Pediatric Neurology
H&P:
● History
○ Timing
○ Symptoms: preceding, during and after
○ Other body systems
○ Birth History
○ Family history
○ Social History
● PE
○ Growth parameters
○ Developmental assessment
○ Reflexes
○ Hallmark of neurologic diagnosis is localization
○ Play!
Diagnostics:
● EEG
● Evoked Potentials
● EMG
● LP
● US
● CT
○ High sensitivity, low specificity
● MRI/MRA
○ Best, but usually requires sedation
Epilepsy:
● Intermittent derangement of the nervous system due presumably to a sudden,
excessive, disorderly discharge of cerebral neurons.
● Two or more generalized seizures is characterized as epilepsy
● Idiopathic epilepsy: NO source is found
Seizure Hx:
● What was the patient doing at the time of the seizure?
● Any prodromal symptoms such as strange smells, odd feelings of
depersonalization?
● Any ingestion of drugs, alcohol etc.?
● How long did it last?
● Was there urinary incontinence?
, ● Any witnesses who can describe it?
● Last thing patient remembers before seizure or during it?
● First thing recalled after seizure?
Generalized Seizures:
● Non motor
○ Absence (Petit Mal)
■ Loss of awareness < 15 sec
■ Often starts in childhood
● Motor
○ Tonic Clonic (Grand Mal)
■ Stiffening of the body and loss of consciousness
■ Short rhythmic bursts of movement in all 4 limbs
■ Post-ictal state
● “Sleepiness”
○ Myoclonic
○ Atonic
Focal Seizures:
● Arise from one region of cortex
● Types:
○ Focal Onset Aware Seizures
■ AKA Simple Partial Seizure
■ No loss of consciousness
○ Focal Onset Impaired Awareness
■ AKA Complex Partial Seizure
■ Loss of consciousness
● Partial seizures can progress into a generalized seizure
Seizures- Dx and Tx:
● Work-up
○ Labs
○ Imaging
■ EEG
■ MRI/CT
● Diagnosis of epilepsy is made best by history*
● Treatment
○ ABCs and protect the patient
○ Anticonvulsant therapy
■ Phenobarbital
■ Valproic acid
, ■ Carbamazepine
■ Phenytoin
Status Epilepticus:
● Recurrent generalized seizures
● Occurring at a rate that does not permit consciousness to be regained in the
intervals between seizures
● Medical emergency
○ Can lead to:
■ Death, hyperthermia, acidosis, renal failure and circulatory collapse
● Tx:
○ ABCs
○ Start glucose-containing IV (unless patient is on ketogenic diet); evaluate
serum glucose, electrolytes, HCO3–, CBC, BUN, anticonvulsant levels.
■ Consider arterial blood gases, pH.
■ Give 50% glucose if serum glucose is low (1–2 mL/kg).
○ Begin IV drug therapy; goal is to control status epilepticus in 20–60 min.
■ Diazepam, 0.3–0.5 mg/kg over 1–5 min (20 mg max); may repeat in
5–20 min; or lorazepam, 0.05–0.2 mg/kg (less effective with
repeated doses, longer-acting than diazepam); or midazolam: IV,
0.1–0.2 mg/kg; intranasally, 0.2 mg/kg.
■ Phenytoin, 10–20 mg/kg IV (not IM) over 5–20 min; (1000 mg
maximum); monitor with blood pressure and ECG. Fosphenytoin
may be given more rapidly in the same dosage and can be given
IM; order 10–20 mg/kg of “phenytoin equivalent” (PE).
■ Phenobarbital, 5–20 mg/kg (sometimes higher in newborns or
refractory status in intubated patients).
○ Correct metabolic perturbations (eg, low-sodium, acidosis).
○ Administer fluids judiciously.
■ Other drug approaches in refractory status:
■ Repeat phenytoin, phenobarbital (10 mg/kg). Monitor blood levels.
Support respiration, blood pressure as necessary.
■ Other medications: valproate sodium, available as 100 mg/mL for
IV use; give 15–30 mg/kg over 5–20 min.
■ Levetiracetam may be helpful (20–40 mg/kg/dose IV).
■ For patients who fail initial intervention consider: midazolam drip:
1–5 mcg/kg/min (even to 20 kg/min); pentobarbital coma; propofol
and general anesthetic.
○ Consider underlying causes:
■ Structural disorders or trauma: MRI or CT scan.
■ Infection: lumbar puncture, blood culture, antibiotics.
H&P:
● History
○ Timing
○ Symptoms: preceding, during and after
○ Other body systems
○ Birth History
○ Family history
○ Social History
● PE
○ Growth parameters
○ Developmental assessment
○ Reflexes
○ Hallmark of neurologic diagnosis is localization
○ Play!
Diagnostics:
● EEG
● Evoked Potentials
● EMG
● LP
● US
● CT
○ High sensitivity, low specificity
● MRI/MRA
○ Best, but usually requires sedation
Epilepsy:
● Intermittent derangement of the nervous system due presumably to a sudden,
excessive, disorderly discharge of cerebral neurons.
● Two or more generalized seizures is characterized as epilepsy
● Idiopathic epilepsy: NO source is found
Seizure Hx:
● What was the patient doing at the time of the seizure?
● Any prodromal symptoms such as strange smells, odd feelings of
depersonalization?
● Any ingestion of drugs, alcohol etc.?
● How long did it last?
● Was there urinary incontinence?
, ● Any witnesses who can describe it?
● Last thing patient remembers before seizure or during it?
● First thing recalled after seizure?
Generalized Seizures:
● Non motor
○ Absence (Petit Mal)
■ Loss of awareness < 15 sec
■ Often starts in childhood
● Motor
○ Tonic Clonic (Grand Mal)
■ Stiffening of the body and loss of consciousness
■ Short rhythmic bursts of movement in all 4 limbs
■ Post-ictal state
● “Sleepiness”
○ Myoclonic
○ Atonic
Focal Seizures:
● Arise from one region of cortex
● Types:
○ Focal Onset Aware Seizures
■ AKA Simple Partial Seizure
■ No loss of consciousness
○ Focal Onset Impaired Awareness
■ AKA Complex Partial Seizure
■ Loss of consciousness
● Partial seizures can progress into a generalized seizure
Seizures- Dx and Tx:
● Work-up
○ Labs
○ Imaging
■ EEG
■ MRI/CT
● Diagnosis of epilepsy is made best by history*
● Treatment
○ ABCs and protect the patient
○ Anticonvulsant therapy
■ Phenobarbital
■ Valproic acid
, ■ Carbamazepine
■ Phenytoin
Status Epilepticus:
● Recurrent generalized seizures
● Occurring at a rate that does not permit consciousness to be regained in the
intervals between seizures
● Medical emergency
○ Can lead to:
■ Death, hyperthermia, acidosis, renal failure and circulatory collapse
● Tx:
○ ABCs
○ Start glucose-containing IV (unless patient is on ketogenic diet); evaluate
serum glucose, electrolytes, HCO3–, CBC, BUN, anticonvulsant levels.
■ Consider arterial blood gases, pH.
■ Give 50% glucose if serum glucose is low (1–2 mL/kg).
○ Begin IV drug therapy; goal is to control status epilepticus in 20–60 min.
■ Diazepam, 0.3–0.5 mg/kg over 1–5 min (20 mg max); may repeat in
5–20 min; or lorazepam, 0.05–0.2 mg/kg (less effective with
repeated doses, longer-acting than diazepam); or midazolam: IV,
0.1–0.2 mg/kg; intranasally, 0.2 mg/kg.
■ Phenytoin, 10–20 mg/kg IV (not IM) over 5–20 min; (1000 mg
maximum); monitor with blood pressure and ECG. Fosphenytoin
may be given more rapidly in the same dosage and can be given
IM; order 10–20 mg/kg of “phenytoin equivalent” (PE).
■ Phenobarbital, 5–20 mg/kg (sometimes higher in newborns or
refractory status in intubated patients).
○ Correct metabolic perturbations (eg, low-sodium, acidosis).
○ Administer fluids judiciously.
■ Other drug approaches in refractory status:
■ Repeat phenytoin, phenobarbital (10 mg/kg). Monitor blood levels.
Support respiration, blood pressure as necessary.
■ Other medications: valproate sodium, available as 100 mg/mL for
IV use; give 15–30 mg/kg over 5–20 min.
■ Levetiracetam may be helpful (20–40 mg/kg/dose IV).
■ For patients who fail initial intervention consider: midazolam drip:
1–5 mcg/kg/min (even to 20 kg/min); pentobarbital coma; propofol
and general anesthetic.
○ Consider underlying causes:
■ Structural disorders or trauma: MRI or CT scan.
■ Infection: lumbar puncture, blood culture, antibiotics.
