Pediatric Primary Care (111 page)

Kleposki RW, & Sehgal K. Common pediatric hip diseases in primary care.
Clinical Advisory.
2010;13(6): 21–26.

Lincoln TL, & Suen PW. Common rotational variations in children,
J Am Acad Orthopaedic Surgeons.
2003;11(5):312–320.

Proulx AM, & Zryd TW. Costochondritis: diagnosis and treatment.
Am Fam Physician.
2009;80(6):617–620.

Shelton YA, & Mortimer E. Orthopaedic problems in the pediatric patient. In G Steinberg, C Akins, & D Baran, eds.
Orthopaedics in primary care.
3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.

Staheli LT.
Fundamentals ofpedicatric orthopaedics.
4th ed. India: Lippincott Williams & Wilkins; 2008.

CHAPTER 31

Neurologic Disorders: Altered
States of Consciousness

Kristin Miller

I.  MENINGITIS

A.  Inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges, usually due to the spread of infection.

B.  Etiology.

1.  Infectious.

a.  Viral infections–most common cause, usually termed
aseptic meningitis
when no bacterial cause can be found

•  Enteroviruses (90%).

•  Herpes simplex virus type 2.

•  Varicella zoster virus.

b.  Bacterial.

•  Newborns to 3 months of age.

i.   Group B streptococci.

ii.  
Escherichia coli.

iii. Listeria monocytogenes.

•  Older children.

i.   
Neisseria meningitidis.

ii.  Streptococcus pneumonia.

iii. 
Haemophilus influenzae
type B especially in countries that do not offer vaccinations.

c.  Parasitic.

•  
Angiostrongylus cantonensis.

•  Gnathostoma spinigerum.

2.  Noninfectious.

a.  Cancer.

b.  Drugs.

•  Nonsteroidal anti-inflammatory drugs (NSAIDs).

•  Antibiotics.

•  Intravenous immunoglobulin.

c.  Inflammatory conditions.

•  Sarcoidosis.

•  Systemic lupus erythematous.

•  Vasculitis.

C.  Occurrence.

1.  Viruses more likely in late summer and fall.

2.  Bacterial: 3 per 100,000.

3.  Viral: 10.9 per 100,000.

4.  Increased risk with crowding and prolonged exposure such as daycare, military, college dorms, and those with compromised immune systems.

5.  Age–most cases occur in children younger than 5 years, but decreased incidence with increased vaccination rates.

6.  Race–higher incidence in African Americans than Caucasians.

7.  Sex–viral 3 times more likely in males than females.

D.  Clinical manifestations.

1.  General population.

a.  Classic triad of severe headache, nuchal rigidity, high fever.

b.  Altered mental status.

•  Confusion.

•  Extreme irritability.

•  Sleepiness

•  Abnormal cry.

•  Seizures.

c.  Sensitivity to light.

E.  Physical findings.

1.  Signs in newborns.

a.  Constant cry.

b.  Excessive sleepiness or irritability.

c.  Poor feeding.

d.  Bulging fontanel (increased ICP).

e.  Stiffness of body and/or neck.

f.  Difficult to comfort, cries harder when picked up.

2.  Positive Kernig's sign or Brudzinski's sign.

F.  Diagnostic tests.

1.  Lumbar puncture (LP)–definitive test for diagnosis, will see low glucose, increased white blood cells (WBC), increased protein, culture and Gram stain should be done.

2.  Complete blood count (CBC), blood culture, C-reactive protein, polymerase chain reaction (PCR), erythrocyte sedimentation rate (ESR).

3.  CT or MRI before LP since LP contraindicated with tumor, abscess, or increased intracranial pressure (ICP); MRI often done later to assess complications/sequelae.

G.  Differential diagnosis.

H.  Treatment.

1.  Viral.

a.  Supportive care–bed rest, fluids, analgesics.

b.  Antiviral drugs–acyclovir for herpes simplex and varicella zoster.

c.  May need to be admitted to monitor ICP or complications.

2.  Bacterial.

a.  Early intervention with antibiotics critical.

b.  Always treat with antibiotic for most commonly known pathogens until diagnosis confirmed.

c.  May need to be admitted to manage ICP, complications, administration of IV fluids and antibiotics.

d.  Birth to 6 weeks–ampicillin and third-generation cephalosporin (Cefotaxime or Ceftriaxine).

e.  Older than 6 weeks–vancomycin and third-generation cephalosporin.

f.  Prophylactic treatment of contacts with patients with
Neisseria meningitidis
–sulfadiazine or rifampin.

I.  Complications.

1.  Increased ICP.

2.  Deafness–may be prevented with prophylactic steroids.

3.  Hydrocephalus.

4.  Seizures.

5.  Venous or cerebral infarction.

6.  Cranial nerve palsies.

7.  Up to 70% sustain sequelae from bacterial meningitis.

8.  Most children with nonherpetic viral meningitis recover completely.

J.  Follow up.

1.  Frequent visits when cared for at home.

2.  Immediately for any decline in neurological condition or respiratory distress.

3.  Shortly after hospitalization to follow neurological status and assess pan for treatment of any sequelae.

K.  Education.

1.  Importance of prevention via immunizations.

2.  Handwashing and infection-control measures, especially in crowded locations.