Neuro

Question 1

What age group do febrile convulsions occur in?

Answer 1

6 months to 6 years

3% of children will have one

Question 2

What differentiates a complex febrile seizure from a simple one?

Answer 2

Complex
- prolonged >15 min
- occurs more than once in same febrile illness
- focal features
- prolonged recovery > 1 hr

Question 3

Load dose in status epilepticus
- IV midazolam
- levitiracetam
- phenytoin
- phenobarbitone

Answer 3

• IV midazolam: 0.15mg/kg IV max 5mg push
• levitiracetam: 60mg/kg IV over 5 minutes
• phenytoin: 20mg/kg IV over 20 min on telemtry
• phenobarbitone: 20mg/kg IV over 20 minutes

Question 4

How do you get botulism?

Answer 4

• ingestion of Clostridium botulinum
• infection of wound with Clostridium botulinum

Sources: ingestion of honey but infants, home canned food by any age group
If ingested can cause GI upset, if wound it should look infected. Bulbar nerves affected most

Question 5

how many days does paralysis tend to occur after a the paralysis tick attaches itself to the host?

Answer 5

5 - 7 days

Paralysis can occur up to 48 hrs AFTER tick removal. Warn patient

Question 6

Causes of acute weakness

Answer 6

• Poisoning: organophosphate poisoning, paralysis tick, snake bite
• Bacteria/toxin: botulism, polio, epidural abscess. infectious myositis
• Autoimmune: Guillian Barre syndrome, myasthenia gravis, juvenille dermatomyositis
• Abnormal antatomy/function: stroke transverse myselitis, spinal cord injury, brain tumour, todds paresis, periodic parlysis (K+ abnormalities)
• benign - hemiplegic migraine, functional, bells palsy

an unimmunised infant can catch polio from another infant who has been vaccinated with the live vaccine via faecal oral route

Question 7

What is the three most common cause of acute ataxia in children?

Answer 7

• Post infectious
• toxins
• posterior fossa tumour

Post infectious most often due to varicella and almost all recovery fully

Question 8

Drugs that cause acute ataxia?

Answer 8

• alcohols: ethanol, methanol, ethylene glycol, ispropanol
• benzodiazapines
• anticonvulsants: pheytoin, carbamazepine, sodium valproate
• essential oils: eucalyptus, tea tree oil, pine oil
• cough suppressants - codeine, dextromethorphan
• drugs of abuse: PCP, solvents, petrol, glue

Question 9

Differentials for non-benign headache

Answer 9

• brain tumour and hydrocephalus
• idiopathic intracranial hypertension
• intracranial haemorrhage
• meningitis, encephalitis, abscess
• hypertensive encephalopathy
• giant cell arteritis (age > 50)

Question 10

Headache red flags

Answer 10

• occipital headache
• meningism
• focal neurological signs
• chronic progressive headache
• seizures
• papilloedema
• ataxia
• presence of VP shunt
• age < 3
• abnormal eye movements
• early morning headche or waking from sleep with headache

Question 11

A 12 year old girl has cyclical vomiting with abdominal pain. What family hx would you enquire about?

Answer 11

Migraines

Children are more likely to have abdominal migraines. Up to 90% of migraine sufferers have a family hx of them

Question 12

Three mostly likely causative organisms for bacterial meningitis age < 3 months

Answer 12

• Group G streptococcus (Strep agalactiae)
• E.coli
• Listeria monocytogenes

Question 13

Three mostly likely causative organisms for bacterial meningitis for older children

Answer 13

-Neiserria meningitidis
- Streptococcus pneumoniae

Question 14

Organisms most likely to be found in bacterial meningitis in immunocompromised host or post neurosurgical procedure

Answer 14

• gram negative bacili
• staphylococcus aurea
• fungi

Question 15

85 - 95% of viral meningitis is caused by what virus?

Answer 15

Enteroviruses (includes coxsacki and echovirus

Question 16

Absolute and relative contraindication to lumbar puncture?

Answer 16

Absolute
GCS <8 or deteriorating/fluctuating level of consciousness
Signs of raised intracranial pressure: diplopia, abnormal pupillary responses, decerebrate or decorticate posture, low HR + elevated BP + irregular respirations, papilloedema
Note: a bulging fontanelle in the absence of other signs of raised ICP is not a contraindication to LP

Relative
Septic shock or haemodynamic compromise
Significant respiratory compromise eg apnoeic episodes
New focal neurological signs or seizures
Seizure within previous 30 min and/or ongoing decreased conscious state following a seizure
INR >1.5 or platelets <50 x 109/L for child on anticoagulant medication
Note: abnormal vital signs eg tachycardia or tachypnoea are not contraindications to LP

Only absolute is signs if rasised ICP
Others: procedure unsafe due to seizures, bleeding, haemodynamic or respiratory compromise
Do NOT use a CT to guide if LP is safe

Question 17

Why should blood glucose be checked at same time as CSF collection?

Answer 17

to compare serum to CSF

Question 18

What dose of dexamethsone should be given for meningitis in anyone > 4 weeks old?

Answer 18

0.25mg/kg max 10mg 6 hrly

prior to antibiotics or withint 1 hour of antibiotics is beneficial in studies

Question 19

What increases and decreases for bacterial meningits on CSF
- Neutrophils
- Lymphocytes
- Protein
- Glucose

Answer 19

• Neutrophils: increased, but can be normal
• Lymphocytes: increased but neutrophilia predominates
• Protein: increased - but can be normal
• Glucose: decreased (but can be normal)

Question 20

What increases and decreases for viral meningits on CSF
- Neutrophils
- Lymphocytes
- Protein
- Glucose

Answer 20

• Neutrophils: increased, but lymphocytosis predominates
• Lymphocytes: increased - but can be normal
• Protein: mildly raised - but can be normal
• Glucose: usually normal

Question 21

What increases and decreases for encephalitis on CSF
- Neutrophils
- Lymphocytes
- Protein
- Glucose

Answer 21

• Neutrophils: increased
• Lymphocytes: increased
• Protein: slightly elevated or normal
• Glucose: decreased

Question 22

Empiric antibiotics for suspected bacterial meningitis age < 2 months
What would you add if concerned about HSV?

Answer 22

• benzylpenicillin 90mg/kg
• cefotaxime 50mg/kg IV max 2g
• HSV: aciclovir 20mg/kg IV 8hrly

frequency of benpen and cefotaxime depends on age

Question 23

Empiric antibiotics for suspected bacterial meningitis age > 2 months
What would you add if age > 50 years

Answer 23

• ceftriaxone 100mg/kg max 2g IV 12 hrly
• age > 50 benzylpenicillin 60mg/kg max 2.4 g IV 4hrly

benzylpencillin covers for listeria
Always give 0.25mg/kg max 10mg dexamethasone

Question 24

Who should get chemoprophylaxis to prevent bacterial meningitis if they had contact with a person with meningitis

Answer 24

• all intimate, household or day care contacts exposed within 10 days
• any person who gave mouth to mouth resus or was in contact with respiratory secretions
• with rifampicin for age < 5 or ciprofloxacin if older than 5

pt should be on droplet precautions until they’ve had 24 hours of antibiotics .Ideally in single room

Question 25

Antibiotics for cerebral abscess

Answer 25

- flucloxacillin 50mg/kg max 2gIV - ceftriaxone or cefotaxime 50mg/kg IV max 2 g - metronidazole 15mg/kg IV max 1g IV ## Footnote metronidazole has a loading dose of 1g then 7.5mg/kg max500mg for subsequent dosing

Question 26

Antibiotics for suspected bacterial meningitis and pt has anaphyaxis to penicillin. What if concerned about listeria?

Answer 26

- moxifoxacilin 10mg/kg max 400mg IV - Listeria cover: trimethoprim + sulfamethoxazole (age > 4 weeks) 5 + 25mg/kg IV up to 400/2400mg

Question 27

What are the biochemical end points for hypertonic saline therapy?

Answer 27

Keep osmolality < 360mOsm ## Footnote No Na+ upper limit

Question 28

What prophylactic antibiotic should be given for an open skull fracture or one communicating with a sinus?

Answer 28

Flucloxacillin 50mg/kg max 2g 6 hrly

Question 29

A patient has a subarachnoid bleed what is the blood pressure goal?

Answer 29

systolic < 140 - 160mmHg

Question 30

A patient has a subarachnoid bleed. What is the dose of nimodipine?

Answer 30

PO 60g Or IV 1mg/hr ## Footnote Calcium channel blocker with cerebral selectivity, helps reduced vasospasm. Will also reduce systolic BP though