Neurologic Emergencies

Published on 06/06/2015 by admin

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10 Neurologic Emergencies

Pediatricians may encounter neurologic emergencies caused by both primary nervous system dysfunction and secondary systemic illness in children with and without underlying neurologic diseases. True neurologic emergencies include acute seizures, altered level of consciousness (ALOC), increased intracranial pressure (ICP), spinal cord compression, and stroke. This chapter focuses on acute seizures (specifically status epilepticus [SE]), ALOC, and the emergent aspects of increased ICP. A detailed discussion of other neurologic disorders is presented in Section XIII.

Status Epilepticus

A seizure is defined as a transient, involuntary alteration of consciousness, behavior, motor activity, sensation, or autonomic function as a result of hypersynchrony and increased rate of cerebral neural discharges (Figure 10-1). Between 3% and 6% of children have at least one seizure in the first 16 years of life. Many seizures are associated with fever. Seizures can occur in individuals with underlying tendencies to seize (i.e., epilepsy) or secondary to other processes that primarily or secondarily affect the central nervous system. Seizures are discussed in detail in Chapter 74.

SE is the most common medical neurologic emergency of childhood and is defined as a group of seizures in rapid succession without remittance or a continuous prolonged episode. Historically, SE had been defined as a seizure that lasted more than 30 minutes. However, in a recent study, first- and second-line medications were effective in terminating seizures in 86% of cases when the duration was less than 20 minutes at presentation and only 15% of cases when it exceeded 30 minutes. As a result, most experts now define SE as a seizure lasting more than 5 minutes in recognition of the importance of rapid recognition and treatment.

Clinical Presentation

Physical Examination

Clinically, seizures are divided into those with generalized onset and those with partial (focal or localization related) onset. Generalized seizures usually involve the entire cerebral cortex, and consciousness is lost. In generalized tonic-clonic seizures, the child falls to the ground unresponsive, the eyes deviate, the muscles contract, and there may be incontinence of urine or stool. The body then begins to shake rhythmically in the clonic phase. After the seizure, there is a postictal period of decreased responsiveness; occasionally, there may be weakness or paralysis of an area of the body (Todd’s paralysis). Absence seizures are a type of generalized seizure characterized by brief loss of consciousness, typically without loss of posture or tone and no postictal period. Simple partial seizures typically present with focal motor signs, although sensory, autonomic, and psychic phenomena are possible. Unlike generalized seizures, consciousness is typically not impaired in partial seizures.

Other than seizure type, the physical examination in a child in SE should focus on eliciting the cause of the seizure. Fever may be a sign of infection. Meningismus and a toxic appearance can be suggestive of meningitis. A toxidrome may lead the clinician to look for potential toxic ingestions (see Chapter 9). Significant hypertension implies hypertensive encephalopathy. Although a complete neurologic examination is difficult in a seizing patient, focal neurologic signs can suggest intracranial or spinal lesions. The entire body should be examined for signs of trauma. Dysmorphic features may be associated with nervous system abnormalities.