CNS Emergencies in Paediatrics

Objectives

• Management of child with deteriorating LOC• Convulsions

Causes of Cerebral pathologies

• Diffuse insults – 95%

• Structural – 5%

Diffuse pathologies can produce asymmetrical neurological signs

DiseaseInjuryIntoxication

DrowsinessMild reduction in alertnessIncrease hours of sleep

Deep comaUnrousable, Unresponsive

AssessmentGCS

Increased Intracranial pressure inside a rigid cranial cavity

• Uncal syndrome (Uncus of the hypocampal gyrus herniare through the tentorium)

• 3rd nerve palsy and ipsi-latarel dilated pupil• External occulomotor palsy• Hemiplegia

• Central syndrome (Cerebella tonsil herniate through foramen magnum)

• Neck stiffness• Slow pulse, high pressure, irregular breathing, apnea

OBJECTIVES OF MANAGEMENT

• ABCD• ? Cerebral edema• ? Infections• ? Other causative factors (What investigations? )

Continuous monitoring and support till patient recovers

Air way in an Unconscious child

• Basic life support – Suck out secretions– Neck position, chin lift…– Oropharyngial airways

• Air way if LOC• Indications for Intubation

– Failed maintain airway by above measures– For ventilating – (example: Increased ICP)

• Empty the stomach

Breathing in an unconscious child

• Give oxygen - but patient may be in respiratory failure

– Via nasal catheter or mask– Blood gases / Monitor saturations while in air

• Indications to ventilate– Failure to maintain saturations by above– Increased intracranial pressure

Circulation in an unconscious child

• IV line – Blood samples for FBC, Sugar, U&E, LFT• Assess & Manage the Circulation•

Cold extremities, CRF, Pulse, Pulse pressure, BP, UOP, Effects on the brain…. • Give fluid bolus Rpt SOS• Ionotrophes

• Failed IV Lines Intra Osciuse• Fluid restriction 60% of requirement – Remember

perfusion is also important

D – Don’t Ever Forget Glucose

• Hypoglycemia– If < 3 m.mol/l 5ml/kg of 10 % dextrose– No Facilities to check 5 ml/kg of 10 % Dextrose– NEVER give 25 or 50% dextrose

• Hyper glycaemia is equally bad !!– Restrict amount of dextrose– May need insulin infusions

D – Assess the level of conscious level

• AVPU scale • A – alert ( GCS >12) • V- responding to voice (GCS<12) , • P- responding to pain only (GCS <8) • U – no response to pain (GCS<4)

• If AVPU score is <8– Air way protection – OP/NP air way– Empty the stomach – but not in dengue

Secondary assessment Look for pathologies

endangering life

What are the Causes of Coma

• Ischemia • shock or increased ICP

• Hypoxia• Infections

• meningitis, Encephalitis, malaria

• Metabolic• Seizure disorders• SOL

• Snake bite• Poisoning• Trauma and hemorrhage,

NAI • Encephalopathies -

hypoglycemia, electrolyte disturbances,

• Liver failure and renal failure

• RS failure and CVS malfunctioning

Can this be infection ?

• Fever – Febrile status epilepticus – (25% meningitis)

• Investigations suggestive of infections• If infection is a possibility

– Cefotaxime or C Penicillin + Chlorampenicol– Quinine– Acyclovir

• Whether to do a LP?

Indicators of Acute Bacterial Meningitis in Children

• Lethargy• Irritability• Inconsolable cry • Cyanosis• Impaired consciousness• Partial seizures • Bulging fontanelle • Neck stiffness• Seizures outside the febrile convulsions age

range

Traditional physical signs may not be helpful

• Bulging fontanel - unhelpful in infants• Age less than 1 yr (6mo) is not a good

predictor• Neck stiffness +/- bulging fontanels present

only in 42% of cases • 41% of meningitis cases had LRTI

When to do a lumbar puncture?

• When ever you suspect meningitis

• If there are no contraindications

Relative contraindications to Lumbar Puncture

• Prolonged or Focal seizure• Focal neurological signs• ( GCS < 13)• Coagulation disorders or thrombocytopenia• Papilloedema• Hypertension• Focal sepsis at LP site• Increased ICP

INCREASED INTRACRANIAL PRESSURE

• Cushing triad – slow pulse, raised BP, irregular Respiration

• Pupils – Dilated or constricted - bilateral or unilateral • Breathing – Hyperventilation or apnea • Papiloedema• Oculocephalic reflexes – lateral ,vertical• Posture

• Decorticate – flexed arms ,extended limbs• Decerebrate – Extended arms & Extended legs

INCREASED INTRACRANIAL PRESSURE MANAGEMENT

• Fluid restriction 50-60% of requirement• Manitol 250-500mg/kg; 1.25 -2.5 ml/kg of 20%

solution over 20 minute 2 hourly• Ventilate to keep CO2 at 30-34 mm.Hg• Dexamethasone – 0.5mg/kg 6 hourly• Nurse with 20-30* head up

Could this be post ictal

• History• No need to give Diazepam if NOT fitting now• Proceed with care for unconscious child

Could this be SOL ?Features that may suggest a SOL

• Focal neurological signs• Unequal pupiles• Cranial nerve palsies• Hemipheresis of cortical type

• Head ache• Up going planters• Endocrine effects

SOL - Management

• CT or MRI • Dexamethasone • Manitol• Ventilate

Trauma or Intracranial bleeding

• History• History and signs may not be evident• Evidence of trauma• CT/MRI• Co existing complications like poisoning

Respiratory or Circulatory failure?

• ABC care will detect this• Reevaluate for ABC

Hypertensive encephalopathy

• Check the BP• May present with facial palsy

Poisoning

• History• Circumstances• Smell of poison• Pin point pupils

– Opiates– Organophosphate

Further general treatment of coma

• Blood sugar • Treat hypoglycemia and control hyperglycemia

• Fluid restrict up 60% but correct dehydration• Maintain Serum Na – 135-145 mmol/lt• Treat seizures• Manage ICP

CARE OF THE UNCONSCIOUS

• Empty the stomach• Maintain the semi prone posture, turning frequently • Provide proper skin care, mouth care • Eye ointment , using eye pads• Bladder• Bowels• Nutrition

The Convulsing Child

The Convulsing ChildCommon causes

• Fever

• Abrupt withdrawal of anticonvulsants

• CNS infections

• Cerebral hypoxia

• Metabolic abnormalities

The Convulsing ChildAssessment

Disability – distinguish fit from

o Posturing (from raised ICP)

o Dystonic reactions

o Pseudo-epilepsy

Don’t Forget to check Glucose level

The Convulsing ChildInitial Resuscitation

• Open and maintain airway

• High flow oxygen

• Ventilatory support if necessary

• Give glucose if necessary

• Manage convulsion

Convulsing ChildAlgorithm

Paraldehyde 0.4 ml/kg PR Phenytoin 20mg/kg over 20 mt or Phenobarb IV/IO

Rapid Sequence Induction with Thiopentone

Diazepam 0.25 mg/kg or Midazolam 0.15 mg/kg IV/IO

YES NO

5 minutes

AirwayHigh-flow oxygen

Don't ever forget glucose

Diazepam 0.5 mg/kg PR or Midazolam 0.15 mg/kg IM

5 minutes

Get Help

Vascular Access?

Diazepam 0.25 mg/kg or Midazolam 0.15 mg/kg IV/IO

10 minutes

Diazepam 0.5 mg/kg PR or Midazolam 0.15 mg/kg IM

10 minutes

Access

Access & Help

Status EpilepticusMedical complications

• Cardiac dysrhythmias• Hypertension• Myoglobinuria• Pulmonary oedema• Hyperthermia• Disseminated intravascular coagulation

The Convulsing ChildKey Features

Convulsion with:• irritability/fever/rash meningitis• rapid onset poisoning/CVA• head/multitrauma intracranial injury• hypertension hypertensive encephalopathy

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