Seizures-neonatal, infants, febrile

CNS Infections

COMA

STROKES in Pediatrics

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,ryan-

pediatrics-2009)

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

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

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

• 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

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

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

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

generalized LOC tonic, clonic, tonic-clonic, myoclonic, atonic,

absence partial – focal onset

simple partial – no LOC complex partial – LOC partial secondarily generalized

unclassified

infectious metabolic traumatic toxic neoplastic epileptic other

syncope breath holding sleep disorders (eg. narcolepsy) paroxysmal movement disorder

tics,tremors migraines psychogenic seizures

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

< 15 mins

no focal features

no greater than 1 episode in 24h

neurologically and developmentally normal

>15 min febrile epilepticus >30min or recurrent

without regaining consciousness > 30min

focal

recurrence within 24h

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

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%

ABC’s brief directed Hx and Px

glucose antibiotics/antivirals

if meningitis/encephalitis considered

1st line anticonvulsants IV

lorazepam 0.1mg/kg diazepam 0.2 mg/kg midazolam 0.2 mg/kg

rectal diazepam 2-5 yrs – 0.5 mg/kg 6-11 yrs – 0.3 mg/kg >12 yrs – 0.2 mg/kg

IM, intranasal, buccal midazolam

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

• consider midazolam– 0.2 mg/kg bolus– then 1-10 mcg/kg/min infusion

• induce barbiturate coma– 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

history pre-seizure

what was child doing when attack occurred precipitants – fever, trauma, poisoning, drug/med use aura

seizure what movements – incl. eyes how long LOC? consequences – resp distress, incontinence, injury

post seizure Post-ictal

physical directed towards systemic disease infection toxic exposure focal neuro signs

blood glucose? electrolytes? magnesium, calcium?

anything at all? what about first time seizures? recurrent?

• 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?

patients at greatest risk for meningitis under 18 months of age seizure in the ED focal or prolonged seizure seen a physician within the past 48 hours

other indications 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

WHO? which patients?

WHAT? CT vs. MRI ultrasound in neonates

WHEN? emergent vs. elective

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

• 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

MENINGITIS

• Fever or hypothermia• Poor Feeding• Irritability or lethargy• Seizures• Rash• Tachypnea or apnea• Jaundice• Bulging fontanelle (late)• Vomiting or diarrhea• Altered Sleep Pattern Norris, Cecilia M.R. et al. Aseptic Meningitis in the Newborn and Young Infant.

AAFP. 15 May 1999; 59.

***INCREASE INTRACRANIAL PRES.3 DE CUSHING

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.

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.

< 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.

• 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.

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.

Exam for signs of infection Kernig’s Sign Brudzinski’s sign Glasgow Coma Scale

• Encephalitis• Brain Inflammation• HSV – 1 Most common cause

• Aseptic Meningitis• 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.

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

LABORATORIES

Pathogen WBC’s

% Neut Glucose Protein + Grampresent

Pyogenic >500 >80 Low >100 ~70

Listeria Monoctyogenes

>100 ~50 Normal >50 ~30

Partial Treated Pyogenic

>100 ~50 Normal >70 ~60

Aseptic, Often Viral

10 – 1, 000

Early: >50Late: <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): 1491-1498..

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.

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.

Inpatient ( often ICU ) Appropriate Antibiotic TherapySupportive 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.

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.

Etiology: more with pneumococcal

Seizure after 72 hours

CSF sugar < 20 mg per dl at admission

Delayed sterilization of CSF : > 24 hours

The End

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.

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

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)

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?