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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