Paediatric Emergency Neurology
title: Neurological Emergencies in Children tags: #FFICM notebook: ð-FFICM type: anki
source: [[Paediatric Intensive Care]] category: [[paediatrics]]
Traumatic Brain Injury
So most of paeds brain injury stuff is the same as adults [[traumatic-brain-injury]] but:
Diffuse Cerebral Swelling
Children with brain injuries can have brain swelling without oedema. This is caused be cerebral vasodilation. It generally resolves within a couple of days if there aren't any other injuries. It can also occur in addition to more serious traditional injuries.
| Flashcard | type:basic |
|---|---|
| Do kids always have oedematous brains when swollen? | No You can have "Diffuse Cerebral Swelling" without oedema |
| How much bigger is an infants brain than an adults? | 6x! Infant Brain = 12% Body Weight Adult Brain = 2% Body Weight |
Cerebral Blood Flow
Target CPP is adjusted with age. If age ~ 5 target CPP may be 50. wherease for adolescent may be 60.
An infant's brain is 12% of body weight (an adults is 2%). That's why infants metabolic demand for O2 is way higher. That's also why it's easier to cause hypoxic/hypoglycaemic damage in infants.
Hypovolaemia
Infants can get hypovolaemic from a scalp injury! The blood volume of a 5kg infant is only 400mls.
Anatomical
Being short as a toddler means your head is at height of a car bumper.
Neck muscles in infancy are relatively weak.
Bone Development
In young children there's less bony protection from trauma, with open fontanelles.
Undiagnosed Coma
Causes are the same as in adults, but with extra things:
- Main extra thing is inborn errors of metabolism
- Second main extra thing would be herpes simplex encephalitis (So start aciclovir)
- So main extra test is to send off a serum ammonia
- If greater than 300-400 will need filtered
Mneumonic For Causes of Collapsed Infant (Neuro and Non-Neuro, just v sick)
- SCAMS
- Sepsis
- Cardiac
- Abuse
- Metabolic
- Seizures
| Flashcard | type:basic |
|---|---|
| What's the main weird, non-adult non-abuse thing you need to worry about, when you have a neonate or infant with a coma? | Inborn errors of metabolism - Send an ammonia |
| What's the mneumonic for a shocked/collapsed infant? | SCAMS! Sepsis Cardiac Abuse Metabolic Seizures |
| Treating a hypo in a child? | 2.5ml/kg of 10% dextrose |
Hypoglycaemia
Treat with 2.5ml/kg of 10% Glucose
Children Glasgow Coma Scale (Age under 4)
Eyes and motor are much the same.
Verbal:
- Alert, Babbles, Coos, Usual Words (5)
- Less than usual words, spontaneous irritable cry (4)
- Cries only to pain (3)
- Moans to pain (2)
- No response to pain (1)
| Flashcard | type:basic |
|---|---|
| How many verbal points does being alert and using usual amount of words get you on paediatric GCS? | 5 |
| How many verbal points does being less than usual words get you on paediatric GCS? | 4 |
| How many verbal points does having a spontaneous irritable cry get you on paediatric GCS? | 4 |
| How many verbal points does crying only to pain get you on paediatric GCS? | 3 |
| How many verbal points does moaning to pain get you on paediatric GCS? | 2 |
Osmolar Therapy
- Same as in adults
- Hypertonic saline 3ml/kg 3%
- Mannitol 0.25-0.5g/kg
| Flashcard | type:basic |
|---|---|
| How do you give hypertonic saline in kids? | 3ml/kg of 3% Saline |
Status Epilepticus
Nowadays call it status and treat it as status when seizures ongoing for > 5mins
Other division would be:
- Impending SE (more than 5 mins less than 30)
- Refractory SE (more than 60 mins)
- Super Refractory SE (More than 24hours post general anaesthesia)
| Flashcard | type:basic |
|---|---|
| What is super refractory status epilepticus | When going on for 24 hours post general anaesthetic |
| What is it called when your status epilepticus goes on for 24hrs post onset of general anaesthetic? | Super Refractory |
Pathophysiology
Brain damage can occur when a deficit in brain energy develops (from impeded glucose and O2 transport, from loss of cerebral autoregulation and blood flow)
Acquired Brain Injury Post Status
"Mesial Temporal Sclerosis" - Accumulation of amino acids, stimulation of NMDA receptors, results in influx of intracellular calcium, cytotoxic events and cell death.
AEDs
Mostly same as adults:
- Keppra 40mg/kg up to 60mg/kg
- Phenytoin 20mg/kg
- Fosphenytoin (can be given IM, is a pro-drug of phenytoin)
- Phenobarb 20mg/kg
- Valproate (20-40mgkg)
| Flashcard | type:basic |
|---|---|
| What is the starting dose for levetiracetam (keppra) in paediatric status? | 40mg/kg |
Electrographic Status
Electrical activity without witnessed seizures clinically is associated with a worse prognosis (uncertain if cause or effect though).
Bacterial Meningitis
Signs and symptoms, same as adults/same as generic sick kids.
Treatments, same as adults.
Steroids? Only if > 3 months
| Flashcard | type:basic |
|---|---|
| Which kids with bacterial meningitis (age-range) do you not give steroids too? | Younger than 3 months |
Outcomes: Overall mortality of 5-10% in kids. Mortality of 30% in kids who are ventilated. 1/3 ventilated survivors having major neuro consequences.
Organisms For Paeds
- Strep Pneumo
- Neisseria meningitidis
- Haemophilus influenzae
Abx Cover: Cefotaxime/Ceftriaxone
| Flashcard | type:basic |
|---|---|
| What are the three most common organisms to cause meningitis in children older than neonates? | Strep Pneumo Neisseria Haemophilus influenzae |
| What are the three most common organisms to cause meningitis in neonates? | Group B Strep E. Coli Listeria |
| What would be starting antibiotics for neonate with bacterial meningitis? | Ampicillin and Cefotaxime |
Organisms for Neonates
- Group B Strep
- E. Coli
- Listeria
Abx Cover: Ampicillin Plus Cefotaxime
Viral Encephalitis
Caused by:
- Herpes Virus
- Respiratory Viruses - Adenovirus and Flu
MRI better than CT
Aciclovir improves outcome
Patients can also get transverse myelitis or Guillain-Barre
NMDA-Receptor Encephalitis
NMDA = N-Methyl-d-Aspartate
60% present with psychosis/hallucinations
Can present with:
- Movement disorders
- Seizures/Status
- Behavioural Changes
- Psychiatric Changes
- Autonomic Instability
- Apnoeas
Test for serum/CSF NMDAR antibodies
Non specific CSF/MRI changes
Can be a paraneoplastic thing:
- Ovarian
- Testicular
- Mediastinal Teratoma
- Hodgkin Lymphoma
- Neuroblastoma
So look for cancers too.
| Flashcard | type:basic |
|---|---|
| What are the most common cancers to cause NMDA-R encephalitis? | Germ Cell (Ovarian and Testicular) Teratoma Hodgkin Lymphoma |
| How likely are you to get better from an NMDA-R encephalitis? | 50% make full recovery |
| How do you treat NMDA-R encephalitis? | No evidence but can give immunosuppression (methylpred, IVIG, plasmapharesis) |
| How long does it take to get better from NMDA-R encephalitis? | Weeks to months |
| How likely is it that you might relapse from NMDA-R encephalitis? | ~10% |
Treatments
- Immunotherapy (methypred, IVIG, plasmapharesis)
Outcome
Slow recovery (weeks to months)
50/50 of complete recovery The 50 who don't get full recovery, 1/3 of them will have good outcome at two years
Can relapse (1/10)
Spontaneous ICH
In kids usually caused by an AVM
Treat same as adults
Hypoxic Ischamic Encephalopathy
Cerebral ischaemia can cause cerebral damage in ~ 2 mins
Treat with neuroprotective targets as same as adults
Don't cool them but don't let them get hot.
Ancilliary tests: Somatosensory evoked potentials (SEPs).
Guillain Barre
Causes: Same as in adults
Up to 1/3 need ventilatory support
Can have serious autonomic dysfunction. Can also be sore.
Treat with IVIG
ADEM
Acute Disseminated Encephalomyelitis
Is an inflammatory demyelination with multiple seperate neurological deficits, plus encephalopathy. Maybe an autoimmune reaction to myelin
| Flashcard | type:basic |
|---|---|
| What does ADEM stand for? | Acute Disseminated Encephalomyelitis |
| What is the pathophysiology that causes ADEM? | We don't know, maybe an autoimmune reaction to myelin, triggered by a viral illness |
| What is the necessary clinical sign that you have to have, to have ADEM? | Encephalopathy |
| Overall, what does a patient with ADEM look like? | They'll have encephalopathy (can be subtle or profound), plus multiple seperate neuro deficits |
| What test is needed to help confirm ADEM? | MRI |
| How can you treat ADEM? | Pred, IVIG, Plasmapharesis |
| How likely is it that you get better from ADEM? | Very likely, most do. |
Causes
- 70% caused by something identifiable
- Mostly resp viral
Signs and Symptoms
- Encephalopathy (essential for dx)
- Can be subtle, or can be coma with decerebrate signs
- Can have brainsetm respiratory involvement
- ~1/10 need ventilated
- Ataxia
- Hemiparesis
- Cranial Nerve Palsies
- Hypotonia
- Seizures
- Misc neuro deficits
Investigation
LP to exclude other stuff
MRI to show demyelinating lesions
Treatment
- High dose methylpred
- IVIG
- Plasmapharesis
Outcomes
- Most fully recover
- Some have lifelong impairment
- Rarely it's fatal
- ~20% get recurrence/progress to MS
Metabolic Encephalopathy
~1:1000 babies have inborn error of metabolism
Spinal Injury
~5% of all spinal injuries are paediatric
Differences with adults is that you can have spinal cord injury without radiographic abnormality.
Outcomes are probably better than in adults
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