PROFESSOR’S TEST HINTS & EXTRAS (with details and explanations) {Glasgow Coma Scale: 8 or less = coma, intubate} • GCS is used to assess LOC in children with neurological injury. • {A score of 15 is normal, 11–13 is moderate, 8 or less = severe coma.} • {If GCS is 8 or below, airway protection/intubation is indicated.} • Lecture quote: “If my number is eight, what does that mean? Coma… Once they start going under eight, we’re not looking good.” • PDF: “The Glasgow Coma Scale (GCS) is the most widely used tool for assessing the level of consciousness in children with acute brain injury. A score of 8 or less indicates severe injury and the need for airway protection.” {Signs of increased ICP: bulging fontanelle, shrill cry, vomiting, lethargy} • Increased intracranial pressure (ICP) is a medical emergency in pediatrics. • {Classic signs in infants: bulging anterior fontanelle, high-pitched (shrill) cry, vomiting, lethargy, poor feeding, “sunsetting” eyes, increased head circumference.} • Lecture quote: “Bulging fontanelles may indicate increased intracranial pressure… high shrill cry, that is a sign of what? Intracranial pressure.” • PDF: “Early signs of increased ICP in infants include bulging fontanelle, irritability, poor feeding, vomiting, and a high-pitched cry.” {Do NOT do LP if suspect increased ICP or papilledema} • Lumbar puncture (LP) is used to diagnose meningitis but is contraindicated if increased ICP is suspected (risk of herniation). • {NEVER do an LP if the child has bulging fontanelle, papilledema, or focal neurological deficits.} • Lecture quote: “When am I not going to do this? Very important. Increased intracranial pressure? Yes… If I feel like the patient has ICP, I’m not going to do an LP.” • PDF: “A lumbar puncture should not be performed in children with signs of increased ICP or papilledema due to the risk of brain herniation.” {Know types of CP and their features, especially spastic} • Cerebral Palsy (CP) types: • {Spastic (most common): stiff, rigid muscles, scissoring gait} • Athetoid (dyskinetic): involuntary movements • Ataxic: poor coordination and balance • Mixed: combination • Key features of spastic CP: {stiff/rigid limbs, poor head control, delayed milestones, persistent primitive reflexes} • Lecture quote: “What are the four types of cerebral palsy? Help me out. You have spastic, right? You have athetoid, you have ataxia, and you have mixed…” • PDF: “Spastic cerebral palsy is characterized by increased muscle tone, hyperreflexia, and persistent primitive reflexes.” {Know red flags for head injury and when to send to ER} • Red flag symptoms after head injury: • {Severe or worsening headache} • {Repeated vomiting} • {Loss of consciousness, amnesia} • {Seizures} • {Difficulty arousing, confusion, irritability} • {CSF leak (clear fluid from nose/ears, positive for glucose)} • {Unequal, fixed, or dilated pupils} • {Gait disturbance} • Lecture quote: “If that headache is severe, worsens and interferes… or lasts more than 24 hours, they need to go back to the hospital… If they have a liquid fluid coming out… that’s a medical emergency.” • PDF: “Children with severe headache, persistent vomiting, altered mental status, or signs of basilar skull fracture require immediate evaluation.” {Know classic signs of meningitis in infants vs. older kids} • Infants: • {Bulging fontanelle} • {Poor feeding} • {Irritability} • {High-pitched cry} • {Lethargy} • {Seizures} • Older children: • {Fever, headache} • {Stiff neck (nuchal rigidity)} • {Photophobia} • {Vomiting} • {Rash (purpuric = meningococcal)} • Lecture quote: “Put your neonate. You’re going to have poor tone. You’re going to have vomiting and diarrhea… high shrill cry, that is a sign of what? Intracranial pressure.” • PDF: “Classic symptoms of meningitis in infants include bulging fontanelle, poor feeding, irritability, and a high-pitched cry. In older children, fever, headache, neck stiffness, and photophobia predominate.” {Know Gower’s sign and waddling gait for DMD} • Duchenne Muscular Dystrophy (DMD): • {Waddling gait} • {Gower’s sign: child uses hands to “climb up” legs to stand} • {Frequent falls, large calves (pseudohypertrophy)} • Lecture quote: “What is the G word called? Gower sign… they start almost on their tiptoes, bending over, and then work their self up.” • PDF: “Children with Duchenne muscular dystrophy characteristically exhibit a waddling gait and use Gower’s maneuver to rise from the floor.” {Know management priorities for CP and hydrocephalus} • CP: • {Safety first} • {PT, OT, speech therapy} • {Muscle relaxants (baclofen, Botox)} • {Seizure meds if needed} • {G-tube feeding for severe dysphagia} • {Promote socialization, play, family support} • Hydrocephalus: • {Monitor head circumference} • {VP shunt placement} • {Monitor for shunt infection/malfunction: vomiting, fever, lethargy, swelling along shunt tract} • Lecture quote: “If you have a child with cerebral palsy, what is your priority? Safety. Safety. Safety.” • PDF: “Management of CP focuses on maximizing function and safety… Hydrocephalus is managed with shunt placement and close monitoring for complications.” {If you see “sunsetting eyes” or rapid head growth, think hydrocephalus} • Hydrocephalus: • {“Sunsetting eyes” = downward deviation of eyes} • {Rapid increase in head circumference} • {Bulging fontanelle, dilated scalp veins, vomiting, lethargy} • Lecture quote: “Setting sun eyes. That is one of the main signs, right? An infant… the anterior fontanel is tense. It’s going to be bulging.” • PDF: “Sunsetting eyes and rapid head growth are classic findings in infants with hydrocephalus.” {If you see “purpuric rash + fever,” think meningococcemia – EMERGENCY} • Meningococcal meningitis: • {Fever + purpuric (non-blanching, purple) rash = sepsis, DIC, EMERGENCY} • Immediate antibiotics, isolation, supportive care • Lecture quote: “You may notice a type of rash, right? It’s called a purpuric rash… that is a medical emergency.” • PDF: “A purpuric rash in a febrile child is a hallmark of meningococcemia and requires immediate intervention.” {If question mentions “child can’t swallow” or “feeding issues” in CP, answer is G-tube feeding} • Severe CP: {Dysphagia, poor suck/swallow coordination, risk of aspiration} • {G-tube feeding is indicated for nutrition and safety} • Lecture quote: “They may need manual jaw control… Speech is not just talking, speech also teaches a child how to eat… A lot of these children have G-tubes.” • PDF: “Children with severe oropharyngeal dysfunction may require gastrostomy tube (G-tube) feeding.” Summary Table of Hints Neurological Assessment History • Orientation (time, place, person) – {not for infants} • Behavior: {Alertness, irritability, lethargy, stupor} • School performance, bedwetting (enuresis), posture/gait changes • Recent accidents, falls, head injuries, altered consciousness Physical Exam • Pupils: {PERLA (Pupils Equal, Round, Reactive to Light and Accommodation)} • Cranial Nerves: Facial movement (smile), eye movement, etc. • Reflexes: Babinski, rooting, Moro • Gait/Balance: Steady vs. unsteady • Developmental Milestones: {Delayed or regressing = RED FLAG} • Fontanelles (infants): {Bulging = increased ICP} • Posturing: Decorticate (flexion), decerebrate (extension) • Vital Signs: {Cheyne-Stokes breathing, pulse, BP changes} 4. Level of Consciousness (LOC) & Glasgow Coma Scale • GCS: • {15 = normal} • {11–13 = moderate injury} • {8 or less = coma/severe injury (intubate!)} • {3 = deep coma/near death} • Infants: Use {alertness, activity, responsiveness} (not orientation) • Red Flag: {If GCS is 8 or below, airway protection/intubation is needed} • Professor Hint: {If you see a two-month-old “alert and oriented x4” in a chart, that’s wrong! Use “awake, alert, playful.”} 5. Head Injury & Concussion • Manifestations: {Headache (if severe or wakes from sleep, ER!), vomiting, changes in vital signs, unsteady gait, irritability, altered mental status, amnesia, loss of consciousness, bleeding from nose/ears (CSF leak = medical emergency), seizures, blackened eyes, difficulty arousing} • Red Flags: {Severe/worsening headache, vomiting, altered consciousness, seizure, CSF leak, unequal pupils, persistent sleepiness} • Discharge: {Return if severe headache, vomiting, confusion, or difficulty waking} • Professor’s Hint: {CSF leak (clear fluid from nose/ears, positive for glucose) = EMERGENCY} 6. Diagnostic Procedures • Lumbar Puncture (LP): {Analyzes CSF for infection (meningitis), contraindicated with increased ICP or papilledema} • EEG: {Monitors brain waves for seizure activity} • Nuclear Brain Scan: Detects lesions, visualizes CSF flow • Imaging (CT/MRI): {For trauma, tumors, hydrocephalus} • Professor’s Hint: {If child has papilledema or bulging fontanelle, NO LP!} 7. Cerebral Palsy (CP) • Definition: Non-progressive motor disorder from brain injury (prenatal, perinatal, postnatal) • Types: {Spastic (most common), athetoid, ataxic, mixed} • Signs: {Poor head control after 3 months, stiff/rigid limbs, arching back, floppy tone, delayed milestones, persistent fist clenching, persistent primitive reflexes, feeding/swallowing difficulty} • Management: {Safety, PT/OT/speech therapy, socialization, play, assistive devices, muscle relaxants (baclofen, Botox), seizure meds, feeding support (jaw control, G-tube)} • Family Support: {Education, involvement in care, psychosocial support} • Professor’s Hint: {If question mentions “child can’t swallow” or “feeding issues” in CP, answer is G-tube feeding} • Key: {Safety is #1 for CP. Know the 4 types and their features. If child with CP can’t swallow, use G-tube.} 8. Muscular Dystrophy (Duchenne, DMD) • Definition: Progressive muscle weakness (X-linked, boys) • Signs: {Waddling gait, Gower’s sign (uses hands to “climb up” legs to stand), frequent falls, lordosis, muscle atrophy, pseudohypertrophy (large calves), mental deficiency} • Complications: {Respiratory/cardiac failure, loss of ambulation} • Management: {Maintain independence, PT/OT, bracing, contracture release, gene therapy (research)} • Professor’s Hint: {Know Gower’s sign and waddling gait for DMD} 9. Cognitive Impairment • IQ Classifications: • {50–75: Educable} • {35–55: Trainable} • {20–40: Severe} • {<20: Profound} • Prevention: {Folic acid, prenatal care, immunizations, avoid toxins} 10. Meningitis • Definition: Inflammation of meninges (dura, arachnoid, pia) • Causes: {Bacterial (worse), viral (more common), trauma, autoimmune} • Classic Signs: • Older Kids/Adults: {Fever, headache, stiff neck (nuchal rigidity), photophobia, vomiting, altered consciousness, seizures, purpuric rash} • Infants: {High-pitched cry, bulging fontanelles, poor feeding, vomiting, lethargy, seizures, hypothermia/fever, purpuric rash (meningococcal)} • Special Signs: {Kernig’s (BK – knee), Brudzinski’s (neck flexion causes hip/knee flexion)} • Diagnosis: {Lumbar puncture (unless increased ICP)} • Management: {Droplet precautions, antibiotics, antipyretics, seizure precautions, IV fluids, monitor for complications (hearing loss)} • Complications: {Hearing loss, cerebral edema, shock} • Professor’s Hint: {If you see “purpuric rash + fever,” think meningococcemia – EMERGENCY} 11. Hydrocephalus • Definition: {Increased CSF in brain ventricles → increased ICP} • Causes: {Congenital (intrauterine infection, spina bifida), acquired (meningitis, trauma)} • Signs (Infants): {Bulging fontanelles, increased head circumference, dilated scalp veins, poor feeding, decreased consciousness, “setting sun” eyes} • Signs (Older Children): {Headache, vomiting, double vision} • Management: {Monitor head circumference, surgical shunt (VP shunt), manage ICP} • Professor’s Hint: {If you see “sunsetting eyes” or rapid head growth, think hydrocephalus} • Key: {Always measure head circumference in infants. Sudden increase = hydrocephalus.} 12. Red Flags & Emergencies • {Fixed, dilated pupils} • {CSF leak (clear fluid from nose/ears, positive for glucose)} • {Severe/worsening headache after head injury} • {High-pitched cry in infants} • {Bulging fontanelles} • {Purpuric rash with fever (meningococcal sepsis)} • {Unarousable, persistent vomiting, new seizures} • {Loss of consciousness, amnesia, or difficulty arousing} • {Sudden gait disturbance} 13. Professor’s Test Hints & Explanations 14. Practice Scenarios 1. A 9-month-old presents with fever, vomiting, bulging fontanelle, and a high-pitched cry. • {Top concern: Meningitis with increased ICP. NO LP! Start antibiotics, droplet precautions, monitor for seizures.} 2. A child falls off a bunk bed, has a severe headache, vomits, and has clear fluid leaking from nose. • {Top concern: Basilar skull fracture with CSF leak. ER immediately.} 3. A 3-year-old with a history of prematurity is not walking, has stiff legs, and persistent primitive reflexes. • {Top concern: Spastic cerebral palsy. Refer for PT/OT, assess for feeding issues.} 4. A 5-year-old boy uses his hands to climb up his legs to stand, has large calves, and walks with a waddle. • {Top concern: Duchenne muscular dystrophy. Refer for genetic testing, PT, monitor for respiratory decline.} Definition & Epidemiology • {Seizures are the most common neurologic disorder in children; about 5% of all children will have at least one seizure in childhood.} Causes of Seizures in Children • {Fever (febrile seizures)} • {CNS infections (meningitis, encephalitis)} • {Head trauma} • {Hydrocephalus or shunt malfunction} • {Brain malformations, tumors} • {Hypoglycemia, electrolyte imbalances} • {Genetic epilepsy syndromes} • {Spina bifida with CNS involvement} • {Idiopathic (no clear cause)} Types of Seizures • {Generalized (tonic-clonic, absence, myoclonic)} • {Focal (partial)} • {Febrile seizures} (most common in ages 6 months–5 years) • {Status epilepticus: seizure >5 minutes or repeated seizures without return to baseline-medical emergency} Assessment & Recognition • {Observe and document: onset, duration, type of movements, eye deviation, incontinence, post-ictal state} • {Monitor airway, breathing, and circulation (ABCs) during and after a seizure} • {Check for hypoglycemia and treat if needed} Acute Seizure Management • {First priority: ABCs-position on side, suction secretions, provide oxygen if needed} • {Do NOT put anything in the child’s mouth during a seizure} • {Check blood glucose; treat hypoglycemia if present (Rule of 50s: D10, D25, D50 as age-appropriate)} • {First-line medication: benzodiazepines (IV lorazepam, IM/intranasal/buccal midazolam, or rectal diazepam)} • {If seizure persists, give second-line anti-epileptics (fosphenytoin, levetiracetam, phenobarbital, valproate)} • {If still refractory, consider continuous infusions (midazolam, pentobarbital) and ICU care} • {Rapid intervention is critical-longer seizures are harder to stop and increase risk of brain injury} Seizure Precautions in Hospital • {Padded side rails} • {Oxygen and suction at bedside} • {Ambu bag and airway equipment available} • {Supervise during bathing/ambulation} • {Monitor for triggers: fever, infection, medication nonadherence} Chronic Management & Special Therapies • {Anticonvulsant medications: individualized based on seizure type and syndrome} • {Monitor for medication side effects and adherence} • {Some children with refractory epilepsy may be candidates for:} • {Ketogenic diet} • {Vagus nerve stimulation (VNS)} • {Epilepsy surgery or neurostimulation devices} • {Early identification of medication-resistant epilepsy is important for referral to a specialty center} Complications • {Status epilepticus: prolonged seizure, risk of neuronal injury, increased mortality} • {Aspiration, respiratory compromise} • {Cognitive or behavioral changes if seizures are frequent or prolonged} • {Injury during seizure (falls, head trauma)} Professor’s Exam Hints • {If a child with hydrocephalus or a VP shunt develops a seizure, suspect shunt malfunction or increased ICP} • {If a child with spina bifida has a seizure and latex exposure, think latex allergy/anaphylaxis} • {Always document seizure details and post-ictal state} • {Never leave a seizing child unattended; protect airway and safety first} • {If seizure lasts >5 minutes, treat as status epilepticus-give benzodiazepine and call for help} Spina Bifida {High-Yield Study Notes} Definition & Types • {Spina bifida is a neural tube defect where the spinal column fails to close completely.} • {Myelomeningocele is the most severe and common form associated with long-term neurologic complications.} Hydrocephalus Link • {Most children (up to 85%) with myelomeningocele develop hydrocephalus, often after surgical closure of the back.} • {Hydrocephalus may not be present at birth but often develops in the first days or weeks.} • {Chiari II malformation is commonly associated, causing hindbrain herniation and further risk for hydrocephalus.} • {Monitor head circumference and neuro status closely after birth and surgery.} Symptoms and Complications • {Hydrocephalus: rapid head growth, bulging fontanelle, sunsetting eyes, vomiting, irritability, seizures, drowsiness, poor feeding, prominent scalp veins.} • {Seizures can occur due to hydrocephalus or shunt malfunction.} • {Cognitive impairment and learning disabilities may result from hydrocephalus or brain malformations.} Management • {Hydrocephalus is usually treated with a VP shunt, which drains excess CSF from the brain to the abdomen. Shunts are lifelong and require monitoring for malfunction/infection.} • {Signs of shunt problems: full/bulging fontanelle, vomiting, headache, swelling/redness along shunt tract, fever, irritability, drowsiness, loss of abilities, change in appetite, seizures.} • {Regular head circumference measurement is essential in infants.} Latex Allergy • {Children with spina bifida are at high risk for latex allergy-rates up to 70%.} • {Latex allergy can cause mild (rash) to severe (anaphylaxis) reactions.} • {Strict latex avoidance is essential in all care settings and daily life.} • {Multiple surgeries and procedures increase the risk of developing latex allergy.} • {Have epinephrine available and educate families/schools about latex allergy risk.} Other Key Issues • {Monitor for skin breakdown, mobility problems, and incontinence.} • {Tethered cord, orthopedic deformities, and cognitive challenges may occur.} Professor’s Key Hints • {If you see “spina bifida + hydrocephalus,” always monitor for increased ICP and shunt complications.} • {If a child with spina bifida has a sudden allergic reaction, think latex allergy.} • {Always use latex-free equipment for spina bifida patients.} • {Measure head circumference regularly in infants with spina bifida.} • {Educate family about shunt signs, latex allergy, and skin care.}