Neurology: Trauma, Coma, CNS Infections & Acute Paralysis

Traumatic brain/spinal injury (accidental & non-accidental) · Coma & encephalopathy · Meningitis · Encephalitis · Acute paraparesis/quadriparesis · Neurorehabilitation
🧠 Key concepts: TBI management (ABCDE, ICP), abusive head trauma (triad: SDH+RH+encephalopathy), GCS, status epilepticus, bacterial/viral meningitis, Guillain-Barré, transverse myelitis, spinal cord compression.

📖 TBI, non-accidental injury, coma, infections & acute paralysis

🧠 Traumatic brain injury (TBI)
Primary (coup/contrecoup, diffuse axonal) and secondary (hypoxia, oedema, raised ICP). Abusive head trauma: subdural+retinal+encephalopathy. Neurorehabilitation essential.
🩺 Decreased consciousness & coma
Glasgow Coma Scale (modified for children). Causes: traumatic, hypoxic-ischaemic, metabolic (hypoglycaemia, DKA, liver failure), toxic (opiates, anticonvulsants), infection.
🦠 CNS infections
Bacterial meningitis (N. meningitidis, S. pneumoniae, GBS, E. coli). Viral meningitis (enterovirus, HSV, VZV). Encephalitis (HSV-1 → temporal lobe). Brain abscess (cyanotic CHD, otitis).
🦵 Acute paraparesis/quadriparesis
Spinal cord compression (trauma, tumour, abscess, epidural haematoma), transverse myelitis, Guillain-Barré syndrome (ascending areflexic paralysis), poliomyelitis.
⚠️ Red flags in acute paralysis: Spinal shock (areflexia + flaccid below lesion), sensory level, bladder/bowel dysfunction → emergency MRI. Guillain-Barré: progressive ascending weakness, areflexia, raised CSF protein, normal cells.

🩺 Clinical approach to coma, spinal cord syndromes & suspected abuse

1
ABC + rapid neurological assessment – Airway, breathing, circulation, glucose, GCS/pediatric GCS. Pupils, brainstem reflexes, motor response. Rule out hypoglycaemia, opioid overdose (naloxone).
2
Suspected abusive head trauma – Triad: subdural haemorrhage + retinal haemorrhages + encephalopathy. Skeletal survey, ophthalmology, notify safeguarding, avoid delay.
3
Acute flaccid paralysis differential – Guillain-Barré (areflexia, ascending, CSF protein), transverse myelitis (sensory level, MRI T2 hyperintensity), spinal cord compression (trauma, tumour, abscess), tick paralysis, botulism (descending, pupils).
4
Meningitis vs encephalitis – Meningitis: fever, neck stiffness, photophobia, Kernig/Brudzinski. Encephalitis: altered consciousness, focal seizures, personality change, MRI temporal lobe (HSV).
📌 LP contraindications: Signs of raised ICP, focal neurology, GCS <9, coagulopathy, cardiorespiratory instability. CT brain before LP if any red flag.

📋 Stepwise management: trauma, coma, infections & paralysis

1
Severe TBI (GCS ≤8) – Intubate, maintain CPP (cerebral perfusion pressure). Avoid hypoxia/hypotension. Neurosurgical: ICP monitor, evacuation of mass lesions, decompressive craniectomy.
2
Bacterial meningitis (suspected) – IV ceftriaxone (or cefotaxime) + vancomycin (pneumococcus). Dexamethasone (before/with first dose) reduces neurological sequelae. LP after imaging if contraindications.
3
Status epilepticus in comatose child – IV lorazepam → levetiracetam/phenytoin → ICU (midazolam, thiopentone). Continuous EEG for non-convulsive status.
4
Guillain-Barré syndrome – Monitor vital capacity (FVC). IVIG (2g/kg over 2 days) or plasma exchange. Respiratory support if FVC <20ml/kg or bulbar weakness.
5
Spinal cord compression (acute) – High-dose methylprednisolone (controversial), urgent neurosurgical/spinal decompression, treat underlying cause (abscess, tumour).
6
Neurorehabilitation after TBI/SCI – Multidisciplinary: physio, OT, speech, psychology, orthotics, spasticity management, educational reintegration, family support.
🚨 Key investigations: CT head (acute trauma/bleed), MRI brain/spine (non-traumatic myelopathy, encephalitis), LP (CSF: cells, protein, glucose, PCR), NCS/EMG (GBS, myopathy).

🧠 Reflex prompts: trauma, coma, infections & paralysis

👶 Infant with subdural haemorrhage, retinal haemorrhages, and no history of major trauma. Most likely diagnosis?
Abusive head trauma (shaken baby syndrome). Urgent safeguarding referral, skeletal survey, ophthalmology.
🧠 6-year-old post-head injury, GCS 7, unequal pupils. Next step?
Intubate, hyperventilate (briefly if herniation), mannitol (0.5-1g/kg), urgent CT head, neurosurgical consultation.
🦠 Child with fever, headache, neck stiffness, photophobia. Kernig sign positive. Immediate management?
Blood cultures, IV ceftriaxone + dexamethasone, CT before LP if focal signs/raised ICP.
🧬 10-year-old with ascending weakness, areflexia, normal CSF cell count but protein 1.2 g/L. Diagnosis?
Guillain-Barré syndrome. Monitor respiratory function, IVIG, neurorehabilitation.
🦵 Child with acute flaccid paraplegia, sensory level at T4, urinary retention. Most likely diagnosis?
Transverse myelitis. MRI spine (T2 hyperintensity). Treat with high-dose steroids or plasmapheresis.
🧪 Hypoglycaemic coma – immediate treatment?
IV 10% dextrose (2-4 ml/kg) or glucagon IM if no IV access. Check glucose urgently.
🚨 Contraindication to lumbar puncture in suspected meningitis?
GCS <9, signs of raised ICP (papilloedema, focal neurology), coagulopathy, unstable cardiorespiratory status.
🧠 What is the most common cause of bacterial meningitis in neonates?
Group B Streptococcus (GBS), Escherichia coli, Listeria monocytogenes.
🦠 First-line antiviral for suspected herpes simplex encephalitis?
IV aciclovir (20 mg/kg/dose 8 hourly). Do not wait for PCR result if clinical suspicion.
🩺 What is the paediatric Glasgow Coma Scale (GCS) modification for infants?
Verbal response: coos/babbles (5) → irritable cry (4) → cries to pain (3) → moans (2) → none (1). Motor response: normal spontaneous (6) etc.