Neurologic Emergencies and Stabilization in Pediatrics

Neurologic Emergencies and Stabilization in Pediatrics

Introduction

Neurologic emergencies in the pediatric population represent a diverse group of potentially life-threatening conditions that require prompt recognition and intervention. The developing nervous system of children responds differently to insults compared to adults, and age-specific considerations are crucial for optimal management. This guide provides an overview of common pediatric neurologic emergencies, emphasizing rapid assessment, stabilization, and initial management strategies.

General Principles of Assessment

Primary Survey

Follow the ABCDE approach with attention to neurologic status:

  • Airway: Assess patency and protect as needed, considering C-spine immobilization in trauma cases.
  • Breathing: Evaluate respiratory rate, effort, and oxygenation. Be alert for patterns suggestive of increased intracranial pressure (e.g., Cheyne-Stokes respiration).
  • Circulation: Monitor heart rate, blood pressure, and perfusion. Recognize that Cushing's triad (hypertension, bradycardia, and irregular respirations) is a late sign of elevated intracranial pressure in children.
  • Disability: Rapidly assess neurologic status using age-appropriate scales:
    • AVPU scale (Alert, Voice responsive, Pain responsive, Unresponsive)
    • Pediatric Glasgow Coma Scale (GCS)
    • Pupillary response, posturing, focal deficits
  • Exposure: Fully expose the patient while preventing hypothermia. Look for signs of trauma, infection, or toxidromes.

Secondary Survey

Once the patient is stabilized, conduct a more detailed neurologic examination:

  • Mental status: Level of consciousness, orientation, behavior
  • Cranial nerves: Particularly note pupillary responses, extraocular movements, and symmetry of facial movements
  • Motor function: Strength, tone, abnormal movements
  • Sensory function: When feasible based on the child's age and cooperation
  • Reflexes: Deep tendon reflexes, plantar responses, presence of clonus
  • Cerebellar function: Assess gait and coordination if appropriate
  • Meningeal signs: Nuchal rigidity, Kernig's and Brudzinski's signs (recognizing limitations in younger children)

History

Obtain a focused history from caregivers or prehospital providers:

  • Onset and progression of symptoms
  • Recent illnesses or injuries
  • Developmental history and baseline neurologic function
  • Medications and allergies
  • Relevant family history (e.g., bleeding disorders, metabolic conditions)

Specific Neurologic Emergencies

1. Status Epilepticus

Defined as continuous seizure activity lasting >5 minutes or recurrent seizures without return to baseline.

Management:

  1. Stabilize ABCs; administer oxygen and place the patient in the lateral decubitus position if not intubated.
  2. Secure IV/IO access and send labs (glucose, electrolytes, AED levels if applicable, toxicology screen).
  3. Treat hypoglycemia if present (D10W 2-4 mL/kg).
  4. Administer antiepileptic drugs in a stepwise manner:
    • First-line: Benzodiazepines (e.g., lorazepam 0.1 mg/kg IV/IO, max 4 mg/dose; or midazolam 0.2 mg/kg IM, max 10 mg/dose)
    • Second-line: Fosphenytoin (20 mg PE/kg IV/IO) or valproic acid (40 mg/kg IV/IO) or levetiracetam (60 mg/kg IV/IO)
    • Third-line: Phenobarbital (20 mg/kg IV/IO) or continuous infusions (midazolam, pentobarbital) with ICU admission and EEG monitoring
  5. Identify and treat underlying causes (e.g., meningitis, hemorrhage, metabolic derangements).

2. Bacterial Meningitis

A life-threatening infection of the meninges requiring immediate intervention.

Management:

  1. Stabilize ABCs; avoid delays in antimicrobial therapy for neuroimaging in most cases.
  2. Obtain blood cultures and initiate empiric antibiotics based on age and local resistance patterns:
    • 0-1 month: Ampicillin + cefotaxime + acyclovir (if HSV suspected)
    • 1-3 months: Ceftriaxone/cefotaxime + vancomycin + acyclovir
    • >3 months: Ceftriaxone/cefotaxime + vancomycin
  3. Consider dexamethasone (0.15 mg/kg/dose IV q6h) in Hib and pneumococcal meningitis, ideally before or with the first dose of antibiotics.
  4. Perform lumbar puncture if no contraindications (e.g., signs of elevated ICP, coagulopathy, soft tissue infection at LP site).
  5. Manage increased ICP if present (head elevation, osmotic therapy, hyperventilation in severe cases).

3. Acute Ischemic Stroke

Although less common than in adults, pediatric stroke requires a high index of suspicion for timely diagnosis.

Management:

  1. Stabilize ABCs and avoid hypotension to maintain cerebral perfusion pressure.
  2. Rapidly obtain neuroimaging (non-contrast head CT and/or MRI with diffusion-weighted imaging).
  3. Consider thrombolysis with tPA in select cases (within 4.5 hours of onset, no hemorrhage on imaging, consult with pediatric stroke expert).
  4. Initiate aspirin therapy (3-5 mg/kg/day) once hemorrhage is excluded, unless thrombolysis was administered.
  5. Investigate underlying causes (congenital heart disease, thrombophilias, vasculopathies).
  6. Admit to a pediatric ICU or stroke unit for close monitoring and early rehabilitation.

4. Intracranial Hemorrhage

May be spontaneous (e.g., AVM rupture, coagulopathy) or traumatic. Rapid deterioration can occur.

Management:

  1. Ensure airway protection and adequate ventilation; intubate if GCS ≤8.
  2. Elevate head of bed to 30 degrees and maintain neck in neutral position.
  3. Target normotension and euvolemia; cautiously treat severe hypertension.
  4. Correct coagulopathy if present (FFP, vitamin K, platelets, or factor replacement as indicated).
  5. Administer osmotic agents (mannitol 0.5-1 g/kg or 3% hypertonic saline 5-10 mL/kg) for signs of elevated ICP.
  6. Urgent neurosurgical consultation for possible EVD placement or hematoma evacuation.
  7. Control seizures and maintain normothermia.

5. Traumatic Brain Injury (TBI)

Pediatric TBI has unique pathophysiological responses compared to adults.

Management:

  1. Adhere to ATLS principles with emphasis on oxygenation and perfusion.
  2. Avoid prophylactic hyperventilation (maintain PaCO2 35-40 mmHg unless signs of impending herniation).
  3. Maintain age-appropriate systolic blood pressures to ensure adequate cerebral perfusion pressure (CPP).
  4. Rapid CT imaging for moderate to severe TBI; consider CT angiography if vascular injury suspected.
  5. ICP monitoring for GCS ≤8 or abnormal CT findings; target ICP <20 mmHg and age-appropriate CPP.
  6. Encroach hyperosmolar therapy judiciously (mannitol or hypertonic saline) for elevated ICP refractory to sedation and CSF drainage.
  7. Early seizure prophylaxis with levetiracetam or phenytoin, especially in severe TBI.
  8. Consider decompressive craniectomy in specific scenarios (e.g., diffuse cerebral edema with refractory ICP elevation).

6. Acute Demyelinating Encephalomyelitis (ADEM)

An immune-mediated inflammatory disorder often following a viral illness or vaccination.

Management:

  1. Supportive care with close monitoring of airway and neurologic status.
  2. High-dose intravenous methylprednisolone (20-30 mg/kg/day, max 1 g/day) for 3-5 days, followed by oral prednisolone taper.
  3. Consider IVIG (2 g/kg divided over 2-5 days) or plasmapheresis in severe or steroid-unresponsive cases.
  4. Neuroimaging (preferably MRI) to confirm diagnosis and exclude other pathologies.
  5. CSF analysis to rule out infection and evaluate for oligoclonal bands.
  6. Rehabilitation services for residual deficits.

7. Increased Intracranial Pressure (ICP)

A common pathway in many neurologic emergencies that requires vigilant monitoring and aggressive management.

Management:

  1. Elevate head of bed to 30 degrees with head midline.
  2. Provide adequate sedation and analgesia; avoid noxious stimuli.
  3. Maintain normothermia, normoglycemia, and normovolemia.
  4. Treat seizures promptly.
  5. Osmotic therapy:
    • Mannitol: 0.25-1 g/kg IV bolus over 10-20 minutes; repeat q4-6h as needed. Monitor serum osmolality and electrolytes.
    • Hypertonic saline (3%): 2-5 mL/kg bolus over 10-20 minutes; may be followed by continuous infusion (0.1-1 mL/kg/h). Target serum sodium 145-155 mEq/L.
  6. Consider short-term hyperventilation (target PaCO2 30-35 mmHg) for impending herniation, but not as a prolonged strategy.
  7. CSF diversion via external ventricular drain in select cases.
  8. Neurosurgical decompression for refractory elevations or specific pathologies (e.g., posterior fossa lesions).

Diagnostic Studies

Neuroimaging

  • Computed Tomography (CT):
    • Rapid, widely available; best for detecting acute hemorrhage, hydrocephalus, mass effect, or skull fractures.
    • Limitations include radiation exposure and poor visualization of posterior fossa and brainstem.
  • Magnetic Resonance Imaging (MRI):
    • Superior tissue contrast and multiplanar imaging; ideal for evaluating myelination, white matter diseases, and subtle parenchymal abnormalities.
    • Constraints include longer acquisition times, need for sedation in young children, and limited availability in some centers.
  • Consider CT or MR angiography/venography when vascular pathologies are suspected.

Laboratory Studies

  • Basic metabolic panel, complete blood count, coagulation studies.
  • Toxicology screen in appropriate clinical contexts.
  • Blood cultures if infection is suspected.
  • Serum lactate and pyruvate levels, ammonia in suspected metabolic disorders.
  • CSF analysis when safe:
    • Opening pressure, cell count with differential, protein, glucose.
    • Gram stain, culture, PCR for pathogens.
    • Oligoclonal bands, IgG index in demyelinating conditions.

Electroencephalography (EEG)

  • Crucial for diagnosing non-convulsive status epilepticus.
  • Helps assess cortical function in comatose patients.
  • Continuous EEG monitoring recommended in patients with refractory status epilepticus or those receiving pharmacologic neuromuscular blockade.

Pharmacologic Considerations

Rapid Sequence Intubation (RSI) in Neurologic Emergencies

Choose agents that will not exacerbate increased ICP:

  • Premedication: Consider fentanyl (1-2 mcg/kg) to blunt sympathetic response.
  • Sedation: Etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) in hemodynamically unstable patients.
  • Paralysis: Rocuronium (1 mg/kg) or succinylcholine (1-2 mg/kg, avoid in crush injuries or burns >24h old).

Analgesia and Sedation

  • Optimize analgesia to minimize pain-induced ICP elevations.
  • Short-acting agents preferred (e.g., fentanyl, remifentanil) to allow neurologic assessments.
  • Propofol infusion may be used cautiously for sedation; monitor for propofol infusion syndrome.
  • Avoid benzodiazepines if serial exams are crucial, or use short-acting options (midazolam).

Anticonvulsants

  • Levetiracetam: Fewer drug interactions, no hepatic metabolism. Load 40-60 mg/kg (max 3000 mg).
  • Fosphenytoin: Faster administration, less irritation than phenytoin. Load 20 mg PE/kg.
  • Valproic acid: Consider in refractory cases. Load 40 mg/kg (max 3000 mg).
  • Avoid hepatic enzyme-inducing AEDs in patients requiring chemotherapy or anticoagulation.

Neuromonitoring in the ICU

Multimodal monitoring can guide management in severe neurologic injuries:

  • Intracranial pressure (ICP) monitoring: Intraventricular catheter (gold standard, allows CSF drainage) or intraparenchymal monitor.
  • Brain tissue oxygen tension (PbtO2): Target >20 mmHg.
  • Cerebral microdialysis: Measures local brain metabolism (glucose, lactate, pyruvate, glutamate).
  • Transcranial Doppler: Non-invasively assesses cerebral blood flow velocities; useful for monitoring vasospasm or evaluating cerebral circulatory arrest.
  • Near-infrared spectroscopy (NIRS): Provides a measure of regional cerebral oxygenation.

Family-Centered Care and Communication

  • Provide frequent updates to family members using clear, jargon-free language.
  • Acknowledge the uncertainty in prognostication, especially in the acute phase.
  • Involve child life specialists and spiritual care as appropriate.
  • Prepare families for the ICU environment (alarms, equipment, patient's appearance).
  • Discuss goals of care and consider palliative care consultation in severe cases.

Disposition and Follow-up

  • Most pediatric neurologic emergencies warrant ICU admission for close monitoring and management.
  • Arrange follow-up with pediatric neurology, rehabilitation services, and other subspecialties as indicated.
  • Provide resources for family support and education about the specific condition.
  • Consider neurodevelopmental follow-up to assess long-term outcomes and academic needs.

Prevention of Secondary Injury

Vigilantly avoid and promptly correct factors that can exacerbate neurologic injury:

  • Hypoxemia (target PaO2 >80 mmHg or SpO2 >95%)
  • Hypotension (maintain age-appropriate SBP; in general, SBP >70 mmHg + (2 × age in years))
  • Hyper- or hypocarbia (aim for normocarbia with PaCO2 35-40 mmHg unless otherwise indicated)
  • Hyper- or hypoglycemia (target glucose 100-180 mg/dL)
  • Fever (maintain normothermia; consider targeted temperature management in select cases)
  • Hyponatremia (which can exacerbate cerebral edema; correct cautiously)
  • Seizures (including subclinical seizures, hence the importance of cEEG in high-risk patients)

Further Reading

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