Study Examines Neurologic Emergencies at the Extremes of Age

Patients with neurologic conditions present to the emergency department (ED) daily. The diagnosis and management of such conditions can be more complex when patients are at the extremes of age.¹ A publication in Emergency Medicine Clinics of North America discusses clinical pearls useful to clinicians who treat patients with neurologic conditions.

Pediatrics

Investigators highlighted 4 emergency conditions in the pediatric population: acute ischemic stroke (AIS), intracranial hemorrhage, fever and altered mental status (AMS), and seizures.¹

Pediatric stroke is rare, and children younger than 5 years are the most likely to experience AIS. Children with AIS can also present with AMS, fever, or seizure. The management of pediatric stroke requires administering weight-based tPA.¹

In intracranial hemorrhage, many principles of adult care are the same in pediatric patients. However, guidelines are less clear about target blood pressure in the pediatric population. In cases of cerebral edema or impending herniation, administration of either mannitol or hypertonic saline are equally acceptable.¹

When a pediatric patient presents with AMS, pharmacists and other health care providers should consider acute disseminated encephalomyelitis (ADEM) and anti—N-methyl-D-aspartate receptor encephalitis (NMDAR). Both ADEM and anti-NMDAR encephalitis require early initiation of steroids and empiric treatment for bacterial and viral meningitis.

In pediatric patients, seizures can take many forms, such as neonatal seizures and nonconvulsive status epilepticus. Neonatal seizures can present with mouthing (touching hands and objects to the lips or placing them in the mouth), horizontal eye deviation, blinking, or single limb extension. First-line treatment is phenobarbital 20 mg/kg.^1,2

Nonconvulsive status epilepticus is associated with higher mortality, longer pediatric ICU stays, and increased long-term disability. Treatment includes a trial of a short-acting antiepileptic medications and close observation.¹

Elderly

The researchers also focused on 4 neurologic conditions in the elderly: AIS, AMS, Parkinson disease, and meningitis.¹

Some atypical AIS presentations in the elderly include dizziness, falls, headache, nausea, vomiting, difficulty walking, seizure, and urinary incontinence. Advanced age alone is not a contraindication for IV tPA within 3 hours. Around 25% of older adults in the ED have some form of AMS. The Delirium Triage Screen is a valid tool to diagnose delirium, another form of cognitive impairment.¹

Parkinson disease is a neurodegenerative disorder affecting 1% of the population above the age of 60 years. Acute worsening in Parkinson disease is usually due to a medication change, infection, or missed subdural hemorrhage.¹

In bacterial meningitis, the elderly present with atypical symptoms and are less likely to have a fever, neck stiffness, rash, or leukocytosis. Empiric antibiotics should include vancomycin and a third-generation cephalosporin.¹

Raquel S. Mateus is a 2021 PharmD candidate at the University of Connecticut in Storrs.

REFERENCES

• Khoujah D, Cobb MJ. Neurologic Emergencies at the Extremes of Age. Emerg Med Clin North Am. 2021;39(1):47-65. doi:10.1016/j.emc.2020.09.003
• Kwong LH, Ercumen A, Pickering AJ, Unicomb L, Davis J, Luby SP. Hand- and Object-Mouthing of Rural Bangladeshi Children 3-18 Months Old. Int J Environ Res Public Health. 2016;13(6):563. Published 2016 Jun 4. doi:10.3390/ijerph13060563