Management of acute neurologic syndromes in infants and children

Neurological problems in the pediatric intensive care unit all too frequently seem to be among the most mysterious of disorders. This review provides a framework to diagnose and treat four frequently observed neurological syndromes: coma, status epilepticus, central nervous system infections, and post-infectious polyneuropathy (Guillain-Barré syndrome). An emphasis is placed on the diagnosis of coma due to metabolic disorders, the most common cause of coma, and coma as a result of supratentorial lesions. This differentiation can be effected by an easily performed assessment (Glasgow Scale) supplemented by a limited number of tests of brain stem function (pupillary responses, oculocephalic, and oculovestibular responses). Preserved pupillary responses are characteristic of the metabolic coma while an orderly rostral-caudal deterioration, termed the central syndrome, is characteristic of coma resulting from an enlarging supratentorial mass. If confusion exists, the CT scan may be helpful. The approach to emergency management emphasizes the establishment and maintenance of airway and circulation. Management of status epilepticus emphasizes the role of pharmacotherapy, particularly the use of diazepam and phenytoin in combination. The management of infections details antibiotic therapy of bacterial infections and new antiviral therapy for herpesvirus infections. The section on Guillain-Barré syndrome emphasizes good supportive care.