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Pediatric neurologic emergencies

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Pediatric neurologic emergencies

  1. 1.  Seizures-neonatal, infants, febrile  CNS Infections  COMA  STROKES in Pediatrics
  2. 2.  brief and subtle       eye blinking mouth/tongue movements “bicycling” motion to limbs typically sz’s can’t be provoked/consoled autonomic changes EEG alone less predictable-unless together with mri.(murray,boylan,r yan-pediatrics-2009 )
  3. 3.  etiology  hypoxic-ischemic encephalopathy-(30-50%)        Presents within first day (0-24hrs) congenital CNS anomalies intracranial hemorrhage electrolyte abnormalities – hypoglycemia and hypocalcemia infections drug withdrawal pyrodoxine deficiency
  4. 4.        Drug withdrawal CNS trauma – maternal drug toxicity 4 EPILEPTIC SYNDROMES: 1)Benign familial conv.2)fifth day fits 3)Myoclonic encephalopathy 4)epileptic encephalopathy(Ontahara syn) 5) DE VIVO SYNDROME
  5. 5.       HISTORY- PHYSICAL EXAM LAB STUDIES RADIOLOGIC – EEG 1)ULTRASOUND- CHOICE 2)CT-LOTS OF RADIATION BETTER,CONGENITAL, INFARCTION 3)MRI- MORE DEF OF INFARTS AND MORE ACCURATE FOR PROGNOSIS
  6. 6. • Phenobarbital-20mg/kg slowly(can go up to 40mg/kg total in intractable seizures) • Phenitoin-20mg/kg iv slowly over 30-45 mts • Lorazepan-.1mg/kg q 6-8hrs • Piridoxin-50-100 mg iv after previous 3 meds
  7. 7.       Midazolam .1-.4mg/kg/hr Pentotal sodium-2-4mg/kg Valproic acid- 10-25mg/kg in 3 doses Carbamacepine- 10mg/kg/day in 3 doses Clonacepan- .1mg/kg orally (ng) Mysoline- 10-15mg/kg /day
  8. 8.  Neonatal seizure – in first 28 days of life (typically first few days)  Status epilepticus  seizure lasting >30 mins   NB rose 5-10 mins sequential seizures without regain LOC >30min
  9. 9.  Febrile seizure – NIH defn. - event of infancy/childhood, typically between age 3mo and 5yrs, with no evidence intracranial infection or defined cause  Epilepsy - two or more seizures not provoked by a specific event such as fever, trauma, infection, or chemical change
  10. 10.  generalized    partial – focal onset     LOC tonic, clonic, tonic-clonic, myoclonic, atonic, absence simple partial – no LOC complex partial – LOC partial secondarily generalized unclassified
  11. 11.        infectious metabolic traumatic toxic neoplastic epileptic other
  12. 12.     syncope breath holding sleep disorders (eg. narcolepsy) paroxysmal movement disorder    tics,tremors migraines psychogenic seizures
  13. 13.  Epidemiology       age 3mo – 5yrs peak age 9-20 mo 2-5% children will have before age 5 25-40% will have family history 80 – 97% simple 3 - 20% complex
  14. 14.  < 15 mins  no focal features  no greater than 1 episode in 24h  neurologically and developmentally normal
  15. 15.  >15 min  febrile epilepticus >30min or recurrent without regaining consciousness > 30min  focal  recurrence within 24h
  16. 16.  Recurrence    risk recurrence 25-50% risk recurrence after 2nd – 50% most recurrences within 6-12 mo   (20% within same febrile illness) Risk of epilepsy   2-3% (baseline 1%) increased in    family history of epilepsy abnormal developmental status complex febrile seizure
  17. 17.  definition  seizure lasting >30 mins     NB Rosen 5-10 mins sequential seizures without regain LOC >30min mortality in pediatric status epilepticus 4% morbidity may be as high as 30%
  18. 18.     ABC’s brief directed Hx and Px glucose antibiotics/antivirals  if meningitis/encephalitis considered
  19. 19.  1st line anticonvulsants  IV     rectal diazepam     lorazepam 0.1mg/kg diazepam 0.2 mg/kg midazolam 0.2 mg/kg 2-5 yrs – 0.5 mg/kg 6-11 yrs – 0.3 mg/kg >12 yrs – 0.2 mg/kg IM, intranasal, buccal midazolam
  20. 20.  2nd line agents    phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min) fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min) 3rd line agents    phenobarbital 20mg/kg @ 100mg/min repeat prn 5-10mg/kg maximum 40 mg/kg or 1 gram
  21. 21. • consider midazolam – – • induce barbiturate coma – – • 0.2 mg/kg bolus then 1-10 mcg/kg/min infusion pentobarbital 5-15 mg/kg @ 25 mg/min then 1-5 mg/kg/hour others – – – – valproic acid paraldehyde, chloral hydrate propofol, inhalational anesthesia, paralysis lidocaine
  22. 22.  history  pre-seizure     seizure      what was child doing when attack occurred precipitants – fever, trauma, poisoning, drug/med use aura what movements – incl. eyes how long LOC? consequences – resp distress, incontinence, injury post seizure  Post-ictal
  23. 23.  physical directed towards     systemic disease infection toxic exposure focal neuro signs
  24. 24.      blood glucose? electrolytes? magnesium, calcium? anything at all? what about first time seizures? recurrent?
  25. 25. • septic work-up (CBC, BC, urine C+S, CXR, LP) – as indicated • • sick child < 12 - 18 mo • therapeutic drug levels • other – – – – ABG toxicologic screen TORCH, ammonia, amino acids in neonate CPK, lactate, prolactin – ?confirm seizure?
  26. 26.  patients at greatest risk for meningitis      other indications    under 18 months of age seizure in the ED focal or prolonged seizure seen a physician within the past 48 hours concern about follow-up prior treatment with antibiotics The American Academy of Pediatrics  “strongly consider” in infants under 12 months of age with a first febrile seizure
  27. 27.  WHO? which patients?  WHAT? CT vs. MRI   ultrasound in neonates WHEN? emergent vs. elective
  28. 28.  predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures  Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23   retrospective case series predicts CT scan results normal if  no underlying high-risk condition      malignancy, NCT, recent CHI, or recent CSF shunt revision older than 6 months sustained a seizure of 15 minutes or less no new-onset focal neurologic deficit not prospectively validated
  29. 29. • • • correct underlying pathology, if any antipyretics ineffective in febrile seizure anti-epileptic choice often trial and error • • no anti-epileptic 100% effective febrile seizure – diazepam, phenobarbital, valproic acid – • • • • • Currently AAP does not recommend neonatal - phenobarbital generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid, primidone absence – ethosuximide, valproic acid new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate, tiagabine, vigabatrine in consultation with neurologist
  30. 30. MENINGITIS
  31. 31. • Fever or hypothermia Poor Feeding Irritability or lethargy Seizures Rash Tachypnea or apnea Jaundice Bulging fontanelle (late) Vomiting or diarrhea • Altered Sleep Pattern • • • • • • • • ***INCREASE INTRACRANIAL PRES.3 DE CUSHING Norris, Cecilia M.R. et al. Aseptic Meningitis in the Newborn and Young Infant. AAFP. 15 May 1999; 59.
  32. 32. Affects all age groups  Male = Female  Newborns ( 0 - 4 weeks )       Group b strep ( 50 % ) E. coli ( 25 % ) Other gram - negative rods ( 8 % ) Listeria monocytogenes ( 6 % ) S. pneumoniae ( 5 % ) Stoll BJ, Hansen NI, Sanchez PJ, et al. Early onset neonatal sepsis: the burden of group B Streptococcal and E. Coli disease continues. Pediatrics 2011; 127: 817.
  33. 33.  Infants ( > 1 month - < 3 months )  Group b streptococcus ( 39 % )  Gram-negative bacilli ( 32 % )  S. pneumoniae ( 14 % )  N. meningitidis ( 12 % ) Nigrovic LE, Kuppermann N, Malley R, Bacterial Meningitis Study Group of the Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era. Acad Emerg Med 2008; 15: 522.
  34. 34. < 1 month old  Amp + Aminoglycoside  Amp + 3rd Gen Ceph  Amp + aminoglycoside + 3rd Gen Ceph  No Ceftriaxone in above = Kernicterus  1 – 23 months old  Vancomycin + 3rd Gen Ceph  Tunkel, Allan R. Practice guidelines for the management of bacterial meningitis. Clinical Infectious Disease. 1 November 2004.
  35. 35. • • GBS + : Pen G or Amp for 14 - 21 days E. Coli Amp Resistant: 3rd Gen Ceph plus Aminoglycoside • • • Must repeat LP with all Gram Neg Bacilli Min 7 - 14 days combination + total 21 days of 3rd gen ceph or 14 days after CSF Sterility whichever is longer ( A III ) L. Monocytogenes: Amp x 14 – 21 days Tunkel, Allan R. Practice guidelines for the management of bacterial meningitis. Clinical Infectious Disease. 1 November 2004.
  36. 36. Symptoms lasting < 24 hours ( 48 % )  Focal Neurologic Deficit ( 33 % )  Rash ( 26 % )  Petechiae  Palpable purpura  Coma ( 14 % )  Seizure ( 5 % )  Van de Beek D et al. Clinical features and prognostic features in adults with bacterial meningitis. NEJM. 28 October 2004.
  37. 37.     Exam for signs of infection Kernig’s Sign Brudzinski’s sign Glasgow Coma Scale
  38. 38. • Encephalitis • • • Aseptic Meningitis • • • • • • • • Brain Inflammation HSV – 1 Most common cause Viral: Enterovirus, HIV, WNV, Mumps, LCM, HSV - 2 Fungal: Coccidioidomycosis, Cryptococcus Tuberculosis Parasites ( Angiostrongyliasis ) Ehrlichosis, RMSF, Lyme, Syphillis Neoplasm of the leptomeninges Drug - Induced: NSAIDs, Septra, Pyridium, Allopurinol Intracranial Abscess Sadoun, Tania and Amandeep Singh. Adult Bacterial Meningitis in the United States: 2009 Update. Emergency Medicine Practice. September 2009.Volume 11, Number 9.
  39. 39. LABORATORIES Leukocytosis or leukopenia  Possible thrombocytopenia  Normal renal function  + Blood cultures ( 40 – 75 % )  CSF studies   Gram Stain  Glucose  Protein  WBC’s ( Neutrophils, Lymphocytes )  CULTURE – GOLD STANDARD
  40. 40. Pathogen WBC’s % Neut Glucose Protein + Gram present Pyogenic >500 >80 Low >100 ~70 Listeria Monoctyogen es >100 ~50 Normal >50 ~30 Partial Treated Pyogenic >100 ~50 Normal >70 ~60 Aseptic, Often Viral 10 – 1, 000 Early: >50 Late: <20 Normal <200 N/A TB 50-500 <30 Low >100 Rare Fungal 50-500 <30 Low Varies High in Crypto Banmberger, David, Diagnosis, Initial Management, and Prevention of Meningitis Am Fam Physician. 2010 Dec 15;82(12):
  41. 41. Neurological • • • • Impaired mental status ( most irritable / lethargic 15 % comatose at admission ) Cerebral edema and increased intracranial pressure Seizures ( 20 – 30 % )-lorazepan + dilantin Focal Deficits • • • • • • Hearing loss ( 11 % ) CN VI - most commonly affected Cerebrovascular abnormalities Neuropsychological impairment ( 4 % ) Subdural effusion ( 10 – 33 % ) Hydrocephalus Kaplan, Sheldon et al. Neurologic complications of bacterial meningitis in children. UpToDate. 24 Jan 2011.
  42. 42. 2 - 50 years of age - Empiric  Vancomycin + 3rd gen ceph  For Gram Stain +  N. meningitidis / H. influenzae: 3rd gen ceph  S. pneumoniae: Vancomycin + 3rd gen ceph  Tunkel, Allan R. et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 1 November 2004.
  43. 43. Inpatient ( often ICU )  Appropriate Antibiotic Therapy Supportive Care(hemo-dinamic ,respiratory, renal & electrolytes, myocardial support)  Treat coexisting conditions(seizures ,brain edema)  Prevent hypothermia and dehydration  Tunkel, Allan R. et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 1 November 2004.
  44. 44.       CSF positive Gram staining Seizure Presence of purpura Toxic appearance CSF protein > 50 mg / dl Serum Procalcitonin > 0.5 ng / ml Dubos, Francois et al. Clinical decision rules for evaluating meningitis in children. Current Opinion in Neurology 2009, 22:288–293.
  45. 45.  Etiology: more with pneumococcal  Seizure after 72 hours  CSF sugar < 20 mg per dl at admission  Delayed sterilization of CSF : > 24 hours
  46. 46. The End
  47. 47.        Estado patologico caracterizado por 1)inconciencia profunda-perdida de via area , broncoaspiracion. 2)ojos cerrados 3)resistencia a estimulos externos 4)DISFUNCION de ARAS 5)Bien en tronco o hemisferios cer. 6)requiere minimo una hora para distingirlo de contusion,sincope u otras entidades de aparicion transitoria.
  48. 48.      Management of ABC ,S comes first Airway clearing comes first If hx. Of trauma or not CSPINE stabilization Respiratory effort evaluation + 02 supp or providing airway May need assist control respiration plus volume support
  49. 49.       Evaluation of “DERM” D- depth of coma or response to stimuli E- pupils equal ,reactive ,dilated ,constricted R- respiration altered?taquipnea,distress ? M- paralysis? Motor response? How is the response ? Decorticate? Decerabrate? VITAL-SIGNS:SHOCK?ARRYTMIA??FEVER? CUSHING TRIAD(icp high)
  50. 50.     Injuries causing coma?-injuries caused by fall? What do witness referred? Causes: not enough 02? Low sugar? Decreased brain perfusion with decrease 02 and sugar. Structural causes: trauma plus consequences Metabolic, toxins, infection, fever?

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