Transcript CNS Disorders in Pediatrics

HOMOEOPATHIC
APPROACH
IN
CNS Disorders
CASE 1
Pre term breech difficult delivery (7mA)
at 6.30 pm
Child didn’t cry after birth.
Birth weight 1.5kg
No spontaneous respiration
Limp
Extremities Cyanosed
Heart rate 110/min
No response to catheter
APGAR SCORE 3/10
RESUSCITATION
Intubation done
Continuous Ambu bag respiration given
through ET
Continuous oxygen
Inj. Sodabicarb 1 ml IV stat given
IVF D 10% 40 ml slow through microset
started
FOLLOW UP
No spontaneous respiration for 2 -3
hrs
Baby still on artificial respiration
Pediatrician advices to stop oxygen
and resuscitation as prognosis poor.
Artificial respiration continued
By 9.30 pm started with
spontaneous jerky respiration
Oxygen continued
By 10 pm clonus started in
lower extremity which spread
all over body
Clonus <3 touch
>3 Holding part
TOTALITY
1.Direction ascending
2.Clonus <3 touch
3.>3 Holding part
Rx. Cuprum Met 30
With in 1 hr respiration stabilized
Jerks >
Cuprum Met 30 given in multiple dose
Follow up in 12 hrs
No cry, no response to pain, reflex absent
Irregular stertorious breathing
Flaccid hypotonia.
Froathing at mouth
Hypotonia of bladder  full bladder till
umbilicus but not passed urine.
Opium 30 1 hrly.
Follow up in 24 hrs
Profuse urine passed
spontaneously
Developed hypertonia of lower
extremity
Is it secondary
action of Opium??
OPIUM OMITTED
With in 4 hrs of stopping
opium
respiration
again
became
stertorius
with
prolonged apnoic spells.
Opium 200 1 hrly
3rd day
Opium 200  1 M 1hrly
Within 12 hrs showed response
to pain  withdrawal reflex
On 4th day
Response to touch started  Rooting
reflex positive
Cry good
Rigidity>3
Activity good
Moving all 4 limbs
Pediatrician asks baby to be transferred
to Sion hospital for further
investigations as baby has survived
IMPORTANT LEARNING
1. ACCURATE OBSERVATION
2. FINDING CHARACTERSTICS IN A CASE
WITH ONLY SIGNS AND EXAMINATION
FINDINGS
3. ALERTNESS TO IDENTIFY CHANGING
TOTALITY
4. EVALUATION OF REMEDY RESPONSE
CASE 2
6 hours / Neonate
Born to a mother from rural background
No homoeopathic orientation
Call received at 1 am in the night for stabilizing a neonate
having respiratory distress and convulsions immediately after
birth following difficult labor.
A/F: BIRTH TRAUMA + BIRTH ASPHYXIA
PRESENTATION
NO AURA
ICTAL PHASE-
BITING LIPS
TWITCHING FACE DISTORTION FACE
HEAD ROLLING TO SIDES
TONIC CLONIC MOVEMENTS OF
EXTREMITIES
CLENCHED FIST
POST ICTAL – PROSTRATION
PUPILS DILATED
Examination:
General condition: Poor
Peripheral cyanosis
Heart rate: 160 / minute
Heart sounds Normal
Respiratory Rate: 60/ minute
Conducted sounds and crepitation
CNS: Generalized tonic - colonic movements of upper and lower
extremities, facial distortion and frothing at mouth
Hyper tonic spasm
Plantars extensor
Investigation :
Serum Glucose : Normal
Serum Calcium : Normal
Brain Oedma and Hypoxia
6 hours
Cerebral irritation
A/F: Birth Trauma
and asphyxia
Convulsions
Status epilepticus
Facial distortion
STRUCTURE
TIME
FORM
FUNCTION
Brain Oedma and Hypoxia
6 hours
Cerebral irritation
A/F: Birth Trauma
and asphyxia
Convulsions
Status epilepticus
Facial distortion
TOTALITY
A/F: Cerebral Concussion
Facial distortion
CICUTA
Pupils dilated
Head turning sides
Prostration
SUSCEPTIBILITY ASSESSMENT
Pace of disease
: Rapid
Pathology
: Acute Oedma of brain
Vitality
: Compromised
Characteristic
: Present
Correspondence
: Adequate
200 C
frequently
1 hrly---4 hrly
ANCILLARY MEASURES
Continuous Oxygen
Radiant warmer
Intermittent Naso – Oral Suction
Naso gastric Intubations
Intra Venous fluids
FOLLOW UP
CHILD RELAXED
1st hr.
Convulsions better in Freq.
2nd hr.
Convulsions better 50%
5th hr.
Convulsions better 75%
Only facial twitching
Child appeared PEACEFUL
8th hr.
Convulsions – NIL
24th hr.
CHILD ACTIVE
CONCLUSIONS
 CLINICO PATHOLOGICAL CO
RELATION
 IMPORTANCE OF OBSERVATION TO
UNDERSTAND EVOLUTION OF
ILLNESS
 POSOLOGY IN A LIFE THREATING
ILLNESS
Case 3
Day4 male baby, Unconscious ,was referred from
PHC for Emergency NICU management
at 10.35 am
Precious child born to a couple after 12 yrs of
marriage
CHIEF COMPLAINT
Not responding to stimuli and no cry since few
hours
History of:
Fever and
Refusal to feed
since 3 days
OBSTRETIC HISTORY:
• Baby conceived after 12 years of married life
BIRTH HISTORY:
• Antenatal history: Uneventful
• Preterm vaginal Home delivery
• Cried immediately after birth.
ON EXAMINATION:
• No spontaneous activity
• Cry - no cry to painful stimuli
T- 99.2 f
Heart Rate
Respiratory Rate
• R.S
- basal crepts present
• C.V.S
-S1S2 Normal
• P/A
-soft
• CNS
tone –hypotonia
Pupils -sluggish reactions
Reflexes- Absent
• Anterior Fontanel- Boggy
- 140/min
-56/min
DIAGNOSIS
Meningitis with septicemia with
? Hydrocephalus
TREATMENT GIVEN BY PAEDIATRICIAN
• Continuous oxygen
• Antibiotics: Inj Monocef,
Inj Mikacin,
Inj Pipzo,
• Inj Sodabicarb
• Inj Rantac
• IVFluids
RESPONSE IN 24 HRS
General condition- Same
Temperature - 100-101 F
No spontaneous activity
No cry
Pupils dilated fixed
Developed Sun set sign
SUN SET
SIGN
Conclusion
Disease progression
Hydrocephalus increasing
Poor response to treatment
Pediatrician Assessment
? Brain Dead
Action:
• No Use Of Any Medications.
• Advised To Take Baby Back Home.
• No Medicinal Intervention.
PARENT’S MENTAL STATE
• Precious Child…….Conceived after 12 years
of Marriage
• Worried about Baby
• Poor family but not willing to give up Hope
• Wants to continue treatment – Not willing to
take home
Scope of Homoeopathy?
Understanding the Role in
critical life threatening situation
OBSERVATION….
• Baby …..Unconscious, no activity
• Cry……….Not cried even after painful
stimuli.
• Anterior fontanel………….Tense
• Eyes……..Sun set sign
• Clenched fingers
• Closed thumb
• Dilated pupils
• Baby passes urine 2-3 times in 24 hrs
• O/E bladder….Palpable, distended
TOTALITY
•Unconsciousness / Coma hydrocephalus in
•Eyes turned downward
•Clenched fingers
•Closed thumb
•Bladder paralysis
•Dilated pupils
REMEDY DIFFERENTIATION
1. CUPRUM MET
2. HELLEBORUS
3. HYOSCYAMUS
CUPRUM MET
• Convulsions and spasms
• Distortion of head on one side and backward
with red face during convulsion.
• Restlessness between the attack.
• Spasms from peripheral to center.
HELLEBORUS
• Stupor ,dullness of sensorium.
• Asymmetry:
Involuntary movement of one arm
and one leg other extremities paralyzed.
One pupil larger than other.
• Suppressed urine with coffee ground
sediment.
• Pulse slow and feeble, respiration slow,
temperature low.
• Torpidity and apathy.
HYOSCYAMUS
• Loss of consciousness with attack of
cerebral congestion.
• Pupils dilated.
• Clenched fingers and closed thumb.
• Retention of urine---bladder paralysis.
SUSCEPTIBILITY
Pathology: Meningitis with
hydrocephalus
Vitality: Compromised
Characteristics: Few
POTENCY SELECTION
50 millicimal potency
1)Involvement of vital organ
2)Vitality poor
3)Need to accelerate the cure by giving freq. repetition
4)Less chance of aggravation
LAST HOPE
HYOSCYAMUS 0/1……2 DROPS
Stat Dose 10.15 PM 19/6/2009
Wait And Watch
Assessment After 2hrs
FOLLOW UP
SUMMARY
TIME(20/06/09)
12:45AM
3:45AM
Activity
Moved all limbs on
stimulus
Activity Improved
Cry
For 30-40sec on
stimulus
30-40sec spontanuous
Tone
Hypotonia
Improved-partially
flexed limbs
Withdrawal response
(to tap on the sole)
Dorsiflexion of toes
Same
Blink to light
Slight
Improved
Pupils reaction to light Sluggish
Urine
3 times
Same
TIME(20/06/09)
7:15AM(2ND DOSE)
8:00PM
Activity
Same (moving on
stimulus)
Spontaneously moving
limbs
Cry
Same (weak on
stimulus)
Spontaneous cry.
Tone
Same (hypotonic)
Improved- flexion of
limbs
Withdrawal response
Dorsiflexion of foot
Improved (flexion at
knee)
Blink to light
Improved
Pupils reaction to light Same (sluggish)
Improved
Same
Urine
Passed 4 times
Not passed since 12
am
•Normal activity within 24 hours
•Put on Breast feeding within 48
hours
•Child discharged on the
th
4
day
Case 4
th
8
month old baby girl comes with
complaints of frequent
convulsions not responding to
modern line of treatment.
CHIEF COMPLAINT
• Focal
convulsion on face especially eyes
since 3-4 days with UREB. Frequency
every 10 to 25 minutes.
• Occasionally focal convulsions progress
to develop a generalized tonic clonic
convulsion.
Patient on Syp. Gardenal and Syp.
Valparin
EVOLUTION
Day 3:
Vomiting persistent dehydration.
Diagnosed as congenital hypertrophied pyloric stenosis (HPS)
Day 4: Admitted to KEM NICU
Day 24: Operated for HPS
Day 26: Focal convulsion.
Diagnosed as “Epilepsy secondary to cerebral hypoxia”
3 Months Later:
GTC with UREB and frothing which continued till date and
occasionally patient also goes into status epilecticus
PHYSICAL CHARACTERISTICS
 Dazed look
 Gazing continuously
 Doesn’t follow sound/voice
 Craving: Sweets2
 Thermal: Hot
Milestones: Not achieved anything
MENTAL STATE
 Child
cries if lights are put off
 Child lies down peacefully without making
much movements
PHYSICAL EXAMINATION
Baby conscious
Temp:
Normal
Heart Rate: 110/min
Resp. Rate: 36/min
R. S:
Bilateral scattered crepts +
CVS:
S1 S2 – N
Pupils:
BERL
Tone:
Normal
Focal twitching mostly over left eyes +
INVESTIGATION
CT BRAIN (10.10.2006)
Mild to moderate atrophy of supratentorial brain
parenchyma
MRI (12.10.06)
- Diffuse voluminous ? loss of periventricular white
matter. More marked in parieto occipital hemispheres
with relative sparing of frontal lobes.
- Associated prominence of lateral ventricles is noted
with irregular ventricular margins.
- There is diffuse thinning of corpus callosum.
- These features likely to be due to perinatal cerebral
insult.
TOTALITY
1. A/F- Surgery, hypoxia
2. Cerebral atrophy
3. Convulsion starting in face
4. Convulsion spreading to extremities
REMEDY GIVEN
Cicuta 30 single dose weekly
FOLLOW UP
Over 8 months
No convulsions till date
Milestones
• Activity improved- now moves all around in 360º
• Initially used to lie down placid, now tries to turn to
prone
• Smiles and laughs a lot.
• Responds to communication by parents
• Understands whatever said
CONCEPTS

Clinico pathological co-relation

Evolutionary history

Converting symptom to rubric

Repertorization
Therapeutics of Convulsions
Cicuta:
- A/F: Concussion of Brain
- Convulsion spread from center to
periphery. Begins in face
- Violent distortion of face
- Dilated pupils
- Opisthotonus position – back bent
backwards like an arch
- < touch3, Noise3
Cuprum Met:
- A/F Suppressed Eruption /discharges
- Convulsion spread from periphery to
center. Begins in fingers and toes
- Intense pain- Shrieking
- Complaints begin in LEFT Side
- Tonic clonic spasms with blue face
- < Touch
- > Laying hand on affected part
Zincum metallicum:
-A/F Suppressed Eruption
/discharges
- Ill Effects of concussion of brain
- Isolated effects – one part hot other
part cold, one part numb another
sensitive
-Descending Paralysis
-< Noise, Touch
-> Hard pressure, FREE Discharges
- FIDGETY FEET
Opium:
-A/F Suppressed discharges
- Involuntary movement with contracted
pupils
- Painlessness
- Stupid heavy sleep between spasms
- Opisthotonos
- Deep snoring, rattling, Sertorius
breathing.
- < sleep
-> Uncovering, Continous walking
Causticum:
-A/F: Suppressed eruptions, Puberty
- Rt Sided
- Paralysis following convulsion
- During Epilepsy, runs in circle then
falls down
- < New moon
Artemisia vulgaris:
-A/F Blow on head, puberty, violent
emotions
- Epilepsy without aura
- Petitmal- Rt side convulsed, Lt .side
paralyzed
-Attacks accompanied by profuse
offensive sweat
-- Somnambulism
Agaricus Muscarius:
-A/F: Fright, punished or being
scolded
- Diagonal affection- Rt arm and lt leg
- During epilepsy, physical strength
increased, can lift heavy load
- Yawning before complaints
Bufo rana:
-AF: Sexual disturbance, at time of
menses
- Convulsion preceded by irritability
and rambling
- Aura begins in genitals
- Convulsions from suppurative
conditions