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Peds. Neurolgic Disorders

Peds. Neurolgic Disorders . Salih Alhetela . Content . ABM Seizures Headache Breath-holding spells. ABM. Acute Bacterial Meningitis. ABM. Mortality of treated cases 20%-40% neonate 5%-10% infant/child Morbidity 25%-50% of survivors Incidence Highest in the neonate, then

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Peds. Neurolgic Disorders

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  1. Peds. Neurolgic Disorders Salih Alhetela

  2. Content • ABM • Seizures • Headache • Breath-holding spells

  3. ABM Acute Bacterial Meningitis

  4. ABM • Mortality of treated cases • 20%-40% neonate • 5%-10% infant/child • Morbidity 25%-50% of survivors • Incidence • Highest in the neonate, then • 3-8 months • < 2 years • > 90% of cases occur before 5 years

  5. Q: What the causative organisms of ABM?

  6. Neonate GB strep >50% E.coli & other coliform 25% S. epid., S. aureus S. pneumoniae N. meningitidis GDS HIB INF. +CHILD HIB ? Less after vaccin 90 % caused by S. pneumoniae N. meningitidis Unusual organisms Salmonella Campylobacter Francisella ABMOrganisms

  7. ABMPrinciple of disease Host factors • Premature & neonate • Male • African Americans • Day care attendants • Immunodeficiency • SCA, AIDS , asplenia, renal disease • Liver dis., DM, dysgammaglobulinemia • Immunosupp. Therapy

  8. ABMPrinciple of disease Mechanical disturbances • Surgical procedure • Skull fracture • Cong. CNS abnormality • Intracranial cyst • Epidermoid /dermoid tumors • neurenteric fistula

  9. ABMPrinciple of disease • Subarachnoid space entrance • Haematogenous spread > 90% • direct extension • In the SA space Endotoxin  inflammatory response vascular and parenchymal changes • Vasculitis , microthrombi, venous sinuses occlusion • Reduced blood flow, cerebral edema, hemorrhage

  10. ABMclinical features Presentation • 75% with nonspecific subacute presentation 2-5 days • 25% with acute illnesses <24 hrs • Easier to diagnose • Higher risk for death &complication Age • The younger the infant, the more nonspecific S/S

  11. ABMclinical features Newborn • General : Hypo/hyperthermia- apnea-tachypnea- brady/tachcardia • Behavioral :Restless -irritability – lethargy • Neuro: high Pitched cry- seizure- nystagmus- bulging fontanelle • Derm: Cyanosis- petechiae- purpura- livedo reticularis • GI: Altered feeding- diarrhea- vomiting-jaundice

  12. Q: What is livedo reticularis sign? Generalized pallor accompanied by indistinctly outlined truncal patches of blue discoloration

  13. ABMclinical features Infant/child • General:Fever-chills-myalgia neck back pain- tachy • Behavioral: irritability - lethargy • Neuro:Altered mentation- focal neurologic signs- seizure- hearing deficit- photophobia- nuchal rigidity- kernig & burdzinski • Derm: Cyanosis- petechiae- purpura- • GI:Anorexia- nausea- vomiting

  14. Q: Describe kernig & burdzinski signs .

  15. What the complication of the LP? How can you prevent each? • Lumbar pain : use of anesthetic agent • Post-LP cephalgia: smaller needle, reinserting the stylet and smaller amount of CSF • Infection: proper aseptic technique • Herniation: rarely occurs / check S/S of ICP-CT

  16. s/s of meningitis Suspected neonatal sepsis Suspected ABM Febrile infant 4-8 wks ? Toxic appearance Documented bacteremia Febrile illness after intimate contact Febrile seizures Fever and petechiae sepsis suspected in an abnormal host Penetration of dura Acute hearing loss What is the indication for LP?

  17. What is the normal and abnormal value of CSF glucose and protein ? • Glucose • Normal CSF serum glucose ratio 0.6 • < 0.4 is found in ABM +TB • Protein • Normal range is 40-170 mg/dl in neonate • Normal range is 15-45 mg/dl in children • Modestly elevated in viral M. • Higher level in ABM +traumatic LP

  18. What is the normal range of CSF WBC in deferent age group? What is your threshold of abnormal? • Preterm 0-44 >9 • Newborn 0-32 >22 • Neonate 0-50 >35 • 4-8 wks 0-50 >10 • >8 wks 0-8 > 6 • Classically WBC in ABM ranges from 1000-20000 * wbc/mm3

  19. How about PMN? • <4 wks 60 % of WBC is PMN • >4wks not more than 3pmn/mm3

  20. How accurate is gram stain? • Depend on number of bacterial organism present. • 25% positive with 103 CFU/ml • 60% positive with 103 -105 CFU/ml • 97% positive with 106 CFU/ml

  21. What is the DDX of ABM? • Infectious : Septicemia, subdural empyema, epidural abscess, (viral, fungal and TB meningitis ) • Traumatic Closed head injury, shaken impact syndrome • Metabolic Hypoglycemia, DKA, hypo/hypernatremia, uremia • Others Toxin, seizure, brain tumer, ruptured dermoid cyst

  22. Outline your management priority for ABM ? • Airway protection and oxygenation • Volume resuscitation +/- pressor • Prevention of hypoglycemia • Control of seizures • Maintain CBF/ and ICP control measures • Antibiotic therapy

  23. When will you give the antibiotic for suspected ABM ?considering patient stability and risk • Classically 1-2 hrs of presentation for all suspected ABM • Offered clinical scenario by Rosen • Non toxic, low risk ---blood  LP  wait • Non toxic, high risk --blood  LP  • Critical, stable blood  ABx  LP • Critical, unstable stabilize  blood  ABx +/- LP

  24. What is the initial empiric antibiotic regiment ? • 0-4 wks ampicillin plus genta or cefotaxim • 1-3 months ampicillin plus cefotaxim or ceftriaxon or chloram • >3months cefotaxim or ceftriaxon +/- vanco

  25. Is there any role for steroid in ABM ? • Dexamethason may improve some neurologic sequelae, particularly hearing loss with ABM caused by h. inf • Risk of GI bleed , false sense of improvement and reduced penetration of vanco • AAP limit the use for h. inf. Meningitis

  26. Seizures

  27. What is the difference between seizures and epilepsy ? • A seizure is a paroxysmal event characterized by a change in behavior of the patient • results when a large population of neurons in the brain discharges synchronously • Epilepsy is the occurrence of two or more unprovoked seizures

  28. Seizures and brain damage • Children with seizures at a significant risk for cognitive impairment and behavioral abnormality • It is difficult to distinguish the effect of seizures from the underlying pathology and the effect of anticonvulsants • There is a growing evidence pointing to the lasting effect of repetitive , brief seizures in early childhood

  29. What the difference between partial and generalized seizures? • Partial seizures involve only part of the brain at onset , clinically distinguished from GS by a lack of complete loss of conscious

  30. Partial seizures are further subdivided into simple and complex partial seizures, What the difference between them ? • Simple partial seizures do not impaired consciousness, complex partial seizures do and the patient usually amnestic for the ictal event • Either may spread and become secondary generalized • An aura may occur at the beginning of either type ( noxious smell or taste )

  31. Generalized seizures are further subdivided into convulsive and nonconvulsive seizures, What the difference between them ? • Convulsive seizures include tonic-clonic, tonic and clonic seizures , with post ictal confusion • Nonconvulsive include absence , myoclonic and atonic seizuers • No post ictal drowsiness in absence seizures

  32. What the criteria for febrile seizures? • Febrile seizures are defined as seizures in the presence of fever without CNS infection or other causes • Generalized • last less than 15 min • In child 6 months -5 years • Neurologically and developmentally normal

  33. what the chance of developing epilepsy in febrile seizures ? • 2-3% while in normal population 1% • Higher in • Presence of family history of epilepsy • Abnormal developmental status • Complex febrile seizures

  34. What the common precipitants of status epilepticus ? • Febrile illness ( the most common ) • Medication change • Idiopathic • Metabolic derangement • Congenital abnormality

  35. What the common complications of status epilepticus ? • Hyper/hypotension • Dysrhythmia • CHF • Apnea • Aspiration • Non cardiogenic pulmonary edema • Rhabdomyolysis • Hypo/hyperglycemia

  36. What are the etiology of seizures? • Febrile seizures • CNS infection • Trauma ( contusion, hematoma and impact ) • Toxins ( intoxication or withdrawal) • CNS tumor ( primary or mets) • Metabolic ( hypoglycemia, electrolyte, inborn errors, renal and liver disorders) • Vascular ( hemorrhage, A-V malformation, cerebral vein thrombosis • Other ( hypoxia, post immunization, V-P shunt malf.)

  37. Diagnostic strategies • History is the cornerstone • To differentiate actual and pseudo seizures • Type of seizure • The cause or precipitant • Exam • Mainly looking for the cause • No abnormality referred to the seizures

  38. How about imaging and EEG after a first seizure? • Imaging indicated in • Partial seizures • Abnormal neurological exam • EEG • Rarely needed in the acute setting • 10-40% don’t show epileptiform abnormalities in EEG

  39. Approach in actively convulsing child? • ABC • Stop seizure • Benzo, phenytoin , Phenobarb then • IV drip ( midazolam, propofol or pentobarbital ) • Prevent seizure recurrent • Identify precipitant or cause and treat

  40. Approach if the child presents after the event? • Determine if truly seizure • Determine seizure type • Identify precipitant or cause and treat • Determine if further work up needed • Determine if anticonvulsant therapy is appropriate

  41. Riske factor of recurrence of a seizure ? • Todd’s paralysis • Abnormal EEG • Family history of epilepsy • Remote symptomatic seizure • Seizure while asleep

  42. Headache • History • Headache data base • Neurological symptoms • Past medical/ medication history • EXAM • Vital sign • Growth parameter (wt, head circumference, height) • G. exam including the skin • Full neurological exam appropriate to age

  43. Types of headache in pediatric • Acute headache • Chronic progressive headache • Migraine headache • Chronic non progressive headache tension headache • Cluster headache

  44. Causes of acute headache ? • Infection (CNS infection, viral illnesses, sinusitis) • Hypertension • Vascular ( hemorrhages ) • Trauma • Toxin • Dental disorder • Opthalmologic problem

  45. Causes of chronic progressive headache ? • Increased ICP • Brain tumors • Pseudo tumor cerbri • Hydrocephalus • Brain abscess • Subdural heamatoma

  46. Classification of migraine headache • Migraine with aura • Classic • Complicated ( hemiplegic, opthalmoplegic, basilar artery migraine) • Migraine without aura ( common migraine) • Migraine variants • Abdominal migraine • Benign paroxysmal vertigo • Paroxysmal torticollis

  47. Criteria for pediatric migraine without aura • ≥ 5 attacks each last 1-48 hrs • Headache with 2 of • Bilateral or unilateral • Pulsating quality • Moderate to severe • Aggravated by routine physical activity • Associated symptoms 1 of • Nausea or vomiting • Photophobia or photophobia

  48. Criteria for pediatric migraine with aura • At least 2 episodes with the following criteria • Reversible symptoms arising from focal cerebral or brainstem dysfunction • Gradual development of the headache • Aura with a duration of less than 60 min • Headache either before or within 60 min of aura

  49. Treatment of migraine in peds? • Acetaminophen • NSAIDs • Narcotic (codeine or oxycodon) • Antiemetic • Metoclopromide • Promethazine • Ergotamine • Sumatriptan

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