Pediatric neurological exam

[cointosser13]

So I ran this call last night, 9 month old who fell off a couch and landed onto his back hitting the back of his head. Mother states kid didn’t cry after landing onto the hard wood floor. Negative loss of conscious/vomiting. When we arrived on scene kid looked like he was sleeping in mother’s arms. When assessing pupils he would squirm just a little (pupils constricted). After palpating and visualization no trauma to the head noted. The part that weirded me out, during transport I opened up both eye lids, but the kids eyes didn’t move, nor did he budge. Usually kids are curious, but this one appeared just sleepy even after a fall? I pinched his big toe to see if I would get a response and I only got a small withdraw from his leg. I know their could be a million things that could be up with this kid but my question is, how do you do a good neurological exam for a kid?

 

[luke_31]

So I ran this call last night, 9 month old who fell off a couch and landed onto his back hitting the back of his head. Mother states kid didn’t cry after landing onto the hard wood floor. Negative loss of conscious/vomiting. When we arrived on scene kid looked like he was sleeping in mother’s arms. When assessing pupils he would squirm just a little (pupils constricted). After palpating and visualization no trauma to the head noted. The part that weirded me out, during transport I opened up both eye lids, but the kids eyes didn’t move, nor did he budge. Usually kids are curious, but this one appeared just sleepy even after a fall? I pinched his big toe to see if I would get a response and I only got a small withdraw from his leg. I know their could be a million things that could be up with this kid but my question is, how do you do a good neurological exam for a kid?

Ask mother if the child is acting normally for the time of day and anything unusual presently going on.

 

[Peak]

What was the infant doing before they fell, were they awake and active or were they already asleep? There is a substantial difference between an infant who was awake and active and now difficult to rouse compared to one who was already asleep and continues to sleep.

Does the MOC report a history of the infant being a heavy sleeper? I wouldn't necessarily expect an infant to be awake just because you open their eyelids or pinch their toe for a second.

I don't think a further exam is necessarily warranted if you are transporting anyway, but if the MOC wanted to refuse transport then there are a couple of things you could examine. Keeping in mind that infants don't talk and a 9 month old may or may not have a fear of strangers; socialization is not a great benchmark for neurological examination.

While I highly doubt that there would be a problem with their BGL you could have done a heel stick for a glucose, this would also have given you a better assessment for pain response.

Their anterior fontanelle is probably still be open, so you could palpate for bulging. Keep in mind that if the infant is crying that a bulging fontanelle is not abnormal, it should be flat/soft but not sunken while sleeping and the head is slightly elevated. If you can feel a pulse you know that it is still open, however as the cartridge is becoming calcified the absence of palpable pulse does not exclude an open fontanelle.

I wouldn't feed the infant if transporting but you can see if the baby will feed if the MOC wants to stay. Not vomiting is a great sign and if the infant can feed without difficulty then that is even more reassuring. That being said if you have awoken them from a heavy sleep and now have them crying I wouldn't necessarily expect them to want to eat. If you are concerned about keeping the baby NPO a dab of sweet ease (which is pretty much just D25) on a pacifier or bottle nipple will still demonstrate a suck/swallow reflex without actually feeding them.

You could check for developmental milestones and reflexes, however these are going to be difficult to reliably assess in the middle of the night on a sleeping infant.

You could check a blood pressure, but being normotensive does not exclude a neurological insult. Further I doubt you have infant sized cuffs on your bus, I don't carry them in the field because I find them to be of little help in my prehospital assessment.

You could run a strip to make sure they aren't having brady episodes, however keep in mind that sinus arrhythmia is normal in infants. Similarly you could attempt to evaluate their breaths but infants often have respirations that vary in depth and rhythm at baseline.

The vast majority of infants that present to a peds ED after a low risk fall will be have a physical exam and may be observed for a bit but will not be imaged if they have a benign exam. Unfortunately if they are taken to a general population ED and are evaluated by a general ED physician they are more likely to be imaged than if evaluated by a PEM or PNPAC. If they were transported to a general ED I would not take the kid being imaged as being any sign of your exam to be limited or your findings wrong.

 

[Carlos Danger]

That’s a tough one. I think Peak covered it pretty well. Looking forward to other responses.

 

[COmedic17]

Ask the mother is patient is acting normally, and if not, how does the patient normally act. Most 9 month olds have some degree of stranger anxiety, so be suspicious if that's absent. You're best bet is to ask the people who know him best - the parents.

Monitor vitals. Pulse, bp, respirations, look for anything indicative of ICP. How does the fontanel look?

.........Or you could ask him who the president is and what year it is.