Neurologic Emergencies and Stabilization in Pediatrics

Topic Name Introduction Status Epilepticus Altered Mental Status Increased ICP Acute Stroke Spinal Emergencies Stabilization Principles

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

Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.