Approach to a baby presenting with a 'Funny Do'

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

APPROACH TO A FUNNY DO:

APPROACH TO A FUNNY DO By Robert Straker-Bennett

OUTLINE:

OUTLINE Introduction Causes History Examination Investigation Clinical features of non-epileptic causes Treatment Case presentations Summary

Introduction (1):

Introduction (1) Non-specific term Many conditions and causes May be considered as epileptic or non-epileptic Non-epileptic causes may be considered according to age Non-epileptic causes may be considered with, without altered consciousness and related to sleep.

Introduction (2) : some definitions:

Introduction (2) : some definitions Seizure “clinical phenomena resulting from abnormal and excessive excitability of the neurones of the cerebral hemispheres”. Epilepsy is a condition in which seizures recur, usually spontaneously .

Causes : epilepsy:

Causes : epilepsy Generalised seizures: absence,myoclonic,clonic,tonic,tonic-clonic,atonic. Partial seizures: simple (consciousness not impaired), complex (consciousness impaired)

Causes : Non-epileptic: without altered consciousness (1):

Causes : Non-epileptic: without altered consciousness (1) Jitteriness (infancy) Benign myoclonus of early infancy (infancy) Benign paroxysmal torticollis (infancy) Gastro-oesophageal reflux (infancy/childhood) Shuddering attacks (infancy/childhood) Startle disease (infancy/childhood)

Causes: Without altered consciousness (2):

Causes: Without altered consciousness (2) Benign paroxysmal vertigo (childhood) Tics and ritualistic movements (childhood) Paroxysmal choreoathetosis (childhood/adolescence) Anxiety states (adolescence) Drug induced dystonias (any)

Causes: With altered consciousness (1):

Causes: With altered consciousness (1) Febrile seizures Blue breath-holding attacks (childhood) Pallid syncopal attacks (childhood) Vasovagal syncope (childhood/adolescence) Munchausen’s syndrome by proxy , Meadow’s syndrome (infancy/childhood) Daydreaming (childhood) Pseudo-epileptic seizures (childhood/adolescence)

Causes: With altered consciousness (2):

Causes: With altered consciousness (2) Migraine (childhood/adolescence) Narcolepsy (childhood/adolescence) Substance abuse (adolescence) Delirium (any) Metabolic Disorders (any) Cardiac syncope (any)

Causes: Related to sleep:

Causes: Related to sleep Benign sleep myoclonus of infancy (infancy) Head bobbing or banging (infancy and childhood) Night terrors (childhood) Ritualistic movements (childhood) Hypnagogic jerks (childhood/adolescence) Sleep walking (childhood/adolescence)

The History:

The History Preceding events Details regarding event: video recording What happened after the event Witnesses very important Full history: particulary important are trauma, birth details, previous illness, injuries, development, accidental overdose, family history History of fever, symptoms of infection source.

The Examination:

The Examination Temperature Anterior fontanelle, sutures Full examination: particularly vitals, pupils and fundi To look for a source of infection esp. ENT Signs of meningism Focal neurology

Investigations (1):

Investigations (1) BM (Monitor temperature) Urinalysis CXR LP Bloods inc U&E’s, Ca, glucose ECG,echo,24hr tape UV light examination CT,EEG,

Investigations (2) Indications for neuroimaging:

Investigations (2) Indications for neuroimaging Persistent neurological deficit Evidence of neurocutaneous syndrome Evidence of developmental regression Partial seizures Infantile spasms/myoclonic seizures in the first year of life Persisting unclassified seizures Relapse following good control Complicated febrile seizure under 1 year

Investigations (3) The role of the EEG:

Investigations (3) The role of the EEG Not to be used alone for diagnosis History is the most important Can aid diagnosis Can aid classification e.g. differentiating between primary and secondarily generalized seizures Identification of structural brain lesions or neurodegenerative disorders e.g. Rett’s

Clinical features of non-epileptic causes (1):

Clinical features of non-epileptic causes (1) Jitteriness: tremulousness occasionally clonus, not jerky, usually easily stopped by holding Benign myoclonus of early infancy: brief bursts of spasms, usually within first year, resolves by 2-3 years, normal development and EEG (differential West’s syndrome/infantile spasms)

Clinical features of non-epileptic causes (2):

Clinical features of non-epileptic causes (2) Benign paroxysmal torticollis: abnormal head movements with vomiting GORD: writhing head movements with opisthotonic posturing Startle disease: exaggerated startle response, does not diminish with repeated stimulus, usually resolves by 2-3 years Benign paroxysmal vertigo: frightened, pale, off balance (older can describe vertigo) ,?assoc with migraine, FH migraine, usually last 2-3 years

Clinical features of non-epileptic causes (3):

Clinical features of non-epileptic causes (3) Paroxysmal choreoathetosis: rare, uni/bilateral, dystonic, stress, coffee, mins to hours

Clinical features of non-epileptic causes (4):

Clinical features of non-epileptic causes (4) Febrile seizure: 6 months and 5 years with out evidence of men/encephalitis,3-4%,simple,complicated: longer 15 mins, focal, deficit, 30% more than one, 3% develop epilepsy Pallid syncopal attacks/reflex anoxic seizures: after a fright or injury, brady/asytole, loc, clonic jerks Vasovagals: older children, invariably provoked e.g. prolonged standing, cold and clammy, sheet of blackness, seizure, urinary incontinence

Clinical features of non-epileptic causes (5):

Clinical features of non-epileptic causes (5) Munchausen’s syndrome by proxy: episodes never occur in the absence of the abusing parent, difficult to diagnose Meadow’s syndrome: parent, usually the mother fabricates a history of epilepsy, usually medical or nursing background Daydreaming: differential absences, will occur not just when bored but during speak

Clinical features of non-epileptic causes (6):

Clinical features of non-epileptic causes (6) Pseudo seizure: like a seizure, unusual movements like pelvic thrusting, wax and wane, rare post-ictal confusion, normal EEG and prolactin levels Migraine: aura usually lasts minutes, usually followed by a headache Narcolepsy: irresistible urge to sleep Cataplexy: sudden loss of muscle tone, can be a feature of narcolepsy, precipitated by laughter, startle

Clinical features of non-epileptic causes (7):

Clinical features of non-epileptic causes (7) Metabolic disorders: apparent epileptic seizures only occurring during illness or fasting Cardiac: with exercise, atonic seizures in neurologically normal children

Clinical features of non-epileptic causes (8):

Clinical features of non-epileptic causes (8) Benign sleep myoclonus of infancy: never involve face, do not wake, normal EEG, usually cease by 9 months Head bobbing or banging: do not cause injury, ritualistic while settling in bed Night terrors: last few mins, usually no more than one; differential frontal lobe seizure, usually shorter and multiple Hypnagogic jerks: on sleeping or waking plus hallucinations

Treatment of status epilepticus (1):

Treatment of status epilepticus (1) Secure airway (ABC)/recovery/don’t restrain/prevent injury High flow oxygen BM iva U&E, Ca, glucose, save 2mls heparin tube for toxicology

Treatment of status epilepticus (2):

Treatment of status epilepticus (2) Blood gas fits over 30 mins BP Seizure control in 4 stages, with/out iva:0,10,20,40 mins Includes lorazepam 0.1mg/kg, diazepam 2.5,5,10,15mg Involves paraldehyde, fosphenytoin, anaesthesia with thiopentone

Treatment of epilepsy:

Treatment of epilepsy Medical, surgical. Generalised: valproate Partial: carbamazepine West’s syndrome: vigabatrin Aim: complete control, no unacceptable side effects, appropriate formulation

Treatment of Epilepsy (2):

Treatment of Epilepsy (2) Monotherapy control 65% Two drugs extra 5-10% Stopping: 2-3 year seizure free, 20-25%relapse rate, depends on many things e.g. type of seizure Communication & Advice

Treatment of Epilepsy (3):

Treatment of Epilepsy (3) Measurement of levels… Major non-compliance suspected Status epilepticus Learning difficulties Phenytoin

Treatment of Epilepsy (4) Consider surgery:

Treatment of Epilepsy (4) Consider surgery Partial seizures refractory to optimal tolerated doses of AED’s Particulary if an abnormality on scan Best within 2 years

Treatment of a febrile seizure:

Treatment of a febrile seizure A,B,C Control of fever Control of seizure Look for cause Treat cause appropriately Parental advice, diazepam, emergency measures

Treatment of some other causes of funny do:

Treatment of some other causes of funny do Reflux disease: self limiting, outgrow, positions, thickening, medications, (very rarely surgery) Benign paroxysmal vertigo: usually self limiting, mild no treatment, severe, anti-migraine treatment. Tics: mild reassure, moderate;relaxation and behavioural therapy, severe; neuroleptics Choreoathetosis: anticonvulsants and clonazepam

Treatment of other causes:

Treatment of other causes Blue breath holding attacks: reassure, don’t give in, distraction, prevent injury, usually stop by 6 Pallid syncopal attacks: recovery, atropine, pacemakers, 75% stop by 5, some never stop

Treatment of other causes:

Treatment of other causes Narcolepsy: amphetamine based, cataplexy; antidepressants Prolonged QT: propanolol WPW: antiarrhthmics, radioablation, surgery HOCM: medical e.g. beta blockers, surgical; myomectomy, pacemaker, transplant

Treatment of other causes:

Treatment of other causes Night terrors: reassure, self limiting, protect from injury, reduce stress

Case 1:

Case 1 2 year old, increasing loc with rigidity since 9 months Cry, go rigid, arch back and head, arms twisted and legs tremored, teeth clenched, urinary incontinence Pale after and sleepy after

Case 1 cont:

Case 1 cont Always after a bump to head or face ECG/EEG event monitor: 14 sec asystole, typical appearance of an anoxic seizure Atropine

Case 2:

Case 2 8 year old boy with idiopathic epilepsy, 3 grand mal attacks in previous 6 months, on AED Parents ask can he ride his bicycle, pony, do PE and swim

Summary:

Summary Many causes: epileptic, non-epileptic Very accurate and detailed history most important Awareness needed of features of less common causes Reassurance and advice is appropriate for many causes of funny do’s and must not be forgotten

authorStream Live Help