Pediatric Neurology and Infectious Moci Concepts - Vocabulary Flashcards

Pediatric Neuro: Key Concepts and Assessment

• Pediatric neuro topics covered: seizures (various types and management), meningitis and encephalitis, traumatic brain injury (TBI) and concussion, and cerebral palsy (CP). Also emphasized clinical assessment, safety, family education, and integration with pharmacology and nonpharmacologic therapies.

• Clinician stance: encourage in-person visits for appointments; emphasize clarifying objectives and blueprint-based study approaches.

• Pediatric neurology assessments rely on developmental baselines, parental input, and age-appropriate examination techniques (e.g., fontanels, occipital frontal circumference, primitive reflexes).

• Watch for red flags: stagnation in eating/playing, regression, persistent developmental delays, and abnormal reflexes beyond expected ages (e.g., primitive reflexes not disappearing by 12–14 months).

Seizures: Definition, Pathophysiology, and Epidemiology

• Definition: a sudden abnormal discharge of neurons in the cerebral cortex that alters self-function or behavior.

• Typical duration: most seizures are ≤ 2 ext{ minutes} (about 90% fall in this range).

• Trigger factors: external factors (stress, lack of sleep), fever, photosensitivity (especially in diagnosed seizure disorders).

• Seizure onset: can occur at any age; onset may be gradual or abrupt and may involve auras (sensory warnings).

• Aura: a warning signal (e.g., tunnel vision, flashing lights, certain smells) allowing patients to take precautions.

• Common seizure characteristics: urinary incontinence is common; bowel incontinence is less common; postictal confusion and lethargy follow in most cases.

• Postictal phase: recovery period after a seizure; usually 5–15 minutes, but can be longer (even 30–45 minutes or more).

• Epilepsy vs single seizure: a single unprovoked seizure does not necessarily mean epilepsy; recurrent seizures or status epilepticus changes management.

• Status epilepticus: continuous repetitive seizure activity lasting > 30 ext{ minutes}, or a seizure lasting > 5 ext{ minutes} that does not stop spontaneously; two primary diagnostic criteria described in the lecture.

• Seizure types (pediatric focus):

  • Tonic-clonic (grand mal): both tonic stiffening and clonic jerking; can be focal onset with secondary generalization.

  • Absence (petit mal): brief pauses/staring episodes; often difficult to detect unless ongoing.

  • Atonic/akinetic (drop attacks): sudden loss of muscle tone; risk of head injury; helmet sometimes used.

  • Myoclonic: sudden, brief, muscle jerks; can be unilateral or bilateral.

  • Infantile spasms: brief tonic-like episodes in infancy; can be precursors to more severe epilepsies; often associated with developmental issues.

  • Febrile seizures: most common in young children; typically tonic-clonic; duration usually brief (often < 1 minute, rarely > 2 minutes); mechanism linked to fever; prognosis generally good but requires evaluation for underlying infection or other triggers.

• Diagnostic approaches:

  • EEG: can be 24–72 hours in some cases; sometimes combined with CCTV monitoring for continuous data and precise seizure start location; a seizure marker button is used for event logging.

  • Neuro assessment: assess respiratory effort during seizures; obtain detailed history from family (onset, aura, progression, postictal state).

  • Imaging: CT or MRI as indicated when seizures present with new or recurrent symptoms to localize lesions or structural changes.

  • Catheter-based labs: fever or seizure workups may initiate blood cultures, CSF analysis, and imaging; identify underlying etiologies (genetic, structural, infectious).

• Seizure assessment and documentation: record onset, sequence of events, movements, autonomic features, incontinence, duration, and postictal state; maintain safety prioritizing airway first, then patient protection.

Acute Seizure Management and Safety in Hospital

• Immediate priorities: patient safety (prevent head injury, aspiration risk); protect airway after initial stabilization.

• Seizure precautions in hospital:

  • Turn patient on their side (to prevent aspiration) and protect the head; never restrain the neck or limbs.

  • Four side rails up (in many primaries); in some units, a restraint protocol may require orders; follow institutional policy.

  • Pad bed rails (or use padded rails) to reduce head injury from striking rails; use soft coverings (bath blankets taped in place) if needed.

  • Keep oxygen, suction, and a bag-valve-mask at the bedside; ensure pediatric-sized equipment is available.

  • Call for help (use call light/Vocera) when a seizure occurs; document time and characteristics; notify team.

• Acute medications:

  • First-line emergency benzodiazepine: ext{lorazepam} ext{ (Ativan)} is commonly used; multiple routes available in home and hospital settings (intranasal, buccal, rectal, IV).

  • Nasal midazolam (nasal Versed) and buccal/rectal formulations are used when IV access is difficult during a seizure.

  • After seizure cessation, administer longer-acting anticonvulsants as indicated; if ongoing, consider ketogenic diet or VNS in select cases.

• Other emergency measures:

  • Dextrose 50% if hypoglycemia suspected or confirmed (rapid correction of hypoglycemia can rapidly improve consciousness).

  • Antipyretics for fever management (ibuprofen/acetaminophen).

  • Oxygenation support as needed; use high-concentration oxygen if respiratory status worsens.

• Postictal care:

  • Monitor airway, breathing, circulation; maintain side-lying position; monitor for airway compromise and aspiration risk.

  • Assess and document orientation and neurologic status; gradual return to baseline; treat for headache and fatigue.

  • When the patient is stable, reassess need for continued seizure precautions and medical therapy.

• Nonpharmacologic strategies and long-term management:

  • Ketogenic diet: high-fat, very low carbohydrate; aims to induce ketosis; ketones become primary energy source; initial 24 hours NPO to monitor blood glucose and ensure metabolic stability; ketosis reduces seizures in a subset of patients (about one-third become seizure-free; another third have reduced seizure burden; the rest see little change).

  • Ketosis explained: ketosis means the body burns fat for energy, producing ketones detected in urine; long-term adherence challenges; potential vitamin/mineral considerations; no carbohydrates in early-phase therapy.

  • Vagus Nerve Stimulation (VNS): implanted device delivering pulses to the vagus nerve, reducing seizure frequency; magnets at home to deliver a stronger hit to the device during seizures; requires training and follow-up.

  • Corpus callosotomy/front two-thirds hemispherectomy: surgical options for localization-related pharmacoresistant epilepsy that fails medical therapy; partial/hemispherectomies reduce seizure spread; often used in carefully selected severe cases.

  • Selective dorsal rhizotomy (SDR): treatment for spasticity rather than seizure control; used to reduce spasticity via selective cutting of dorsal nerve roots; improves function but not for seizure control.

  • Baclofen and Botox (botulinum toxin): used to manage spasticity; baclofen can be delivered intrathecally via pump; monitor for overdose (opiate-like symptoms: lethargy, respiratory depression) and withdrawal (itchiness, irritability, tremor).

  • Seizure diary/log: family education to track events, time, triggers, and postictal states; essential for provider assessment and treatment adjustments.

EEG Monitoring and Seizure Assessment Tools

• 24–72 hour continuous EEG (C-EEG) with CCTV: used to capture prolonged data to localize seizure onset zones; seizure markers logged by staff during events.

• Seizure assessment elements:

  • Respiratory effort, onset time, and history; behavior pre-, during, and post-event.

  • Movement patterns (eye movements, lip smacking, tonic/postural changes).

  • Incontinence, facial changes, and postictal cognitive status.

  • Safety measures and quick intervention steps when seizures occur.

• Documentation and neuro checks during and after seizures:

  • Time the event; document postictal neurological status; maintain airway and oxygenation as needed.

  • In case of respiratory compromise, readiness to escalate to rapid response/ER care.

Meningitis and Encephalitis: Clinical Features, Diagnosis, and Management

• Meningitis (inflammation of meninges): can be bacterial or viral; bacterial meningitis is more virulent and life-threatening than viral.

• Higher risk in infants and young children due to immature immune systems and developing brain.

• Key clinical features (common in bacterial meningitis, but can appear in viral):

  • Nuchal rigidity (stiff neck); severe headache; photophobia; high fever; irritability and lethargy in infants.

  • Neuro crisis signs: seizures can occur more frequently with bacterial meningitis than viral.

  • Purpuric rash that does not blanch (especially meningococcal meningitis) – urgent isolation and IV antibiotics.

• Immunization impact:

  • Hib (Haemophilus influenzae type b) vaccination dramatically reduced Hib meningitis; pneumococcal and meningococcal vaccines reduce disease burden and mortality.

• Diagnostic approach:

  • Lumbar puncture to obtain CSF for analysis; CSF characteristics vary by etiology (bacterial CSF typically purulent and WBC-rich; viral often more clear).

  • Blood cultures and CSF cultures; imaging as needed; baseline CBC and electrolytes.

  • Kernig and Brudzinski signs described as exam maneuvers suggesting meningeal irritation.

• Treatment principles:

  • Initial broad-spectrum IV antibiotics after obtaining blood cultures; adjust based on culture results (culture and sensitivity).

  • Antipyretics for fever; analgesics for headache; corticosteroids may reduce inflammation in certain cases.

  • Isolation and droplet precautions to prevent spread; vaccination is a preventive cornerstone (HIB, pneumococcal, meningococcal).

  • Disposition and family education about prognosis, potential sequelae (hearing loss, vision issues, cognitive impairment).

• Viral meningitis:

  • Often caused by enteroviruses, measles, mumps, herpes simplex; typically self-limiting in 7–10 days; antibiotics are stopped if bacterial infection is ruled out.

  • Lower risk of neurological sequelae compared to bacterial meningitis.

• Encephalitis (inflammation of brain tissue):

  • Often more acute and severe than meningitis; causes include mosquitoes, ticks (Lyme), herpes simplex virus, HIV, distemper in animals; can present with fever, photophobia, headaches, and aphasia; seizures and coma can occur.

  • Diagnosis and management: IV antivirals (e.g., acyclovir) started empirically if encephalitis suspected; diagnostic workup similar to meningitis but with emphasis on brain parenchymal involvement and neurocognitive impairment.

  • Prognosis: typically worse than meningitis; higher risk of long-term neurological deficits.

• Prevention: vaccines (where applicable), vector protection (insect repellents, tick checks), isolation, hand hygiene, vaccination for Hib, pneumococcus, and meningococcus; prophylactic antibiotics for close contacts in certain exposed cohorts.

Traumatic Brain Injury (TBI) and Concussions in Children

• Key tools and assessments: Glasgow Coma Scale (GCS) and pediatric-modified GCS; orientation and amnesia testing (COAT/NeuroJeopardy-style concepts).

• Concussion is a mild TBI; return-to-play (RTP) guidelines emphasize phased, graded progression with brain rest first, then gradually increasing activity as symptoms resolve.

• Post-injury monitoring: observe for signs of increased intracranial pressure, such as altered mental status, severe headache, vomiting, or papilledema; intermittent neuro checks are common, with careful attention to changes in gait, balance, memory, and behavior.

• Head injury management in children includes no NSAIDs or sedatives early in the recovery phase to avoid masking symptoms or worsening bleeding risks.

• Return-to-play criteria are staged; failure to complete stages or recurrence of symptoms requires regression and medical clearance.

Cerebral Palsy (CP): Types, Causes, and Management

• CP is a nonprogressive but permanent neurodevelopmental disorder affecting motor function due to brain injury around birth.

• Major CP types:

  • Spastic: most common; increased tone and hyperreflexia; stiff posture and movements.

  • Dyskinetic/Athetoid: abnormal involuntary movements; variable tone.

  • Hypotonic: low muscle tone; poor trunk control and delayed motor milestones.

  • Ataxic: disorganized voluntary movement; wide-based gait and coordination deficits.

  • Mixed: combination of deficits across domains.

• Etiologies by timing:

  • Prenatal (in utero): infections, brain malformations, multiple gestations.

  • Perinatal: birth-related hypoxia/anoxia, prolonged labor, cord entanglement.

  • Postnatal: CNS infections, meningitis, CNS injuries, trauma.

• Clinical features and comorbidities:

  • Seizure disorders common in CP.

  • Feeding difficulties and drooling related to oral motor dysfunction; risk of aspiration if not properly managed.

  • Vision and hearing impairments; cognitive/ developmental delays common (variable severity).

  • Primitive reflexes may persist longer than typical (Babinski sign prolongation).

• Management and interventions:

  • PT/OT: critical for mobility, motor control, balance, and daily functioning.

  • Bracing and assistive devices to improve posture and independence.

  • Skin care and repositioning to prevent pressure injuries given limited mobility.

  • Speech therapy to address feeding, swallowing, and communication; jaw exercises and jaw support training.

  • Botox injections to reduce spasticity; baclofen for spasticity management (oral or intrathecal pump); monitor for overdose and withdrawal symptoms.

  • SDR (selective dorsal rhizotomy) to selectively cut sensory nerve roots to reduce spasticity; improves function in appropriately selected cases.

  • Surgical options for focal spasticity reduction or epilepsy control when needed (e.g., corpus callosotomy or hemispherectomy in severe, localized epilepsy).

  • Family education and ongoing care planning: promote independence, maintain routines, and coordinate with PT/OT/speech therapy; monitor skin integrity and prevent contractures.

• Nursing considerations and family education:

  • Encourage continued therapy and adaptive strategies; support braces and orthotics.

  • Emphasize consistent medication administration; monitor for adverse effects and interactions (e.g., baclofen withdrawal or overdose).

  • Use nonverbal communication strategies (squeeze, blink, or expressive cues) to assess needs and comfort.

  • Maintain predictable routines; address nutrition and hydration specifically to reduce aspiration risk.

  • Support life-long care planning, including school accommodations and social integration.

Practical and Ethical Considerations in Pediatric Neuro Care

• Family-centered care: involve all caregivers (parents, grandparents, siblings) in teaching and decision-making; ensure understanding of seizure precautions, CP needs, and TBI management.

• Safety and quality: prioritize patient safety in every setting (hospital, school, home); ensure appropriate equipment (oxygen, suction, masks) and fall prevention strategies.

• Communication: adapt to developmental level and nonverbal communication; document clear caregiver-friendly care instructions and seizure action plans.

• Equity and access: navigate to ensure vaccines, EEG monitoring, and specialized therapies are available; consider social determinants of health affecting follow-up and therapy access.

• Ethical implications: decisions about invasive therapies (e.g., SDR, brain mapping) require careful consideration of potential benefits vs. risks and quality of life consequences for the child.

Quick Reference: Key Formulas and Numeric Points

• Seizure duration benchmarks:

  • Most seizures: ext{duration} \le 2 \,\text{minutes}

  • Status epilepticus criteria: either lasting > 30 \,\text{minutes} without recovery, or a seizure lasting > 5 \,\text{minutes} that does not stop spontaneously.

• Ketogenic diet overview: no carbohydrates initially; body produces ketones as energy source; ketones detected in urine (ketosis).

• Normal pediatric fontanel checks: fontanels are best assessed up to about 18 months; anterior fontanel size and tension can indicate dehydration or intracranial changes when assessed in a seated position.

• Common medical interventions by category:

  • Acute seizures: benzodiazepines (e.g., lorazepam, midazolam, diazepam), rescue meds via intranasal, buccal, rectal routes; IV access when possible; consider dextrose for hypoglycemia.

  • After seizures: postictal care including airway protection, oxygenation, IV access as needed, and neuro checks.

  • Meningitis/encephalitis: antibiotics for bacterial meningitis; antivirals (e.g., acyclovir) for suspected viral encephalitis; corticosteroids when indicated; isolation and vaccination.

  • CP management: PT/OT, braces, Botox, baclofen, SDR, and potential surgical options; emphasis on maintaining independence and preventing deformities.

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