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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