Neurologic Emergencies and Stabilization in Pediatrics

Introduction to Pediatric Neurologic Emergencies

Pediatric neurologic emergencies require rapid assessment and intervention to prevent secondary brain injury and optimize outcomes.

Initial Approach

Primary Survey:
- Rapid neurological assessment
- Airway protection evaluation
- Breathing assessment
- Circulatory status
- Disability (AVPU/GCS)
Key Vital Signs:
- Blood pressure (age-specific norms)
- Heart rate and rhythm
- Respiratory rate and pattern
- Temperature
- Oxygen saturation

Red Flag Symptoms

Altered mental status
Focal neurological deficits
Signs of increased ICP
Abnormal posturing
Status epilepticus
Acute behavior change

Status Epilepticus

Definition and Classification

Early Status Epilepticus: 5-30 minutes of continuous seizure
Established Status: >30 minutes
Refractory Status: Not responding to ≥2 antiepileptic medications
Super-refractory Status: Continues/recurs 24h after anesthetic initiation

Management Algorithm

Time	Intervention	Medication/Dose
0-5 min	Stabilization	- Airway positioning - Oxygen supplementation - Vital signs monitoring
5-10 min	First-line therapy	- Midazolam 0.15mg/kg IM/IN - OR Lorazepam 0.1mg/kg IV - OR Diazepam 0.3mg/kg IV
10-20 min	Second-line therapy	- Repeat first-line dose once - Start IV access if not present
20-40 min	Third-line therapy	- Fosphenytoin 20mg PE/kg IV - OR Valproate 40mg/kg IV - OR Levetiracetam 60mg/kg IV
>40 min	Refractory status	- Consider intubation - Midazolam continuous infusion - OR Pentobarbital/Thiopental

Monitoring Parameters

Clinical Monitoring:
- Continuous cardiorespiratory monitoring
- Frequent neurological checks
- Blood pressure monitoring
- End-tidal CO2 if intubated
Laboratory Monitoring:
- Electrolytes and glucose
- Antiepileptic drug levels
- Complete blood count
- Liver and kidney function

Altered Mental Status

Differential Diagnosis (AEIOU-TIPS)

A - Alcohol, Abuse, Acidosis
- Toxic ingestion
- Child abuse
- Diabetic ketoacidosis
E - Encephalopathy, Electrolytes, Epilepsy
- Metabolic derangements
- Post-ictal state
- Hyponatremia/hypernatremia
I - Infection, Intussusception
- Meningitis/encephalitis
- Sepsis
- Brain abscess
O - Oxygen/Opiates
- Hypoxia
- Carbon monoxide
- Overdose
U - Uremia
- Renal failure
- Hepatic failure

Initial Workup

Point of Care Testing:
- Blood glucose
- Blood gas
- Electrolytes
- Toxicology screen
Imaging:
- CT head if focal signs
- MRI if available/indicated
CSF Studies:
- Opening pressure
- Cell count/differential
- Glucose/protein
- Culture and PCR studies

Increased Intracranial Pressure

Clinical Manifestations

Early Signs:
- Headache
- Vomiting
- Behavioral changes
- Drowsiness
Late Signs:
- Cushing's triad
  - Hypertension
  - Bradycardia
  - Irregular breathing
- Pupillary changes
- Decorticate/decerebrate posturing
- Loss of consciousness

Management Protocol

Immediate Interventions:
- Head elevation 30°
- Midline head position
- Avoid neck compression
- Control fever
- Treat seizures
Medical Management:
- Hyperosmolar therapy:
  - 3% Saline: 5-10mL/kg bolus
  - OR Mannitol: 0.5-1g/kg
- Target serum sodium 145-155 mEq/L
- Consider dexamethasone for vasogenic edema

ICP Monitoring Indications

GCS ≤8 with abnormal CT
Normal CT with ≥2:
- Age >40 years
- Motor posturing
- Systolic BP <90 mmHg
Unable to monitor neurological status

Acute Stroke in Pediatrics

Risk Factors

Cardiac:
- Congenital heart disease
- Cardiomyopathy
- Arrhythmias
Hematologic:
- Sickle cell disease
- Thrombophilia
- Leukemia
Vascular:
- Arteriovenous malformations
- Moyamoya disease
- Vasculitis

Acute Management

Initial Steps:
- Establish time of onset
- Rapid neurological exam
- PedNIHSS score
- Emergent neuroimaging
Treatment Options:
- Consider tPA if within window
- Mechanical thrombectomy evaluation
- Neuroprotective measures
- Blood pressure management

Click to read types of pediatric stroke

Spinal Emergencies

Common Presentations

Trauma:
- Spinal cord injury
- Epidural hematoma
- Vertebral fractures
Non-trauma:
- Transverse myelitis
- Epidural abscess
- Guillain-Barré syndrome

Management Principles

Immobilization:
- Age-appropriate techniques
- Proper sizing of collars
- Log-roll precautions
Medical Management:
- Methylprednisolone protocol
- Blood pressure support
- Respiratory monitoring

Stabilization Principles

Airway Management

Indications for Intubation:
- GCS ≤8
- Unable to protect airway
- Respiratory insufficiency
- Impending herniation
Rapid Sequence Intubation:
- Premedication considerations
- Hemodynamic optimization
- Post-intubation management

Hemodynamic Goals

Age	Target MAP	Target CPP
0-30 days	45-50	40-45
1-12 months	55-60	45-50
1-10 years	65-70	50-60
>10 years	70-75	60-70

Neuroprotective Measures

Temperature Management:
- Normothermia (36.5-37.5°C)
- Therapeutic hypothermia protocols
- Active fever management
- Surface vs. invasive cooling
Glucose Control:
- Target range: 80-180 mg/dL
- Avoid hypoglycemia
- Regular monitoring
- Insulin protocols if needed
Positioning:
- Head midline position
- 30-degree head elevation
- Neck vein compression prevention
- Pressure point protection

Medication Protocols

Medication	Indication	Dosing	Considerations
3% Saline	Increased ICP	5-10mL/kg bolus	Monitor Na+ q2h initially
Mannitol	Increased ICP	0.5-1g/kg	Check serum osmolality
Phenytoin	Seizure prophylaxis	20mg/kg load	Monitor levels
Levetiracetam	Seizure prophylaxis	40-60mg/kg/day	Divided q12h

Monitoring Guidelines

Neurological Monitoring:
- Hourly GCS/FOUR Score
- Pupillary response
- Motor function
- Seizure observation
- ICP monitoring when indicated
Systemic Monitoring:
- Continuous cardiac monitoring
- Regular blood pressure checks
- Pulse oximetry
- End-tidal CO2 if intubated
- Temperature monitoring

Transport Considerations

Pre-transport Stabilization:
- Secure airway if needed
- Hemodynamic stability
- Appropriate monitoring
- Necessary equipment check
Transport Team:
- Skilled pediatric personnel
- Emergency medications
- Monitoring capabilities
- Communication protocols

Documentation Requirements

Essential Elements:
- Neurological status trends
- Intervention timing and response
- Medication administration
- Vital sign trends
- Laboratory results
- Imaging findings
- Consultations
Communication Records:
- Team discussions
- Family updates
- Consult recommendations
- Transfer details

Quality Metrics

Time-Based Metrics:
- Door to CT time
- Time to antibiotics in meningitis
- Time to anticonvulsant in status epilepticus
- Time to neurosurgical intervention
Outcome Measures:
- Mortality rates
- Functional outcomes
- Length of stay
- Complications
- Return to baseline