Pediatric Neurological Disorders PDF

Neurological disorders Dr. Kim Ballone, DNP, FNP-BC  The Neurologic System Central Nervous System (CNS) has significant influence on the child’s overall health Your challenge as a health care provider is to be able to identify normal from abnormal neurologic fun...

Neurological disorders Dr. Kim Ballone, DNP, FNP-BC  The Neurologic System Central Nervous System (CNS) has significant influence on the child’s overall health Your challenge as a health care provider is to be able to identify normal from abnormal neurologic function and when to refer to specialists. A strong knowledge base of the Anatomy and Physiology of the CNS and Peripheral Nervous System is presented in Burns, chapter 28.  History Onset- Symptoms (OLDCART) Pain/or headache- location of pain, character (dull, sharp, stabbing, continuous, intermittent), time of day (especially for headache, morning, night, after meal), changes in vision (double vision, photophobia), balance problems Sensory deficits- changes in hearing, taste, vision, smell, vertigo, numbness/tingling Injury- time and date it occurred; accidental vs. non-accidental, treatment provided Reflexive responses- vomiting (from headache, sign of tumor) coughing, return of primitive reflexes (always abnormal), tics/clonus Behavior changes- LOC, irritability (newborns with neuro deficits), stupor, lack of attention (adolescent), emotional liability Motor and balance changes- ataxia (child with encephalitis walks like a stroke patient), spasticity (cerebral palsy child), increased or decreased tone of muscle  History continued Medical history- Maternal, paternal, birth history (traumatic, preterm, full term), injuries (trauma, resuscitation), illness in childhood Family Disease history- genetic disorders, consanguinity (intermarriage between relatives), intellectual functioning, migraine history Developmental history-loss of milestones: language, gross/fine motor or social skills Functional health- safety, nutrition, elimination, activity, communication, sleep Social context- family composition, culture, financial, and social support Review of Systems-include growth patterns (height, weight, BMI)  The Neurological Exam Begin at highest level of functioning to the lowest Cerebral function- test the cortical functions Cranial nerves- test each cranial nerve I- XII (Certification test questions!!) Motor function- Gait, posture, coordination, balance, strength, symmetry Gower’s sign, muscle tone, involuntary movements, reflexes Sensory function- examine for pain sensation and stereognosis (depth or 3D perception, putting a penny in hand and ask to identify it) Reflexes- deep tendon reflexes, superficial reflexes (brain is responding correct), primitive reflexes return (always abnormal, warrants investigation, ex) Babinski that came back after walking is abnormal)  Physical exam continued Examining the Cranium Head circumference until age 2 or 36 months Inspect for asymmetry, abnormally large or small Auscultate for cranial bruit over the skull or above the eyes Percuss skill for cracked pot sound Palpate anterior fontanelle for injuries Autonomic Nervous System (cannot be controlled) Alterations in BP, sweating, body temperature Meningeal Signs Positive Kernig and Brudzinski signs  Diagnostic Studies Labs- provide indicators of systemic disease, infection, inflammation; such as drug levels especially for those receiving meds for seizures, CBC, LFT, serum glucose (for infection, inflammation, drug levels affecting neuro function) Diagnostic tests MRI- Gold standard: designated radiologic test to provide information Lumbar Puncture- CSF analysis for meningitis/encephalitis Evoked response tests- Electroencephalogram EEG- evaluate brain activity Brain auditory evoked response (BAER)- visual interpretation and perception when child cannot respond and give the information needed Somatosensory evoked potential studies (SSEP)- nerve conduction from extremities via spinal cord and brain Electromyogram (EMG)- test muscle activity and how brain interprets stimuli  Febrile Seizure The most common type of seizures in children Brief, generalized, clonic or tonic Concurrent illness with rapid fever to 102.2 F or greater (39.0 C) Minimal post-ictal confusion Simple febrile seizures last less than 15 minutes Complex febrile seizure last longer than 15 minutes and can reoccur Epilepsy- multiple seizures at a time causing brain damage, last minutes to hours  Etiology / Incidence Unclear Intracranial illness or underlying CNS problem Familial tendency (sibling/parent had febrile seizure, higher risk) Risk is higher for those with predisposing factors (e.g. NICU stay more than 30 days, developmental delays, daycare attendance due to environment with greater infection risk) Age range associated with febrile seizure 6 months – 60 months Males Low sodium levels- monitor sodium levels 30% experience 2nd seizure  Facts Fever after immunizations especially MMR most often occurs 8 to 14 days after the immunization is given A fever that is the result of a virus or bacterial infection ROSEOLA is the most common cause of febrile seizure Referral to Neurologist for diagnosis and initiation of treatment, CPR after first seizure, AEDs are usually prescribed, especially after a 2nd seizure  Differential Diagnosis Consider the following that can cause seizures: Sepsis Meningitis Metabolic or toxic encephalopathy Hypoglycemia especially in adolescents Anoxia Trauma Tumor Hemorrhage Febrile delirium and febrile shivering can be confused with seizures  Drug Therapy for Children Experiencing Febrile Seizure Initiate drug therapy as soon as possible (affects duration of seizue) Reduce the fever with Ibuprofen or Acetaminophen Primary anticonvulsant option for first time seizure Diazepam – children 2-5 years of age 0.5mg/kg rectally children 6-11 years of age 0.3 mg/kg rectally can repeat in 4-12 hours if required for both age groups Secondary options- Fosphenytoin (Cerebyx)15-20 mg/kg IV single dose Tertiary Options - Diazepam and Lorazepam IV  MENINGITIS Inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges Etiology: Viral (infectious) Viral aseptic meningitis called by enteroviruses 90%, herpes simplex virus type 2 or varicella zoster virus Bacterial Newborn -3 months : Grp B strep, E coli, Listeria moncytogenes Older children: Neisseria meningitides, strep pneumonia, Haemophilus influenza type B, esp in countries that do not offer vaccinations. In 80’s and 90’s, lots of HIB, but development of HIB vaccine and varicella has decreased occurrences Parasitic  Occurrence Viruses more likely in late summer and fall - 10.9 per 100,000 annually Bacterial : 3 per 100,000 annually Increase risk with crowding and prolonged exposure such as daycare, military, college dorms, and those with compromised immune systems Age- most cases occur in children younger than 5 years, but decreased incidence with increased vaccination rates Race – higher incidence in African Americans than Caucasians Sex- viral 3 times more likely in males than females  Clinical manifestations Classic triad Severe headache, nuchal rigidity or stiff neck (newborn, test with hyperextension of neck, if more pain, there is increased pressure), high fever Altered mental status Confusion Extreme irritability Sleepiness Abnormal high-pitched cry Seizures Sensitivity to light pediatric bacterial meningitis  Physical findings Newborns Inconsolable crying Excessive sleepiness and irritability (change in LOC) Poor feeding Bulging fontanel (ICP)- increased ICP causes tight fontanel Stiffness of body and/or neck (tight) Positive Kernig’s sign or Brudzinski’s sign Diagnostic tests: LP- definitive test: shows cloudy, low glucose (very low in bacterial and low/normal In viral), increase WBC (>100-5000 in bacterial, 5-1000 in viral), increased protein (increased in bacterial and mild increase in viral), culture and gram stain should be done CBC, CMP, blood cultures, C-reactive protein, ESR, CT or MRI (LP contraindicated with tumor, abscess) LP reveals CSF that presents with inc WBC, inc in protein and a drop in glucose: Bacterial Meningitis. Culture and stain of CSF is needed for diagnosis Perform CT before LP if: papilledema, focal neuro deficit, LOC change, new onset seizure, stroke/mass history, or immunocompromised  Kernig’s Sign and Brudzinski Sign Kernig’s Sign: Sign of meningeal irritation With patient supine, flex patient’s hip and knee, then extend the leg at the knee Back pain and resistance to straining is a positive Kernig’s sign. When positive bilaterally, it is even more suggestive of meningeal irritation Brudzinski Sign: Sign of meningeal irritation With patient supine, place your hand behind patient’s head and lift the head flexing it towards the chest. Involuntary flexion of patient’s hips and knees is a positive Brudzinski’s sign  Treatment Refer immediately to neurologist Until diagnosis of meningitis is made, if child is in hospital, placed on antibiotics immediately after LP. If it comes back viral, discontinue antibiotics Viral Supportive care (bed rest, fluids, analgesics) Antiviral drugs- acyclovir for herpes simplex and varicella zoster May need to be admitted for ICP monitoring or complications if lethargic/very ill NOT treated with antibiotics Bacterial Early intervention with Antibiotics is critical Birth to 6 weeks- AMPICILLIN and 3rd generation CEPHALOSPORIN (cefotaxime or ceftriaxone) Older than 6 weeks- Vancomycin + Ampicillin + 3rd generation CEPHALOSPORIN (ceftriaxone) Prophylactic treatment of contact with patient with Neisseria meningitides (exposed to child)- sulfadiazine or rifampin Complications- initiating treatment quickly is critical to avoid complications Increased ICP, deafness, hydrocephalus, seizures, cerebral infarction, cranial nerve palsies  Education Importance of prevention via immunizations (MCV 4 at 12 and 16) Handwashing and infection control measures Prophylaxis for certain exposures Support and coordination of comprehensive services may be needed Follow up Immediately for any decline in neurological status and assess pain for treatment Referral to pediatric neurologist  Concussion p. 885 Alteration in mental status after a blow to the head, loss of consciousness may or may not occur Etiology Type of TBI caused from a bump, blow, or jolt to the head Blow to body cause head and brain to move rapidly back and forth resulting from falls, MVA and players that collide with each other, on the ground or obstacles  Occurrence 135,000 sports and recreation related TBIs come to the ED each year (includes concussions in children age 5-18 years) Athletes who have had a concussion are at increased risk for another, so want to ask if this is the first concussion, how many in first month, first year, or five years Children and teens are more likely to get a concussion and take longer to recover than adults (attention deficit/learning problems) More than 2 million concussions happen per year, 85% never diagnosed 50% of football players may experience one concussion per year  Clinical manifestations Hallmark signs: confusion and amnesia that may occur immediately or several minutes after injury occurs Early (minutes to hours) symptoms experienced. DO NOT lose consciousness yet Confusion/Headache Dizziness or vertigo/poor balance Lack of awareness of surroundings Nausea or vomiting Late (days to weeks) symptoms experienced Persistent low-grade headache Light-headedness, poor attention, fatigue Irritability, photosensitivity, anxiety or depression  Physical findings Vacant stare Delayed verbal and motor responses Confusion and inability to maintain focus Disorientation Slurred or incoherent speech Incoordination Memory deficits Emotional (any period of unconsciousness) warrants immediate evaluation of concussion  Diagnostic test and Treatment Diagnostic tests Sideline / immediate evaluation ABCs: if unconscious CT if loss of consciousness Orientation to person, place, time and situation Concentration- digits backward, months of the year Memory-recall 3 words or objects Neurological test Pupils, coordination, sensation CN exam (CN II (pupil exam), CN II, IV, VI (EOM), CN VII (facial movements) GCS and SCAT5 Treatment: Remove from contest, monitor neuro changes ED for loss of consciousness, GCS < 15, seizures, recurrent vomiting, abnormal bleeding: Explain to coaches/parents Must be cleared to return to play – asymptomatic and normal neuro assessment CT of Brain with Concussion See uptake where injury occurred (edema, inflammation, impaired circulation)  Complications Seizures (initially or days later) Second impact syndrome Repeat concussion that occurs before the brain recovers from the first can slow recovery and increase likelihood of long-term problems such as brain damage, brain swelling, and even death. Depression Development of blood clot on brain (rare) Headaches  Follow up Repeat Impact test (immediate post concussion assessment and cognitive testing) Call or go to ED for Unequal pupils Drowsy, non arousable Worsening headache Weakness, numbness Repeated vomiting more than twice Seizure Slurred speech Increased confusion Unable to recognize people or places Loss of consciousness  Return to Play to Sports after Concussion State laws on return to play vary on return to play Minimum 7 day waiting period after concussion is required Athlete must not experience any symptoms in order to return Return to Play is a 3-step decision Step 1 evaluation of Medical Factors by PCP – has healing occurred Step 2 evaluation of Participation Risk by the PCP – protective measures ie. Equipment, helmets, padding Step 3 Decision modifiers (when do they return or not return at all based on risk) A 14 year old male is brought to the office is brought to the office after being tackled during a football scrimmage. The NP understands signs to be hallmark clinical manifestations of a concussion? A. Nausea and vomiting B. Headache C. Irritability D. Confusion and amnesia  The correct answer is: D. Confusion and amnesia Rationale Hallmark signs of concussion are confusion and amnesia that may occur immediately or several minutes after injury occurs. Nausea, vomiting, and headache are early symptoms of concussion. Irritability is a late sign of concussion Which cranial nerves innervate the extraocular muscles of the eyes? A. CNs II,III, VI B. CNs III, IV, VI C. CNs IV, V VII D. CNs V, VI, VII  The correct answer is: B. CNs III, IV, VI Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) innervate the extraocular muscles. They are tested by inspecting the eyelids for drooping and inspecting the pupil size for equality and their direct and consensual accomodation