D is for Disability (part 1 of 2)

7 October, 2010 by: colinparker

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Back to the alphabet! D is for Disability, meaning: clinical assessment of neurologic function or dysfunction…

In this episode we talk about the assessment of neurologic status in the unwell or injured child, with particular reference to the Glasgow Coma Scale and its children, being various iterations of a Pediatric GCS. What is the validity and utility of these scales? Are they any more useful than “AVPU”?


D = Disability

Colin: introduction & disclaimer & welcome

Basics of assessing neurologic status:

Colin: “AVPU”

Alert
Verbal
Pain
Unresponsive

Simon: Pupils in the unconscious patient

Colin: causes of small pupils, causes of big pupils, unequal pupils = anisocoria

Simon: oculocephalic reflexes

Susan: GCS (generally) – usefulness in clinical practice – reproducibility, prognostic value for head injury vs other conditions

Colin: children’s GCS – any use at all?
One widely used version is from James 1986 [James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatric Ann. 1986; 15:16–22.]

(comments from group)

Colin: Differential diagnosis of coma / seizures / focal or non-focal neurology (DIMTOPPE mnemonic)

(comments from group, intussusception as a cause for altered conscious state)

DIMTOPPE

“dim, at the top”
This mnemonic covers almost all causes of a global CNS dysfunction, including categories covered by rival mnemonics “COMA” and “TIPPS AEIOU”, but easier to remember, I think…
  • D = drugs & toxins
    • extrinsic toxins
    • intrinsic toxins
      • liver failure
      • CCF
      • renal failure
      • respiratory failure
  • I = infection
    • CNS
    • outside CNS
  • M = metabolic & endocrine eg:
    • hypoglycaemia
    • hyponatraemia
    • hypo- or hyperthyroidism
  • T = trauma
  • O = oxygen deficiency
    • localised eg CVA (thrombotic or haemorrhagic)
    • global hypoxia (eg pneumonia)
  • P = post-ictal state
  • P = psychiatric / psychogenic
  • E = oedema of the brain
    • Hypertensive encephalopathy
    • Space-Occupying Lesion

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