Pediatric emergency medicine trisk 2641 2641
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initially in trauma. MRI of the spine is the procedure of choice to detect
compressive mass lesions, but if not immediately available, plain or CT
myelography is an alternative. LP should not be performed without first imaging
the spine if a diagnosis of spinal cord compression is possible.
Treatment of children with spinal injury from trauma begins with splinting and
immobilization of the spine. The role of high-dose methylprednisolone is
controversial and there is a lack of controlled trials in the pediatric population.
Based on a review of the literature, the American Academy of Neurological
Surgeons and the Congress of Neurosurgical Surgeons no longer recommend the
use of steroid therapy. Neurosurgical consultation should be obtained as soon as
possible to evaluate for possible surgical decompression (see Chapter 122
Neurosurgical Emergencies ).
In cases of possible epidural abscess or tumor-related masses, IV
dexamethasone therapy may be beneficial, and should be considered in
consultation with Neurosurgery and Oncology. IV antibiotic therapy against S.
aureus should be started immediately. In patients with a presumed infectious
cause and those with cancer of unknown origin, emergent surgical decompression
is indicated to alleviate pressure and to aid in diagnosis. Further treatment
depends on the specific organism or exact tumor type.
Acute Polyneuritis (Guillain–Barré Syndrome)
Acute polyneuritis, also called Guillain–Barré syndrome, is characterized by
symmetric ascending paralysis. Pathologically, the hallmark of this disease is
primary demyelination of motor and sensory nerves, believed to be caused by
autoimmune mechanisms. It occurs in children in all age groups but is uncommon
before 3 years of age. An antecedent respiratory or gastrointestinal infection or
immunization precedes the onset of illness by 1 to 2 weeks in more than 75% of
childhood cases.
Weakness, commonly with an insidious onset, is the usual presenting
complaint. Paresthesias or other sensory abnormalities such as pain or numbness
are prominent in up to 50% of cases, particularly in older children. The
paresthesias and paralysis are usually symmetric and ascending, although
variations may occur. Early in the course of illness, distal weakness is more
prominent than proximal weakness. Deep tendon reflexes are depressed or absent
at the time of diagnosis. Affected children often have an unsteady gait.
Cranial nerve abnormalities occur during the illness in 30% to 40% of cases
and may be the predominant finding, especially in the Miller-Fisher variant of
this syndrome, which is characterized by oculomotor palsies, ataxia, and
