Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
49 Cards in this Set
- Front
- Back
|
What types of events can present as “stiffness and shaking”? |
seizures, syncope, rigors, breath holding spells, sleep phenomena myoclonus, shuddering attacks, self gratification, motor steropathies movement disorders, |
|
|
In determining whether a fit is a seizure or not, what significant positives and negatives will you elicit on history? |
Fever? (rigor and febrile seizure) URTI, vomiting/diarrhoea (can reduced threshold for epileptic seizure, febrile siezure or rigor) Precipitating event (breath holding, triggered seizure) No LOC (shudder attack, motor sterotypy, self gratification rigors) Can be distracted (motor stereotypy, self gratification) Family history (epileptic seizure, febril seizure, breath holding, shuddering attack) sleep related hand can be placed and stopped shaking |
|
|
what is epilepsy? |
a tendency to have seizures without obvious precipitants - recurring over a period of time. |
|
|
what are some seizure precipitants |
hyponatraemia, calcaemia, high fever, toxins, cortical distrubacne after head trauma, ICH, ischaemia, infection |
|
|
what is a shuddering attack |
brief episode of altered muscel tone manifesting as rapid trmor of teh head/shoulder and trunk. resemble shiver. occur multiple times per day and cluster during feeding or when excited or distressed. never occur during sleep, rare when being held/cuddles. benign with normal development and resolution in primary school years assoc fhx of benign essential tremor |
|
|
what is breath holding |
Occurs in 4-5% of children, peaking at 2-3 years. The child stops breathing at end expiration after crying, typically because of pain or anger. Simple breath holding occurs when child has pause in breathing but then takes a deep breath before losing consciousness. Episodes with loss of consciousness can be cyanotic (usually emotional precipitant cyanosis apnoea and loss of consciousness) or pallid (usually pain precipitant leads to apnoea and pallor) Spell usually lasts < 1 minute with full recovery. Children grow out of over time. Some links to iron deficiency so this is worth checking. Seizures can occur with prolonged breath hold but note the cyanosis occurs BEFORE the seizure. (So always ask whether the cyanosis came before or after the seizure!) |
|
|
what is a rigor |
shaking episodes occuring with a fever low amplitude shaking/shivering of entire body can be stopped with hand |
|
|
motor stereotypy : what is it - |
common in those with neurodevelopmental syndromes e.g. austristic specturm disorder, cognitive deficiency, and sensory deprivation as well in normla children. movements are variable: body rocking, hand flapping, finger wiggling, head nodding - typified fixed repetitive may be consciously suppressed and decreased by distraction unlike tics, they are not preceded by progressive urge or relief following activity. manifeste as self stimulating behavious in response to tensiona dn anxiety and may comfort hte patinet |
|
|
self gratification: what is it |
infantil masturbation is an underdiagnosed cause of recurrent paryoxysmal movements. consistent features include 1. onset after 3months and before 3 years 2. sterotyped episodes of variable duration 3. vocalisations iwth quiet grunting 4. facial flushing with diaphroesis 5 pressure on the perineum with characteristic posturing on the lower extremitites 6. no ALOC 7. cessation with distraction 8. normal examination 9 normal laboratory studies |
|
|
what is your Ddx for a 10 mo old with URTI and d&v for 2days, sudden onset stiffness and eye rolling, following by limb jerking, associated with facial cyanosis, unresponsive for breif period and drowsy after, fhx of seizure, immunisaitons UTD and attends childcare |
1. febrile convulsion 2. epileptic seizure 3. provoked seizure (CNS infection e.g. meningitis, electrolyte disturbance, gastro provoked) |
|
|
what would you look for in the examination of a 10 month old following seizure if Ddx is febrile convulsion vs epileptic seizure vs provoked seizure (infection, electrolytes, etc) |
Toxic appearance...Signs of infection, source of fever (infection, malignancy, kawasakis) vitals: temperature, vitals signs of haemodynamic compromise or dehydration (electrolyte disturance) altered level of consciousness (infection, metabolic, trauma or toxins) focal neurology - neuroimaging? (vascular, abscess, tumour, trauma) |
|
|
10mo with ?febril convulsion: OEalert and responsivewithdrawn and irritablefebrile, PR 140, RR 32 cap refil <2 o2 sate 98%no signs of dehydrationor respiratory compromise lungs - no crackles or wheeezesabdo SNT no organomegalyno lymphadeo[athy, no rash, no cellulit sor joint swelling /tnedernes how does this change yoru ddx? |
Febrile, Infectious precipitant likely Alert - CNS less likely Hydration good - electrolyte/metabolic disturbance less likely ENT sl red throat and pink TMS - infectious precipitant likely here |
|
|
what extra investigations should be done in a child with a fever who has had a seizure - |
most doctors would do BSL and electrolytes at a minimum. BSL is mandatory in every child with seizure and Es for hx of vomiting/diarrhoea (hyponatraemia concern) Ca and Mg: unusual cause of seizure LP: not needed alert adn non toxic CT/MRI - not needed alert and not focal neuro |
|
|
what is the risk of meningitis in a child presenting with a febrile seizure? |
< 0.5% |
|
|
Tom’s parents ask if he should have an EEG and brain scan because he has had a seizure? |
Febrile convulsions are relativel common - 1 in 25 children will have oneFebrile convulsions are due to a rapid rise in temperatureIt does not mean they have a SBIMost of these children (2 out of 3) won't have another seizureAn EEG does not help with the diagnosis or prognosis in a child who has had a Febrile seizure. There is also no evidence that epileptiform discharges have any diagnostic or prognostic implications in a child with Febrile seizures.Neuroimaging is not necessary in a child with simple FS. Non urgent imaging should be considered in children who have had a complex febrile seizure with other abnormalities such as developmental delay or focal neurology. Urgent neuroimaging (CT with contrast or MRI) should be done in children with abnormally large heads, a persistently abnormal neurologic examination, particularly with focal features, or signs and symptoms of increased intracranial pressure. |
|
|
Febrile seizures; what age associated with temps over ?what is there a CNS infection? can they have a hx of previous afebrile seizure can they have systemic metabolic abnormality tha tmay cause convulsions? can they occur during bacterial and viral infections |
<6 years 38 degrees no cns infection no hx of afebrile seizures no acute systemic metabolic abnormality can occur during any microbe infection |
|
|
which of the follwing characteristics are consistent iwth a complex febrile seizure? Focal features of seizure? seziure duration >30minutes >1 seizure within 24 hours post ictal paresis? Fhx seizures? age >6? temp >39.5? |
the following are features of a complex febrile seizure Focal features of seizure seziure duration >30minutes >1 seizure within 24 hours post ictal paresis? |
|
|
What is the overall recurrence risk for febrile seizures? |
30% |
|
|
What are the risk factors for recurrence of febrile seizure? |
age 12-24 months previous febrile seizure younger child:: onset <18 mo (50-65% if they had first seizure <1 year) lower temp closer to 38 shorter duration of fver <1 hour fhx of feb sizures (first degree relative 10-20% of parents and simbiligns have had febrile siezures) |
|
|
What are the risk factors for developing epilepsy after a febrile seizure |
1. complex febrile seizure (focal, prolonged, multiple) 2. fhx of epilepsy 3. abnormal neuro development being a younger age and having a fhx of febrile seizures is NOT a risk factor for epilepsy |
|
|
How do you counsel a parent after a febrile seizure? |
Tom has had a SIMPLE febrile seizureReassurance: Benign nature of febrile seizures and very low risk of any harmEducate re good prognosis - very low risk of epilepsy in the futureEducate parents about what to do if Tom has another seizure (we will discuss this more in a moment)Educate parents about what to do if Tom is febrile again to reduce excessive anxiety about subsequent febrile illnessTom has had a simple febrile seizure and his only risk factor(s) for recurrence is young age & short duration of fever prior to seizure. The history of seizure in Tom's father needs further clarification as it could have been a febrile seizure or any one of the many differential diagnoses (e.g Breath Holding Attack). You would inform family there is a risk of recurrence which could be in the order of 50%. However, the risk of epilepsy is very small given that he does not have any important risk factors. The RCH Brisbane Parent Information Sheet on Febrile Convulsion is a useful resource. |
|
|
What are 3 indications for admission to hospital following a febrile seizure? |
parental anxiety child unwell/concern SBI diagnosis unclear |
|
|
what advice do you give regarding if a child is to have a recurrent seizure? |
stay calm protect child from objects, rolling out of bed dont restrain or place anything in mouth time it lay on side afterwards call ambulance paretns to do first aid course advise on first aid as above consdier medi alert bracelet ensure supervision swimming, climbing, bikeing and baths refer to epilepsy australia Given that the family lives a reasonable distance from the hospital, this may warrant the family having midazolam available at home should Tom have another seizure. This can be administered bucally (See handout on Midazolam administration at home from Epilepsy Action) |
|
|
What advice will you give regarding if a child with a past febrile seizure develops another febrile illness? |
paraeatmol at the first sign of illness wont prevent febrile convulsions reguar antiepileptic meds may prevent further siezures however thier side effects include ataxia, lethargy and irritability and they don't reduce the risk of developing epilepsy and therefore they are not recommended after a first febrile seizure. |
|
|
You recieve a call from QAS that a 15 mo old boy with a 10minute 'fit' is arriving. buccal midazolam has been administered. how do you prepare for hte arrival of this child? |
A - may need assisted veintilation - bag valve mask, intubabion kitB - high flow o2 and mask readyC - bolus of NS and cannulation equipment ready - Intraosseous gun ready inase hard to establish vasular accessD - intubation kit ready, midazolam, phenobarb readyresus trolly readynurses and expereinced doctors nearbyPreparation involves predicting what personnel, equipment, treatments and procedures you may need. For example: Calculate and prepare: Weight: (Age+4) x 2AETT Age/4 +4, 1 size above and belowSuctionGuedel or other airway adjunctsBO2Appropriate Bag-Valve-Mask (BVM)CIV cannula preparation/ Intraosseous preparationFluid bolus N/saline 20 ml/kg- Calculate for estimated weightAdrenaline 10 mcg/kg (0.1 ml/kg of 1:10 000)DC shock 2J/kg, 4J/kg, 4J/kgDCalculate dextrose for hypoglycaemia (5ml/kg 10% dextrose)Turn on overhead warmer (if neonate)Condition specific- Calculate doses of RSI drugs, 1st and 2nd line anticonvulsants (IV/IM Midazolam and IV Phenytoin) Anticipate if help will be needed, and from whoAssemble Resuscitation Team if requiredAllocate team roles |
|
|
What are your mx priorities for a child in status epilepticus? |
Maintain vital functions ABC 02 turn onto side provide airway support bag valve mask ensure environment safe monitoring cardioresp 2. stop seizure meds time the seizure call for help as needed 3. find and treat underlying cuase check BSL, SOdium Calcium PHosphate magnesium anticonvulsant level check electrolytes on I-stat or blood gas machine for immediate resualt as well as send to lab for formal result blood culturs, FBC, CRP if febrile |
|
|
What is the drug mx of status epilepticus |
1st LINE Midazolam IV/IO IM/IN/buccal Diazepam IV/IO/PR 2nd LINE PR paraldehyde IV phenytoin IV phenobarb 3rd LINE IV thiopentone IV midazolam infusion |
|
|
What investigations hould be done in the ED for a child with status epilepticus? |
FBC, BC CRP (if febrile) ELFTS, calcium, magnesium if CNS infection suspected LP if hypoglycaemia or afebrile seizure with other concerning factors consider metabolic screen if intracranial path suspected CT head |
|
|
15mo old has had status epilepticus. febrile, no focal neurology, normal fundi. hx of being listless and feverish and diffficult to console today. (no cough, rhinorrhea, vomiting, diarrhoea, rash, SOB or unwell contacts) never had a seizure before. What are you concerned about? |
CNS infection given history and no other focus for infection found |
|
|
What are the contraindications for performing LP in a child |
suspected raised ICP (papilloedema, bulging fontanelle, reduced LOC, abnormal pupillary responses, focal neuro signs) seizure in last week, focal seizure, prolonged seizure petechiae/purpura coagulopathy or plt <50, INR > 1.4 soft tissue infection at puncture site cardioresp compromise |
|
|
how will you get consent for a LP? |
LP is where we inert a needle into the spine canal to attain about 3 ml of fluid. it is the best way to diagnose meningitis - which can be deadlythe risks of an lp include- headache, leg tingling transient, epidermal spinal cord tumor, haematoma, cerebral herniation, ultra rarely deathIt's important to discuss with Dick's parents the indications for, risks of and alternatives to the proposed procedure. The lumbar puncture is indicated as we are concerned that Dick may have meningitis or an infection of the fluid around his brain. This can be a very serious condition and it is important to know what we are treating. The procedure should be explained in detail. Complications should be discussed:Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)Post-dural puncture headache (fairly common) - up to 5-15%Transient/persistent paresthesiae/numbness (very uncommon)Respiratory arrest from positioning (rare)Spinal haematoma or abscess (very rare)Tonsillar herniation (extremely rare in the absence of contraindications)See the Q Health consent form for Lumbar puncture which outlines these details. |
|
|
LP, what equipment do you need |
LAsyrnge and needlespinal needle and 3 sterile containersPPE gown gloves and maskdrape sterilechlorhex and alchol and swabstablesterile dressingiodinemanometerBasic Dressing PackChlorhexidine in 70% Alcohol surface disinfectant / Povidone-Iodine SolutionsEMLA topical anaesthetic, or local anaesthetic (as indicated)Sterile Gloves & Gown, Face shieldProcedural DrapeSpinal needle with a stylet (typically a 22G x 5cm long in small children, however 25G x 2.5cm may be used in neonates and 22G x 9cm in large children and adults)Spinal Manometer (as indicated)3 x sterile collection containersSterile Dressing to apply post-procedure |
|
|
how do you perform an LP |
L3/4 to L5/S1 in young children under 12 monthsL2/3 and down in older childrenlateral decubitus with arms restraining around legs and neckadequate flexionLA. to skindon sterile gloves after washingchlorhex then drapeinfiltrative anaestheticbetween PSIS is L4. spae above or below is goodpuncutre skin with stylet and needle until you feel pop of dura, remove stylet and place on manometer to measure opening presure (5-8?) then remove to allow CSF to drip 1mL in to each 3 tubesremove needle and wash with iodine then sterile dressing to coverinform patient to lie still for an hour |
|
|
what will you request on the CSF |
M/CS glc, protein Microscopy (red and white cell counts and any obvious bacteria seen) results are usually available within 30 minutes (BUT DO NOT DELAY TREATMENT IN AN UNWELL CHILD) Culture and sensitivities proceed as relevant CSF glucose is best interpreted in comparison with a blood glucose level from around the same time. Other investigations that may be ordered include: PCR for Neisseria meningitides, Streptococcus pneumoniae, Herpes Simplex and EnterovirusNote that these tests need to be specifically requested on CSF (requires presence of cells)Results are NOT immediately available. These tests are only useful to help guide continuing treatment |
|
|
Can you interpret CSF results? |
Bacterial high WCC 1000, PMN 85% high, low glucose Viral: WCC 100 PMN 15% protein 1.0 glucose 2.6 normal normal: wcc 1 rcc 1 protein 1.0 gluc 2.8 normal neonate: wcc 5 rcc 1 protein 0.8 glucose 3.3 |
|
|
Before they go, Dick’s parents have a few questions for you. Dick’s Dad is very concerned that Dick could have sustained long term damage from the convulsive status epilepticus. Dick’s Mum is worried about whether this is likely to happen again. |
neurological sequaelae are usually cuased by the underlying condition rather than the seizures, the outcome of status epilepticus depends on the durationof seziure, underlying cause and the age of the child the risk of having another seizure of any type after status epilepticus is high up to 50%. more likely that this will be another prologned seizure compared to a child with a hx of brief initial seizure. for febrile status epilptics, the risk of antoher prolonged seizure is about 4% For Dick, whilst he has had a prolonged seizure, this has occurred in the setting of a viral infection in an otherwise healthy child with normal development. We would not expect him to have any neurological sequelae, but he could have another seizure and this may be prolonged. |
|
|
What is the Ddx for generalised seizure in the school aged child? |
seizure - febrile, other provoked, epileptic seizure shuddering episode syncope pseudoseizure cardiac arrhythmia night terror migraine |
|
|
what will help you differentiate between seizures and their Ddx? |
1. identifiable event or illness preceding (provoked siezure) 2. post ictal state (seizure) 3. sterotypical movements 4. eeg abnormal inter-ictally 5. preceding dizzines and pallow (syncope) 6. eyes resit opening during event (psychogenic nonepileptic seizure) 7. co-ordinated clonic acitivty with crescendo (psychogenic) 8. fhx of sudden death (cardiac) 9. sudden loss of consciousness during exercise or stress (cardiac) 10. headache, nausea, vomiting associated (migraine) 11. occurs during sleep (night terror) |
|
|
There is an over reliance of EEG it has a sensitivity of ?% and specificity of ?% |
sensitivity 40-50% specificity 96% |
|
|
What hx will you as of a 9 year old girl who has had her first seizure at school last week - generalised tonic clonic seizure |
HPC: what was she doing at the time, ?migraine sx, ?dizziness and faint , ?exercising/active/stressed, ?precipitating factor, memeory of the event, loss of consciousness, similar episdoes before PMHx development and med conditions/meds FHx of seizures, medical conditions, sudden death |
|
|
what featrues of the exam are important when you see a child with suspected epilepsy? |
vitals, ICP signs dysmorphism neurocutaneious stigmata (cafe au lait, neurofibromas = NF1.... ash leaf spots, shagreen patches, fibrous plaques = TS..... Port wine stain = sturge weber) fundi focal neurology organomegaly metabolic cuase? developmental level (delay?) |
|
|
what are the indications for neuroimaging after first unprovoked seizure? |
focal changes on EEG <2 recurrent seizures ongoing desptie meds papilloedeoma recent trauma focal neuro deficit |
|
|
What risk factors predict seizure recurrence in a child who has had their first unprovoked seizure? |
abnormal MRI or EEG focal neurology general tonic clonic doesn't increase risk tx with drug after 1st seizure doesn't reduce long term recurrence nor long term mortality |
|
|
Harriet has already had an EEG prior to today’s outpatient appointment which was organised by the emergency department. Her EEG is normal. You agree with the doctor who saw her three weeks ago that she does not need any neuroimaging as she has a normal examination and now also a normal EEG. Her parents want to know if Harriet has epilepsy. They also want to know if she needs any medication? And is there anything she should avoid?How will you counsel Harriet and her parents? |
the need for meds can be reviewed if she has another seizure epilepsy is dx when there are recurrent seizures without an obvious precipitant she has 30-40% chance she will have recurrent seizures and thus epilepsy she has only had 1 unprovoked siezure so far, but may go on to develop epilepsy she has a relatively low risk of recurrence because of her normal neurolgoy and EEG she can participate in most of her sports but should take precaustions with swimming, riding (never alone_, wearing a helmet on her bike. avoid high risk sports scuba and rock climbing |
|
|
Harrietn has had a second generalised seizure 2 months later unprovoked 10-15minutes. What is her Dx? should she commence AED? |
idiopathic epilepsy her risk of further seizures now is around 70-80% prevention of recurrence/harm vs side effects personal preference/circumstances natural hx of epilepsy is probably not affected by treatment with an AED, but it is reasonable to commence after 2nd epileptic seizure |
|
|
What medication would you chose for a 9 year old with epileptic seizures. (generalised tonic clonic) |
allergies, drug/drug interactions, sedating properties, side effect profile seizure type, seizure syndrome Generalised tonic clonic epilepsy: Valproate, carbamazepine, topiramate, phenytoin Absence seizures: Ethosuxamide, Valproate, Lamotrigine Infantile spasms: ACTH, prednisolone, Vigabatrin Partial/focal seizures: Carbamazepine |
|
|
what is the likelihood of harriet going into remission with appropriate anticonvulsant medicatioin? she is prescribed valproate. |
70% of not having further seizures |
|
|
how long will harriet need to be treated with AED |
2 years seizure free |
|
|
what is the likelihood of recurrence of seizures off medication? |
30-40% staying on AED for longer than 2 years doesn't greatly reduced subsequent chance of recurrence abnormal neurology or EEG at time of ceasing medication increasees risk of recurrence |
