Prehospital Academy Lesson 40.4
Pediatric Neurological Emergencies
This lesson addresses neurological emergencies in pediatric patients. While some neurological events in children can be benign, others are life-threatening. EMTs must understand the unique aspects of pediatric neurological conditions to provide appropriate assessment and management.
Causes of Altered Mental Status (AMS) in Pediatric Patients
Altered mental status is a common and serious presentation in pediatric neurological emergencies. It's crucial to identify and address the underlying cause promptly. The mnemonic "AEIOU TIPS" can be a helpful tool for remembering potential causes:
Alcohol / Acidosis
Epilepsy / Electrolytes / Endocrine
Infection
Overdose / Oxygenation (hypoxia)
Uremia / Underdose
Trauma / Temperature
Insulin (hypoglycemia/hyperglycemia)
Psychiatric / Poisoning
Stroke / Seizure / Sepsis
Pediatric patients are large cerebral consumers of oxygen and glucose. Therefore, any condition that leads to hypoxia or hypoglycemia can rapidly result in altered mental status and neurological dysfunction. They also have limited reserves for glucose and oxygen.
Pediatric Seizures
Seizures in children can range from subtle changes in behavior to generalized tonic-clonic activity.
Types of Seizures:
Generalized Seizures: Involve both hemispheres of the brain.
Tonic-Clonic (Grand Mal): Loss of consciousness, body stiffening (tonic phase), followed by rhythmic jerking (clonic phase).
Absence Seizures (Petit Mal): Brief periods of staring or unresponsiveness.
Focal (Partial) Seizures: Originate in one area of the brain.
May involve motor, sensory, or autonomic symptoms, or subtle behavioral changes.
Febrile Seizures: Seizures associated with fever, common in children between 6 months and 5 years. Usually benign but can be distressing.
Status Epilepticus: A seizure lasting longer than 5 minutes or recurrent seizures without return to baseline mental status between events. This is a medical emergency.
Prehospital Management for Seizures:
Ensure patient safety (protect from injury, move objects away).
Position patient on their side (recovery position) to protect airway.
Loosen restrictive clothing.
Time the seizure.
Do NOT place anything in the mouth.
Administer oxygen.
Monitor ABCs, vital signs, and blood glucose.
Consider benzodiazepines (e.g., midazolam, diazepam, lorazepam) for prolonged seizures, per protocol (ALS providers).
Rapid transport.
Head Trauma in Children
Children are more susceptible to head injuries due to their larger head size relative to body, thinner skulls, and less developed neck muscles.
Common Causes: Falls, motor vehicle collisions, abuse.
Signs & Symptoms: Altered mental status, vomiting, headache, seizure, lethargy, irritability, bulging fontanel (infants), raccoon eyes, Battle's sign.
Prehospital Management for Head Trauma:
Maintain C-spine immobilization.
Ensure adequate airway, breathing, and circulation.
Administer oxygen to maintain SpO2 >94%.
Monitor for signs of increasing intracranial pressure (e.g., Cushing's triad: bradycardia, hypertension, irregular respirations; pupillary changes).
Monitor blood glucose and body temperature.
Rapid, gentle transport.
Critical Thinking Questions
You are called to a 4-year-old child who experienced a generalized tonic-clonic seizure that lasted for 3 minutes. The child is now postictal and very drowsy. What are your immediate assessment and management priorities?
A 9-month-old infant presents with extreme irritability, a bulging fontanel, and is refusing to feed. What neurological emergency might you suspect, and what is the significance of the bulging fontanel?
Explain why pediatric patients are particularly vulnerable to neurological deficits from hypoglycemia or hypoxia.
Differentiate between a simple febrile seizure and status epilepticus in a pediatric patient. What are the management differences?
You arrive at a scene where a child has fallen from a swing set and hit their head. The child is crying but has no obvious external injury. What subtle signs would you look for to assess for potential serious head injury, and what would be your transport decision?