Podcast #122 - Pediatric Neurological Emergencies with Lawrence Berdan

Lawrence Berdan is a paramedic who has personally experienced the importance of recognizing and acutely managing pediatric neurological emergencies.  This post discusses some of the emergencies we may see in this uniquely challenging population.

Both in EMS and in the ED, we are used to the "hustle and bustle" of the system.  Lawrence talks particularly in regards to the EMS aspect where a thorough history and assessment may be skipped to perform other (often less important) aspects of care such as establishing an IV.  Parents may not be able to go directly to the hospital, are not knowledgeable as to the situation, under stress from the current situation, or simply not available.  As a result, sometimes by the rapid actions we can have inadvertent negative outcomes.

Traumatic Brain Injury

On of many sources that discusses the key aspects of traumatic brain injuries (TBIs) is the University of Miami.  In a recent discussion of CDC guidelines, they discuss some key features.

Mild traumatic brain injury (mTBI) symptoms may include the following:

• Blank Stare
• Dizziness
• Nausea
• Difficulty getting up
• Trouble doing homework

 
More serious findings that would be concerning for a clinically important traumatic brain injury (ciTBI) include the following:

• Becomes confused or agitated (with respect to predisposition demeanor [i.e. puberty or PMS])
• Slurred speech
• Extremely drowsy or can’t wake up
• Seizures (Febrile seizures-usually from an infection) Simple febrile lasts a few seconds to 15 minutes and only happens once in 24-Hours.  Complex febrile seizures last longer than 15 minutes and occurs more than once in 24-hours. 
• Vomiting repeatedly
• Loss of hand-eye coordination (typical tasks such as tying shoes, unlocking doors, or clumsy
• Headaches in 50% of pediatrics present with the headache where the injury likely occurred.

Keep in mind that some of these symptoms can be difficult to discern fully and a good history and physical are essential.  We have discussed rapid neurological assessments in the past on Podcast #70, but it is worth remembering that children will be a little more difficult to assess.  However, the well researched and highly supported PECARN Algorithm is a powerful tool to risk stratify these patients.

Prevention is preferred whenever possible.  The CDC's Heads Up program outlines some of the key components such as proper safety equipment, early recognition, following rules, and taking the appropriate risks.
 
Stroke

Pediatric strokes can be a diagnostic challenge.  The National Stroke Association has a dedicated section on pediatric strokes that is worth reviewing.  We have included the highlights here.  Stroke happens in about 1 in 4,000 live births.  The risk of stroke from birth through 18 is approximately 11 in 100,000  with boys and children of African descent being at the highest risk for stroke. 
 
Common risk factors including the following:

• Congenital heart defects-Aortic stenosis, atrial septal defect, coarctation of aorta, patent ductus arteriosus, and patent foramen ovale
• Sickle-Cell disease
• Immune Disorders
• Blood disorders such as abnormal blood clotting-Hemophilia
• Diseases or disorders of the arteries (Moyamoya-Blocked arteries at the base of the brain, dissection, and vasculitis)
• Head or neck trauma
• Infections such as meningitis or encephalitis
• Trauma
• Metabolic disorders such as mitochondrial myopathy, encephalopathy, and lactic acidosis
• Maternal history of infertility
• Maternal infection in the fluid surrounding an unborn baby
• Premature rupture of membrane during pregnancy
• Eclampsia and pre-eclampsia

 
Unique Symptoms
It is easy to miss stroke symptoms in very young children.  Newborns are unable to communicate and a complete maternal history may not always be available or even known to the mother.  The popular stroke warning assessment, FAST, has been well used in adults but can be used in children with some modifications.  "BE FAST" has included two more components to help reduce the risk of missed strokes.

B - Balance - Poor stability and/or coordination that can be assessed with simple cerebellar activities such as walking

E - Eyes - Double vision (diplopia) or blindness in one or both eyes can be challenging and requires a certain amount of patient input to assess

F - Facial Palsy - Often seen when asking patient to smile 
 
A - Arm Weakness - Similar to adults, but may require some imaginative play such as asking the child to stick out their arms like they are flying 
 
S - Speech - Conversation alone may be sufficient and parents can help clarify what is  baseline
 
T - Time - As with adults, it is vital to recognize the onset of occurrence
 
Symptoms of stroke can include the following:

• Sudden onset of severe and progressive headaches
• Eye movement problems and sudden impaired vision
• Sudden numbness or weakness in the face, arm, or leg particularly one side of the body
• Difficulty speaking or understanding words
• Difficulty swallowing
• Dizziness, loss of balance or lack of coordination
• Brief loss of consciousness, seizures
• Sudden inability to move part of the body

 
Early recognition and management is vital to avoid long term effects such as the following: 

• Unilateral weakness or paralysis of one side of the body
• One-sided neglect, which causes the stroke survivor to ignore or forget about the weaker side
• Difficulty with speech and language
• Trouble swallowing (Dysphagia)
• Decreased field of vision and trouble with visual perception
• Loss of emotional control or change in moods
• Cognitive changes
• Problems with memory, judgment, and problem solving
• Behavioral and/or personality changes
• Improper language or actions
• Development of epilepsy

 
Many therapies are managed at home and in hospital such as controlling high blood pressure, supportive care to maintain normal body temperature (generalized sickness, sepsis, and/or possible neuro storm), proper hydration, blood sugar levels, seizure detection via EEG and anticonvulsant medication (some remain on the medication prophylactically), managing intracranial pressure (ICP), blood transfusions for children with sickle-cell disease, antithrombotic therapy, surgery related to hemorrhagic stroke to relieve pressure (craniotomy).  

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on iTunes.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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