Approach to child with abnormal movement


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Approach to child with abnormal movement

  1. 1. Approach to child with abnormal movement
  2. 2. Quick review of thetypesof convulsion
  3. 3. PERSONAL H/O age *infantile spasm 3m-8m,rare after 2 years, *absence seizures 5-10 years ,rare before 2 years, *febrile convulsions 6m-6years.  sex )absence seizures more in girls(.  Address to know the distance. HISTORY 
  4. 4. Pseudosiezures: ””          
  5. 5. H/O present illness Ictal , Preictal , Postictal. Analysis of abnormal movement Describe this movement,  How does it begin,  Is it focal or generalized,  How much it last,  Is it the first time or not,  Is it associated with: loss of consciousness ,up rolling of eye ,cyanosis, secretions from mouth, head tilting, twitching of face , arching of spine, tongue bite, passage of urine or stool during the attack.
  6. 6. the pre-attack state of child ,is it perceded by: fever & how much it was if measured by mother )thinkof CNS infection orfebrile convulsion “if within suggested age”(  Physical or emotional stress like excessive crying BHA orangerSA.  Loud noisy sounds or strong flashes of light  Sleepy or just awake from sleep  possible Drugs (TCA, sympathomimitics, amphetamine( or toxin ingestion.  Recent vaccinations  Trauma : describe trauma & assess its severity
  7. 7. thepost-attack stateof thechild 1-Was the attack followed by: -Deep sleep -Coma -Weakness or paralysis of limbs &how much each of those persist 2-how was the attack finished: spontaneously or with medications?
  8. 8. Systemic review In systemic review try to roll out: *-Infection of CNS or any other system *-hi ICP :vomiting, (headache & blurred vision in older children(. *-Dehydration & electrolyte imbalance: Suggested by h/o severe diarrhea or vomitting.
  9. 9. Birth H/O “Must be taken in detail” ANH: chronic illness (DM , HTN, PE ( , any bleeding: suggest Ischemic-hypoxic ecephalopathy. Exposure to radiation or ingestion of teratogenic drugs ( as a cause of congenital cerebral malformations( Natal H/O : prolonged or precipitate labour ,abnormal presentation, cord around the neck; (as cause of birth asphyxia(. Maturity (premature more risk of IVH , post mature risk of MAS(.
  10. 10. Post natal H/O -Birth weight (LBW IVH( , cried immediately or not. -Discharged on the same day or stayed in NN ICU. -Any postnatal admission , h/o jaundice ( assess whether it was significant or not , e.g. when appeared, disappeared, how treated?...(
  11. 11. Immunization h/o : if the attack preceded by vaccination. Developmental h/o: How old is child now & what can he do? Was the child well & then regress in development (think of neurodegenerative disorders( Presence of any neurological abnormality exclude febrile convulsions.
  12. 12. Past H/O: *Ask whether this is the first attack or not, if not: Describe the previous attacks , how treated ,and what was the diagnosis? *Any previous admissions to hospital *Any significant illness: -Cerebral palsy: risky to develop seizures -Renal failure: presented with seizures due to hypocalcaemia, hyponatremia -DM : complicated by hypoglycemia
  13. 13. Family H/O 1-Of similar attacks, what was diagnosis (febrile convulsion usually have positive family H/O( 2-Of epilepsy 3-of consanguinity ( may suggest inherited metabolic disorders(
  14. 14. 1-General examination *Level of consciousness (GCS( *Vital signs & search for any obvious focus of infection. *Bulged AF in infant , papilledema in older children may suggest ICP. *In older children ,check signs of meningeal irritation. *Examine skin for stigmata of neuro-cutaneous disorders( café aulait spots, hypopigmented areas ,hemangioma( 2-Complete neurological examination to make sure of normal CNS. 3-Developmental assessment EXAMIANTION
  15. 15. *CBC *Blood glucose *Septic work-up: (Blood culture,urine culture, LP, CXR, throat swab(. *Serum electrolytes( Na ,Mg ,Ca( *Toxicology screen ( if drug overdose suspected( or metabolic screen *CT,MRI : if ho trauma or suspect rise ICP. *EEG may play a role. INVESTIGATION
  16. 16. Initial treatment: A-Maintain airway patent , Put child in semi -prone position with head down to help drainage of secretions. B-Adequate breathing : O2 mask C-Circulation : iv drip , normal saline & dextrose D-Drugs : diazepam ,phenytoin ,phenobarbitone Treatment of the cause accordingly. Treatment
  17. 17.  ‫طاهر‬ ‫فخري‬ ‫فاطمة‬11 months old, female Libyan patient, lives in Benghazi (‫(الليثي‬ , blood group is A+ve , and the history is taken from her mother.  She’s admitted on Friday 23th of may 2008 , at 5 pm,  Complaining of high fever and abnormal movement for 2 days before the admission.
  18. 18.  Fever was high grade, measuring up to 40°C , starting from 2 weeks back as a symptom of gastroenteritis. She had supportive and symptomatic treatment, but fever didn’t relieve completely. Not associated with sweating , skin rash, chills or rigors. No h/o any ill person of the family. Panadol and cold sponging was used to decrease the temperature. With no increasing factors.
  19. 19. Regarding the abnormal movement:  The 1st attack was on Friday before dawn at 2:30 am. Which persist for 15 minutes. The mouth was cyanosed, and jerky movement of upper and lower limbs with loss of consciousness. Post ictally, Fatima was sleepy and fatigue.
  20. 20.  No thing abnormal by examination.
  21. 21. Investigation done:  CBC: Hb 9.9 gm/dl RBC 3800*10³ WBC 12.8*10³ MCV 86 fl MCH 26 fl
  22. 22.  Blood glucose 77  Blood urea 17  S. creatinine 0.5  Na 135  Ca 1.14
  23. 23.  Lumber puncture: ( normal result ) CSF glucose 67 mg CSF protein 19 mg No RBCs or WBCs.
  24. 24.  X-ray hand is done.  And Fatima was putted on convulsion chart.
  25. 25.  Next 2 days : No other attacks had been happened. Mother is advised to notice any rising in temperature of her daughter. And discharged!!!!!.
  26. 26.  ‫مسعود‬ ‫أشرف‬ ‫أحمد‬4 years old Libyan patient, lives in Benghazi. History is taken from his mother.  Admitted to the hospital on Thursday, 12nd of June 2008 because of an abnormal limb movements 2 days before the admission.
  27. 27.  No thing abnormal on examination,  Also no thing abnormal by investigation .
  28. 28.  So what’s the plan