Neurologic emergencies: Guidance for quick, appropriate intervention

Donald Gilbert, MD, FAAP

Neurologic emergencies require quick thinking and fast action. They can be scary even for experienced emergency clinicians, let alone the office-based physician.

In a presentation on Saturday, November 3, at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida, titled "Emergency neurology: Brain 911," Donald Gilbert, MD, FAAP, professor of Pediatrics and Neurology at Cincinnati Children's Hospital Medical Center, Ohio, and Timothy Lotze, MD, FAAP, associate professor of Pediatrics and Child Neurology at Texas Children's Hospital/Baylor College of Medicine, Houston, discussed the most important need-to-know information about neurologic emergencies.

The goal of the session was to arm general pediatricians, particularly those based in an office without much exposure to these issues, with information about how to approach emergencies such as status epilepticus or loss of consciousness.

"Our primary message is that when children present with neurologic symptoms, pediatricians should be vigilant and use key features from the history and physical examination to make good medical decisions," Gilbert tells Contemporary Pediatrics in the week leading up to the conference. "Our session covers diagnosis and management of acute neurologic problems-primarily the types of problems that are seen in the emergency department (ED) or within the hospital."

Gilbert and Lotze shared with attendees what early warning signs they should watch for-including acute states of confusion, malalignment of the eyes, vision loss, new onset focal or diffuse weakness, or difficulty walking-that could possibly foretell an acute neurological problem.

Gilbert says he hopes the presentation will help clinicians more rapidly recognize the presence of actual or impending neurologic crisis; to know when to order emergency medical testing such as brain or spine imaging; and when to call for a Neurology or Neurosurgery consultation. Gilbert and Lotze reviewed appropriate medical diagnostic testing including what to obtain in blood and cerebrospinal fluid, the role of the electroencephalogram, head computed tomography, and magnetic resonance imaging.

"It’s incredibly challenging to be a pediatrician in these settings. There are many medical problems in the ED or hospital that really are not emergencies, or are readily treatable," Gilbert says, "but pediatricians will encounter some fraction of children with a problem where their management decisions can prevent permanent neurologic injury or death in a child. In the short time we have together with attendees, we hope to cover some of the more commonly encountered ones and review key points for diagnosis and treatment."

One of the conditions and interventions the presenters highlighted included an enlarged head circumference. When encountered in practice accompanied by irritability, double vision, a head tilt, or other findings, it may indicate a need for urgent imaging and neurosurgical consultation and placement of a shunt, Gilbert says.

Acute generalized weakness also was discussed, as it has a number of important diagnostic possibilities for which urgent, appropriate treatment is needed. Rules for when to admit to the intensive care unit and when to intubate, and diagnosis and urgent treatment for conditions such as Guillain-Barre syndrome, various infections, and myasthenia gravis also were reviewed.

Gilbert and Lotze also shared the protocol of treating spinal cord trauma with methylprednisone, and initial treatment of status epilepticus with a benzodiazepine and what medications should follow if the seizures do not stop.