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Welcome Applicants!. Morning Report: Thursday, December 8th. The Head CT…. The MRI…. Headaches. When to reassure and when to worry…. Question #1. - PowerPoint PPT Presentation
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Welcome Applicants!
Morning Report: Thursday, December 8th
The Head CT…
The MRI…
HeadachesWhen to reassure and when to worry…
Question #1
A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.
Question #2
An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.
Question #3
A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.
Question #4
A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.
Question #5
A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.
Question #1
A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.
*Migraine
Evaluation No support for routine laboratory studies or LP Routine EEG not recommended Role of neuroimaging
NOT indicated in children with recurrent HAs and a normal neuro exam
Should be considered: Recent onset of severe HA Change in type of HA Neurologic dysfunction
Should be done with an abnormal neurologic exam or with coexistence of seizures
Management
First step: appreciate the degree of disability
Treatment regimen must balance biobehavioral strategies with pharmocologic measures
Acute treatments are the mainstay of migraine management!
1. Take the medication as soon as possible
2. Take the appropriate dose
3. Have the medication available at the location where the patient usually has the HAs
4. Avoid analgesic overuse (>3-5 doses/ week)
**Use should be limited to patients whose HAs occur with sufficient frequency (@ least 3/mo) or severity to warrant daily treatment**
Question #2
An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.
Cluster Headache
Rare in children <10yo 90% of sufferers are male Extreme nonthrobbing deep pain in and around
one eye that spreads onto the face on the affected side
Bursts of pain last 60-90 mins and repeat 2-6 times per day for several weeks, then vanish for a period of months to years
Accompanying facial flushing and eye swelling/ watering
Cluster Headache
Treatments Acute attacks
Sumatriptans 100% O2 @8-10 lpm
Prophylaxis Methysergide Lithium Corticosteroids
Question #3
A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.
*Stress or Tension Headache
Diffuse, symmetrically distributed, throbbing pain around the head (“band like”)
Usually present most of the time, but there may be symptom-free periods
Fatigue is a common feature Nearly all children who have daily HAs
where an organic cause has been eliminated, underlying social or emotional difficulties can be found
*Stress or Tension Headache Treatment
Acute Identify the predisposing, precipitating and
perpetuating factors in the child’s home or school…and avoid them (if possible)!
Rest Analgesia
Chronic Relaxation techniques Massage therapy Acupuncture Amitryptiline
Question #4
A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.
*Medication Overuse Headache
Can occur with opiates, ergotamines, NSAIDs, or acetaminophen
Treatment includes tapering off acute symptomatic treatment (and educating the patient!)
Limit PRNs to one dose/day and 3 doses per week
Consider prophylactic treatment Emphasize the importance of diet, exercise and
sleep
Question #5
A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.
Headache Due to Increased ICP
Time to worry!!!
Causes
Meningitis/ encephalitis Diabetic ketoacidosis Mass lesion
Tumor Hemorrhage
Hydrocephalus Tumor Congenital malformation
Hypoxic-Ischemic encephalopathy Pseudotumor cerebri
Concerning Historical Features
Chronic and PROGRESSIVE HA without pain-free intervals
HA worse at night or immediately after waking HA worse during maneuvers that increase
venous pressure Bending over Coughing Sneezing Straining to stool
Concerning Historical Features
Repetitive vomiting (especially early AM)
Focal neurologic signs or symptoms Visual disturbances Paraesthesias Weakness Ataxia
Signs and Symptoms
Infants Widened sutures Bulging fontanelle Persistent
downward eye deviation (“sunsetting”)
Increased head circumference
Toddler/ School-age Children
Lethargy or irritability
HA Vomiting Papilledema Diplopia/ enlarged
blind spot Abducens palsy Mild ataxia
Cushing’s Triad1. Alterations
in respirations or apnea
2. HTN3. Bradycardi
a
*Management
ABCs!!! BRIEF neurologic exam with assignment
of GCS HOB at 30 degrees
If life-threatening increased ICP with impending or overt signs of herniation Mannitol Moderate hyperventilation
*Management
Imaging/ diagnostic studies CT
Allows rapid definition of surgical lesions Sensitive to bony abnormalities
MRI Exquisite resolution of brain anatomy and
delineation of CBF Sensitive to cerebral edema and demyelinating d/o Superior to CT for visualization of the posterior
fossa, cortical contusions, and white matter shearing lesions
*Management
Imaging/ diagnostic studies LP
Diagnostic for meningitis, encephalitis, pseudotumor cerebri
Contraindicated Signs of increased ICP/ focal deficit Coagulopathy Hemodynamic instability
*Management
Isotonic IVF Vasopressors
CPP=MAP-ICP CPP>60mmHg (>50 mmHg in infants and
young kids) ICP<15-25mmHg
Monitor serum electrolytes DI Cerebral salt wasting SIADH
*Management
Control agitation, fever, seizure activity
Maintain oxygenation, ventilation and hemodynamic stability to prevent secondary brain injury
Steroids Only with cerebral edema associated
with intracranial malignancy
Thanks for your attention!!Noon Conference: Guest speaker, Dr. Peters on VUR