Central Nervous System Emergencies

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Chapter 32 Central Nervous System Emergencies

Nanette C. Dudley, MD

1 Describe the physical findings in Bell’s palsy

Bell’s palsy refers to peripheral facial nerve weakness on one side of the face, including inability to wrinkle the forehead on the affected side, inability to close the affected eye, and flattening of the affected nasolabial fold. Bell’s palsy may also involve hyperacusis in the affected ear (noises sound excessively loud) because the site of injury is thought to be in the facial canal and may involve other branches of C7—including those to the stapedius muscle, which dampens sound waves.

2 What is the definition of status epilepticus?

Seizures that are continuous for 30 minutes or longer or that are repetitive with the patient not regaining consciousness are defined as status epilepticus.

Tharp BR: Clinical features and complications of status epilepticus in children, 2006. Available at www.uptodate.com.

3 What is Todd’s paralysis?

Todd’s paralysis refers to paresis or paralysis of one or more areas of the body that is transient, usually disappearing within 24 hours following a seizure.

4 A child is having an acute seizure. You know that IV access will not be possible quickly. What are your options?

Rectal diazepam

Intranasal midazolam

Buccal midazolam

Intraosseous access (any medication listed in Table 32-1 can be given through an intraosseous line)

Table 32-1 Drugs Commonly Used to Stop Seizures in the Emergency Department

Wiznitzer M: Buccal midazolam for seizures. Lancet 366:182–183, 2005.

5 List the drugs commonly used to stop seizures acutely in the emergency department (ED)

See Table 32-1.

6 Describe the characteristics of absence (petit mal) seizures

Absence seizures usually develop in school-age children before puberty. The seizures are characteristically of abrupt onset with a brief loss of consciousness. Most are less than 30 seconds in duration. Children may appear to be staring or may have eye blinking or rhythmic nodding. The child does not fall, although he or she may drop things. These seizures are often easily precipitated by having the child hyperventilate.

7 What are infantile spasms?

Infantile spasms are characteristic seizures usually beginning when a baby is 4–7 months old. The seizures are usually of sudden onset and generalized, with bilateral and symmetric contraction of the muscles in the neck, trunk, and extremities. The initial contraction typically lasts < 2 seconds and is then followed by a sustained contraction of 2–10 seconds. Patients with infantile spasms have a poor developmental prognosis, and 65–90% are developmentally delayed at the time of diagnosis.

Glaze DG: Management and prognosis of infantile spasms, 2006. Available at www.uptodate.com.

8 A 16-year-old boy presents after an early-morning generalized tonic clonic seizure. On history, he describes occasional, brief, jerking movements in the morning that make teeth brushing and hair combing difficult. These jerking movements resolve and do not recur later in the day. What does this symptom pattern suggest?

Juvenile myoclonic epilepsy most commonly presents between 12 and 18 years of age with brief, bilateral flexor jerking movements of the arms. The seizures can be precipitated by sleep deprivation, alcohol ingestion, and awakening from sleep. Patients may have generalized tonic clonic seizures but are normal neurologically.

Yu KT: Approach to the child with seizures. In Osborn LM, Dewitt TG, First LR, Zenel JA (eds): Pediatrics. St. Louis, Elsevier Mosby, 2005, pp 752–756.

9 How are seizures distinguished from breath-holding spells?

Involuntary muscular contractions occur in both, although they are more prominent with seizures. In breath-holding spells, these contractions are due to transient cerebral hypoperfusion. With breath-holding spells, a precipitating event causes the child to cry or be angry or frustrated, and thus hold his or her breath or perform the Valsalva maneuver. Seizures usually do not have an obvious precipitating event. Breath-holding spells are usually brief, and may feature a short period of sleepiness afterwards. Seizures may be brief, but suspicion for a seizure disorder occurs when the episode lasts > 1 minute or if the postictal period is prolonged. Finally, breath-holding spells usually occur in children 6 months to 4 years of age; episodes outside these limits are more suspicious for seizures.

10 What are the indications for urgent computed tomography (CT) after a seizure?

Postictal focal neurologic deficits not quickly resolving

Signs of increased intracranial pressure

More than a transient change in level of consciousness

Posttraumatic seizures (not impact seizures)

Magnetic resonance imaging (MRI) is the preferred study in all cases but is usually not immediately available in the emergency setting. Patient stability may also be a factor, as CT is typically faster and often does not require sedation.

Hirtz D, Ashwal S, Berg A, et al: Practice parameter: Evaluating a first nonfebrile seizure in children. Neurology 55:616–623, 2000.

11 What are the indications for nonurgent MRI after a seizure?

Focal features of the seizure

Cognitive or motor impairment of unknown etiology

Changes in seizure character, neurologic examination, or electroencephalogram

MRI testing for the preceding indications avoids unnecessary radiation exposure from CT.

Hirtz D, Ashwal S, Berg A, et al: Practice parameter: Evaluating a first nonfebrile seizure in children. Neurology 55:616–623, 2000.

12 What is the incidence of febrile seizures? When do they occur?

About 3–4% of all children have a febrile seizure; most occur in children between the ages of 6 months and 5 years.

American Academy of Pediatrics. Available at www.aap.org/patiented/febrileseizures.htm.

13 What makes a febrile seizure “simple” or “complex”?

A simple febrile seizure has all of the following characteristics:

The seizure is brief (< 15 minutes).

The seizure is generalized.

The child appears well shortly after the seizure stops.

A complex febrile seizure has at least one of the following characteristics:

The seizure is prolonged (> 15 minutes).

The seizure is focal.

The child has two or more seizures in one day.

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