Pediatric Neurologic Emergencies

Patrick Van de Voorde

Pediatrische intensievezorgen &

Urgentiegeneeskunde

UZ Gent

We can do better !! (Pepe, Curr opin Crit Care 2007)

• Bulger et al, CCM 2002:

– retrospective, 34 academic centers US: 182 pt GCS8

– Large variations in care

– “aggressive centres”: mortality ratio 0.43 (95%CI 0.27;0.66)

• Van de Voorde et al, Resuscitation 2008: PENTA 2005

92 trauma cases with ISS>12; problems in AB 38/92, C 29/92, CPR 4/7, CO2 management 14/66...

The brain NEVER

forgives...

The BRAIN: a closed box (Monroe-Kelly)

The BRAIN: under attack...

Courtesy of Pekka Romsi, 2002

Children are different...

• Different insult types...

• Higher water content in younger children...

• More vulnerable BBB

• Age related CBF & CMRO2

• Age specific autoregulation limits

• Immature brain at greater risk of excitotoxicity

• Apoptosis

• Brain plasticity – on-going myelinisation

• Extracerebral differences (T, RR...)

Secondary Brain Damage

Caused by

– CMRO2 (convulsions, fever...)

– substrate delivery (hypoxemia, hypotension...)

– ICP: oedema, mass, hyperemia/hypertension

– direct cell. toxicity: hyperglycemia...

–Dose –response relation?

–Time or concentration dependent?

– multivariate model (interaction & interrelation)

Auer RN, Ann NY Acad Sci 2001; JC Hemphill III, proceedings symp. NCC, NY 2008

Kareltje, 4 months

• 36w°, neonatal ventil. 4 weeks ~ gastroschizis

• Home for 3 w; constipation

• Vomiting++, T 38° (? 1* 39.8 °C); Red blood in stool?

• ED consult adivced by pharmacist

• After 1h sudden tonic – clonic convulsions right> left + eye deviation to right

Status epilepticus

•>30’ continuous or repeated without recovery in-between

•>5’: “pending status”

Status epilepticus

• 20 - 50/100000/Y

• UK 1.2% of all ED visits; 4/1000 kids before the age of 15y

• 10% of all children with epi (early)

• ? NCSE incidence...

• 14% after stop clinical convulsions still EEG NCSE

Status epi: does it hurt??

• mors 2-6%, risk long-term morbidity

• Time is brain!!!!!

– CMRO2 – O2 consumption

– CBF – glucose

– Autonomic: tachycardia…

– after ~30’ failure homeostasis: CBF cerebr glucose; cerebr oxygenation + SYMPATIC: acidosis, hyperthermia, rhabdomyolysis, neurogenic longoedema…

A clockwork orange…

• A coma..., secretions...

• B high flow O2; (? Adequacy ventilation)

• C (sepsis?...) ; IV-IO access (!Time)

• D DRUGS – NEUROPROTECTIVE CARE...

• E environment (AMPLE…)

A clockwork orange• 5’ Benzo

– IV loraz – midaz; IR diaz / IM - IN or intrabucc midaz (dose..)

• 10’ 2de dose benzo (avoid repeating IR diaz!!)

• 5-10’ (IO if no iv access)– IV Phenytoin 20mg/kg in min. 15’ , fysio (10mg/ml, max

50mg/’)

– < 1y or Phenytoin maintenance: Fenobarbital IV 20mg/kg in 15’ (max 60mg/’)

– If Phenytoine maintenance, or no effect 1st dose: 2nd 10mg/kg Phenytoin

…on time?

• ?pyridoxine IV 100mg (Neurobion)

• ? Early

– IV Valproic acid 20 mg/kg (5mg/kg/’) unless ? metabolic or liver pathology

– IV Levetiracetam 20-30 mg/kg (max 3g, 5mg/kg/’)

• Anesthesiology & pediatric neurology input

…on time?• After 20’ refractory SE

– continuous IV dormicum (0.1 tot 1mg/kg) (+ bolus 0.2mg/kg, max 10mg)

AND/OR

– RSI intubation (?Pentobarbital ? Propofol); short-acting curare!!!

• ? NON-CONVULSIVE STATUS:

– Continuous EEG monitoring

– Postictal and/or medication effect vs NCSE

“E”• Hx: known epi, fam, medical disease, medication

or drugs, trauma, AMPLE

• Clinical: signs of infection, lateralisation, focal, partial vs gegeneralised; coma (8-10% possible NCSE)

• Biochemical: PBC, electrolytes, bloodgas, glycemia, liverfct, toxicology and AED levels (admission, 10’ after loading dose..)

• Radiology: CT, NMR

Kareltje, 4 months

• Clinical: fontanel +++

• Hb 8.1, WBC 22800, thrombo normal, coag. normal, Na 128, gluc 156, CRP 1.7, sGOT 234, CK 2150

• LP (?): WBC 200 RBC 49000

• CT: ….

• Intubated, continuous dormicum HD…

• ICP measurement!

COMA

What if Kareltje was admitted with ... without convulsions...

the pediatric brain under attack ..• Hypoxic-ischemic e.g. Shock...• Primary CNS

– Convulsive– Trauma– Intracran. Mass– Central neurological– Infectious, ADEM…

• Systemic– Glycemic ( DEFG: DON’T EVER FORGET GLUCOSE); DKA– Acidosis; CO2; metabolic diseases...– Na, Ca– Temperature– Liver or renal failure– SIRS– Endocrine (panhypopit, thyroid, adrenal…)– Hypertensive crisis

PROTECT UW BRAIN..

…You only have 1 !!

WAT MAKES the DIFFERENCE?

• Normoxemia (fiO2, ?intubation)

• Normocapnia

• CPP (= MAP-ICP); ICP (etiology?)

• CMRO2: convulsions, T°, analgosed.

• Normoglyc, Sodium...

• Systemic derangements!!

COMA IS A multiSYSTEMIC disease

• Hypertension: medic, ICP, adrenerg…• Hypotension: neurogenic ‘stunned’ myocard…• Resp. failure (pCO2 – pO2): aspiration, AW

obstruct, ALI, spinal, Neurogenic LO (OS ~ hypothal dysfct)

• Endocrien: DI / SIADH, CSW (BNP), Adrenal insuff, euthyroid sick sinus…

• GI• Infectious• Autonomic dysfct (T°…)

KARELTJE: level of consciousness?

• lethargic, stupor….

• Alert – Verbal – Pain – Unresponsive

• GCS 8 (Child’s Glasgow Coma scale BPNA 2001)

– Score best answer if unclear or asymmetr.

– Score as usual if interferences (T, P…)

Pediatric GCS

> 5 years < 5 years

Eye

E4 Spontaneous

E3 To voice

E2 To pain

E1 None

C Eyes closed (by swelling or bandage)

Verbal

V5 Orientated (in person or placeor address)

Alerts, babbles, coos, words orsentences to usual ability (normal)

V4 Confused Less than usual ability, irritable cry

V3 Inappropriate words Cries to pain

V2 Incomprehensible sounds Moans to pain

V1 No response to pain

T Intubated

Pediatric GCS

Motor (arms)

M6 Obeys commands Normal spontaneous movements

M5 Localises to supraorbital pain (>9months of age; thumb beneath medial end eyebrow) ) or withdraws to touch

M4 Withdraws from nailbed pain (pressing hard on flat nail surface with the barrel of a pencil)

M3 Flexion to supraorbital pain (decorticatie)

M2 Extension to supraorbital pain (decerebration)

M1 No response to supraorbital pain (flaccid)

P Paralysed (medication or mechanical)

KARELTJE: HOW TO..?

• ABC (+100% O2)

• D: level of severity & adequate R/

• Assess + act + reassess

• History; Clinical evaluation

• Monitoring / Parameters / diagnostic tests

Kareltje: ABCDE• Avoid hypoxemia: initially FiO2 100%, then ~

sat 94-98%

– Fct of FiO2, PEEP, TV (not RR)

• Avoid hypo- or hypercapnie!! (except RESCUE)

– ? etCO2 guidance

– Normoventilatie: infant 25-30/’ child 20-25/’

• Intubation:

– Sometimes necessary, live-saving but dangerous!

– Rapid Sequence Intubation

ABCDE: do NOT tolerate HYPOTENSION

• Euvolemia• SAFE study: higher mortality with Albumin vs Fys• Avoid hypotonic fluids; ? hypertonic • Cave coagulopathy

• Inotropic and Vasopressor support– Noradr.: most efficient on MAP, most predictable– Dopamine: ?brain oedema, hormone suppresion– Adrenaline: ICP elevation?– Vasopressin:?

• Head position

Safe study, NEJM 2007; Pfister, Eur J Anaesth Suppl 2008; Steiner, CCM 2004; Samant, J Neurotrauma 2008

Targeted management CPP

ABCDE: ICP lowering strategies

• Adequate analgosedation!!

• Veneuze outflow

• Osmotherapy

• pCO2

• CSF drainage

• Steroiden: most often NOT!! (certain indications...)

Osmotherapy

• Mannitol: euvolemic pt, high dose bolus (15’)– fast

– Max Posm 320mOsm/l

– Diuretic, risk ATN; ? Reverse osmosis, ? rebound

• Hypertonic Salt: bolus (15’)– Better hemodynamic profile (small-volume

resusc.), less RDS?...

– No proven impact on survival

– Hyperchloremic acidosis (HY-SALT trial), max Posm360 mOsm/l, cave rebound!

Cochrane2005, CD001049; Battison, CCM 2005; Cooper, JAMA 2004; Levine CCM 2006

ABCDE: GOOD CLINICAL PRACTICE• AVOID HypoNa+!

• AVOID HypoMg2+

• AVOID Hypo- / hyperglycemia

• AVOID convulsions (?NCSE)

• AVOID hyperthermia!! (?pre-emptive)

• Prevention for DVT, ulcus, VAP...

Polderman, ICM 2003; Nadler, Lancet 1998; Bilotta, Neurocritical care 2008; Vespa, CCM 2007

IMMINENT Herniation

Symptoms >>>> “RESCUE” >>>> NeuroCH

• Optimal. analgosedation

• Mannitol 20% 1-1.5g/kg in 15’

• Hypertonic salt e.g. NaCl 3% 4ml/kg in 15’

• Moderate Hyperventilation (pCO2 ~ 30mmHg)– follow-up brain oxygenation?

• NEUROCH: evac mass, decompression!

Neurological symptoms and fever....

What if Kareltje was admitted with ...

Convulsions with fever….

• Frequent (~5% prevalence <7j), mostly benign!

• About 10% prolonged: R/ if >5’

• LP?: “each child with fever” – Risk herniation exists

– Funduscopy high specific, low sensitive

– If diminished consciousness always CT before LP

– Never LP if GCS < 8 or clinical signs of ICHT

– ? PBC - Coagulation

Meningitis

• Clinical

– Fever; Meningeal signs (>2 jr)

– consciousness, convulsions (31%), ICHT

– Focal Signs• Subdural collection, abcedation or vascular

– Cranial nerve• Direct inflammation, compression, ICHT

• Biochemistry, LP

• Bacterial? (Meningococcal, pneumococcal, Listeria, E coli..)

Fysiopathology meningitis

– Colonisation + infection

– Hematogenic invasion

– Meningeal invasion

– Meningeal and cerebral inflammation• Bacterial lysis (role AB)

• cerebral vascular lesions (thrombosis), circulation CSF +inflammation parenchym (cerebritis)

– Cerebral oedema + ICHT• Vasogenic, cytotoxic en interstitiëel

Complications bacterial meningitis

– Mortality 3-13%

– SIADH 6-17%

– Subdural collections 10-40%

– Convulsions 6-44%

– Cranial NN 3-13%

– Hemiparesis 3-13%nge termijn

– Neurologic long-term 6-40%

– Hydrocephalus 0-5%

– Deafness 5-43%

Treatment bacterial meningitis

– Neuroprotective and supportive (incl ABCD)

– Etiological

• Steroids (bv. solumedrol 1mg/kg) before antibiotics (or < 60’ after)

• Cetotaxime IV (+ Ampicilline IV) (50 mg/kg Q6u)

– Do NOT wait with R/ because of LP!

? Viral (meningo-) encephalitis

• Suspected if diminished consciousness and 1 or more criteria

– Focal neurological signs

– Changing consciousness for >6h

– Contact with e.g. Herpes, viral coryza...

– No clear etiology of lower consciousness

• LP : routine; viral PCRs (Herpes!, NPE, Coxsackie..)

• Liver tests? Serology? EEG? MRI?

• dD toxic encephalopaty, ADEM...

Treatment presumed viral encephalitis

• Neuroprotective care

• Etiological

– Aciclovir IV (>3mnd: 1500mg/m2/day q8h) 14-21 days, earlier stop if no longer suspicious for herpes

– Consider Ciproxine IV

– Do NOT wait for LP!

– No use for steroids? unless

• POST infectious, Cerebellitis, Limbic...