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Pediatric Epilepsy
Management of Common Pediatric Neurologic Issues
| Question | Answer |
|---|---|
| What is the best diagnostic tool for evaluating a seizure? | A thorough history |
| What are some questions you should ask as part of the history | Get the details. Prenatal, Intral Natal and post-partum hx. Developmental milestones. Previous head trauma, major infections, high temps, seizures. |
| What typtes of behavioral questions should you ask? | Problems in school, special ed classes, decrease in grades. Decrease in social skills. |
| Questions about the event? | When was it noticed, what happened before, after. Was the pt tired, sick, stressed? How long did it last? Did they hit the ground? Did something hit them? any emesis? |
| Who should be interviewed | the patient, the patient's entire family |
| Ask about treatment | Has anyone seen the pt before? did they go to the ER. |
| Ask about diagnostic tests that were done | EEG, MRI, CT, other labs |
| Ask about medications | What meds are they on? Are these new meds? did the event start before or after they started on the medicine |
| Ask about family history | Siblings, parents, are any other family members seizing. |
| Ask about social history | Dieting, diet pills, drug use. |
| What is the most important part of the child's neuro exam | The child's level of consciousness. Are they awake. what's there baseline. Is this an alteration in their baseline. |
| What does asking the child to spell WORLD backwards accomplish | Reflects functioning of large areas of the cortex (language, memory, executive functioning) |
| How do you assess a childs motor ability | Pronator drift (downward drift) - sign of upper motor neuron weakness. patient is asked to hold both arms fully extended at shoulder level in front of him, with the palms upwards. Strength of all 4 (push me, pull me). Tone of muscles (nml flaccid spastic) |
| How do you perform a sensory exam? | Light touch, pain and temp, position and vibration |
| When should the babinski reflex disappear | After a year |
| What is the babinksi reflex? | great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked |
| When should the Moro and rooting reflexes disappear | After 6 months |
| What is the Moro reflex? | "startled" look, and the arms fling out sideways with the palms up and the thumbs flexed |
| What is the rooting reflex? | obtained by gently stroking the cheek towards the lips. The baby should open the mouth towards the stimulus and turn the head to latch on to the object |
| How do you test the cerebellar? | RAM, Finger to nose, heel to shin, Romberg: (test each side individually) |
| What is the significance of assessing gait. | Assess midline cerebellar function and weekness. walk, run, turn tight curves, heel/toe/tandem |
| Practice parameter for closed head injury | Seen by provider within 24h, previously neurologically healthy child, age 2-20, LOC <1 min, vomit, an impact sz, HA or lethargy after event |
| What is the clinical presentation for practice paramenter of Minor closed head injury | Present with normal mental status at initial exam, no abnormal focal neuro findings at initial exam, no evidence of skull fracture |
| Battle Sign | bruise behind the ear. sign of skull fracture |
| Racoon sign | brusing under the eye, periorbital ecchymosis |
| Minor close hear injury exclusion criteria | Victim of multiple trauma (MVA), unobserved LOC, cervical spin injury, Hx of bleeding disorder, AVM (arteriovenous malformation) VP shunt, suspected child abuse, language barrier, not seen by provdier within 24h |
| Minor closed head injury with no LOC | Perform thorough Hx, PE and neuro exame. Observation in the clinic, ER or home under care of a competent adult for at least 24 h. Be on alert for several days after injury |
| Is imaging recommended for minor closed head injry with no LOC | no imaging recommended |
| The number of kids who'll need medical or neurosurgical intervention | 1 in 5000 kids |
| Minor closed head injury with brief <1 min LOC | Perform thorough hx, PE and neuro exam, Observe in clinic ER or home for 24h |
| Is imaging recommended for minor closed head injury with brief <1min LOC | Yes, plain CT scan may be utilized. Skull x-r or MRI not recommended |
| Why use CT in this population | LOC assocaited with increased risk of intracranial injury. Intracranial injyry 0-7% for kis with amnesia and vomit at time of event. Most lesion are insigificant, but 2-5% need neurosurgery. Exam alone may not r/o complications. |
| True false. Ct is able to detect more intracranial bleeds than MRI | True |
| Minor closed head injury with and without LOC | really evaluate cranial nerves, watch those pupils, look for pailledema, be sure to exam cerebellar fxn. Palpate the skull. Drainage (SCF). Look for Battle sign, racoon sign. Glasgow coma scale. Check on the pt next day. Check glucose of draining fluid |
| When do you know the patient is in big trouble | Unequal pupils, fixed no response from pupils, Change in vitals, yawning (herniating), decerebrate posturing, change of LOC |
| What is decerebrate posturing | Decerebrate posture is an abnormal body posture indicated by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. A severe injury to the brain at the level of the brainstem is the usual cause |
| Neurodiagnostic eval of first simple febrile sz criteria | Nuerological healthy children, age 6 months - 5 years, has first simple febrile sz, present for care within 12 h of event |
| Neurodiagnosti eval of fist simple febrile sz exclusion criteria | Pts with complex febriles szs, children with previous neurologic insults, known CNS abnormalities, Hx of afebrile szs. |
| What is a seizure | the body and brain's response to sudden bursts of abnromal electrical activity in the brain. A seizure may affect a person' muscle control, movement, sensation, behavior, speech, vision, or awareness (consciousness) |
| How can a seizure affect a person | Muscle control, movement, sensation, behavior, speech, vision, awareness. Alterations may be as brief as a blank stare and last a few seconds or may last several minutes and b as severe as a generalized tonic clonic convulsion |
| What does the clinical presentation of the seizure reflect | the region of the brain in which the abnormal dischard ORIGINATES and possibly SPREADS to an from |
| What is epilepsy? | Chronic disorder chracterized by RECURRENT, unprovoked seizures. At elast 2 unprooked seizures. their brains are healthy but they keep seizing over and over. |
| What is a febrile seizure? | a seizure accompanied by a fever withou CNS infection. No meningitits. occurs in 2-5% of all kids |
| Simple Febrile Seizure | Generalized seizures lasting less than 15 minutes and not recurring ni 24h |
| complex Febrile Seizure | Focal, prolonged seizure lasting more than 15 mintues and occuring in a flurry. right hand shaking, left leg shaking, they have a seizure, 5 minutes later they have another one, 5 minutes later they have another one. |
| What are some complications of simple febrile seizures? | No evidence of increased mortality, hemiplegia or mental retardation. Only slightly higher risk of developing epilepsy than general population. Benign event with excellent prognosis |
| Who is at risk for developing epilepsy? | Kids with SFS who had abnl neuro dvelopment initially (anoxia at birth), SFS prior to 6 months of age (brains are still developing), kids who had complex febrile sz |
| should pt with 1st SFS have a LP | <12 mos LP strongly recommended (hard to evaluate S/S of meningitis, 12-18 mos: LP should be considered, S/S meng. subtle. >18: Yes if meningeal signgs present |
| What are the signs of meningitis | Fever and chills, Stiff neck (meningismus) Severe headache Nausea and vomiting Sensitivity to light (photophobia) Mental status changes |
| True or False a pt who receives antibiotics should consider LP | True, antibiotics may mask signs and symptoms |
| Should pt with first simple febrile seizure have an EEG | not recommended. have not proven predictive |
| Should pt with first complex febriles sz have an EEG | not recommended |
| What diagnostic labs are recommended for a pt with first complxe febrile seizure | Blood sugar. CBC if pt is < 2yrs old. otherwise no CMP or CBC |
| What should you do with a pt with first complex febrile seizure | Identify sources of the fever and fix that. no neuroimaging (no skull films, no MRI, no CT) |
| Best long term treatment of compelx febrile sz | Prevention and education |
| Long term treatment for complete febrile szs. | AEDs but they have side effects |
| First unprovoked seizure - management | Get an EEG (but very difficult to capture seizure on EEG). It can still show abnormalities. Get Labs (not official part of algorithym) |
| What meds would recommend | Great question - many alternatives. Weigh risk vs. benefits |
| What is epilepsy? | Chronic disorder characterized by recurrent, unprovoked seizures |
Created by:
lknightly
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