blood clotting screen, ABGmagnesium, LFT’s, ammonium, blood clotting screen, ABG

– Diagnostic ImagingDiagnostic Imaging-- CT of head essential if focal causes suspected e.g trauma not if CT of head essential if focal causes suspected e.g trauma not if

diffuse cause e.g infectiondiffuse cause e.g infection-- CRX, C-spine XR, Flat plate of Abdomen, limb XR CRX, C-spine XR, Flat plate of Abdomen, limb XR

-- Urinalysis, C&S, latex agglutinationUrinalysis, C&S, latex agglutination-- LP- CSF analysisLP- CSF analysis-- ECGECG-- EEGEEG

Further management directed at underlying causeSerial Glasgow coma scale assessmentsMaintain homeostasis with Oxygen, IV fluids, electrolytes, nutrition

Thank YouThank You

neurological conditions and diseases (during development)

Education

months of age seizure

prolonged seizure

single seizure stable

development congenital

birth congenital

schoolage children

febrile seizuredefinition

neurological conditions