12.1 Neuro Infection, Neuromuscular Disorders & Neurosurgery
Key Takeaways
- In infants, bacterial meningitis often presents without classic neck stiffness; fever, irritability, poor feeding, and a bulging fontanelle are key PICU red flags.
- HSV encephalitis preferentially involves the temporal lobes and requires early IV acyclovir when clinically suspected, even before PCR returns.
- In Guillain-Barré syndrome, serial forced vital capacity and negative inspiratory force trends guide elective intubation before frank respiratory arrest.
- Myasthenic crisis is treated with airway support plus IVIG or plasmapheresis; cholinergic crisis reflects anticholinesterase overdose with muscarinic excess.
- Pediatric SCIWORA means spinal cord injury without radiographic abnormality on plain films/CT; MRI and serial neuro exams remain essential after high-energy trauma.
Bacterial Meningitis and Viral Encephalitis in the PICU
Central nervous system infection remains a high-acuity CCRN-Pediatric topic because delayed recognition quickly progresses to seizures, shock, and herniation. In older children and adolescents, bacterial meningitis often shows fever, headache, photophobia, nuchal rigidity, and altered mentation. Infants and toddlers frequently lack classic meningismus. Instead, watch for inconsolable irritability, high-pitched cry, poor feeding, vomiting, apnea, seizures, and a bulging fontanelle. Petechiae or purpura raise concern for meningococcemia and demand immediate isolation, cultures, and antibiotics.
Common pediatric bacterial pathogens include Streptococcus pneumoniae and Neisseria meningitidis; Haemophilus influenzae type b is less common where immunization is complete but still appears in under-immunized children. Empiric therapy is age- and locally guided, started after blood cultures when possible, and should not be delayed for imaging if the child is unstable. Lumbar puncture is deferred when there are signs of elevated ICP, coagulopathy, hemodynamic instability, or a focal neurologic exam suggesting mass lesion. In those cases, treat first, stabilize airway and perfusion, obtain imaging, then reconsider CSF sampling.
Viral encephalitis, especially HSV, classically produces fever, altered mental status, behavioral change, and focal seizures. Imaging and EEG often point to temporal lobe involvement. Start IV acyclovir promptly when HSV encephalitis is in the differential; waiting for PCR confirmation risks irreversible injury. Supportive PICU care includes seizure control, careful fluid balance, ICP surveillance when indicated, and isolation precautions appropriate to the organism.
| Feature | Bacterial meningitis | Viral encephalitis (e.g., HSV) |
|---|---|---|
| Onset | Often rapid, toxic | Subacute to acute, behavioral change common |
| CSF pattern (typical) | Neutrophilic, low glucose, high protein | Lymphocytic, normal/near-normal glucose |
| Key imaging clue | May be normal early; complications later | Temporal lobe abnormalities (HSV) |
| Immediate drug priority | Empiric IV antibiotics ± steroids per protocol | Empiric IV acyclovir if HSV suspected |
| PICU danger signals | Shock, DIC, herniation, SIADH | Status epilepticus, ICP crisis |
Nursing priorities include frequent neurologic checks, fever control, seizure precautions, droplet/contact precautions as indicated, family education about vaccine-preventable disease, and monitoring for complications such as SIADH, subdural effusion, hearing risk, and cerebral edema.
Guillain-Barré, Muscular Dystrophy, and Myasthenia Gravis
Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy that typically follows infection and produces ascending, symmetric weakness, areflexia, and variable sensory symptoms. Autonomic instability — labile blood pressure, arrhythmias, ileus, and urinary retention — is common and can be life-threatening. The CCRN-Pediatric exam focuses on respiratory surveillance. Track forced vital capacity (FVC), negative inspiratory force (NIF/MIP), work of breathing, weak cough, and ability to protect the airway. An FVC trending toward roughly 15–20 mL/kg, a rapidly falling vital capacity, hypercarbia, or ineffective secretion clearance supports elective intubation rather than waiting for arrest. Treatment often includes IVIG or plasmapheresis plus meticulous supportive care; pain and neuropathic dysesthesias need active management.
Duchenne muscular dystrophy (DMD) and related dystrophinopathies create progressive respiratory muscle weakness, nocturnal hypoventilation, cardiomyopathy, and difficult airway/secretions management during acute illness. PICU admissions often follow pneumonia, atelectasis, or perioperative decompensation after scoliosis surgery. Noninvasive ventilation, assisted cough, early cardiology collaboration, and avoidance of prolonged succinylcholine exposure (hyperkalemia risk in myopathies) are core safety themes.
Myasthenia gravis (MG) causes fatigable weakness from antibody-mediated impairment of neuromuscular transmission. Myasthenic crisis is life-threatening respiratory failure triggered by infection, surgery, or medication changes. Treat with ventilatory support and IVIG or plasmapheresis; corticosteroids and escalation of immunotherapy follow specialist guidance. Distinguish this from cholinergic crisis caused by excess acetylcholinesterase inhibitor, which features muscarinic excess (diarrhea, salivation, bradycardia, lacrimation, urination) plus weakness. When the crisis type is unclear, secure the airway first and involve neurology before re-dosing anticholinesterase drugs.
| Disorder | Pattern | PICU watch items | Acute therapy focus |
|---|---|---|---|
| GBS | Ascending paralysis, areflexia | FVC/NIF, autonomic swings | IVIG or plasma exchange; airway |
| DMD / MD | Progressive proximal weakness | Hypoventilation, cardiomyopathy | NIV, cough assist, cardio-pulm support |
| MG crisis | Fatigable weakness, bulbar signs | Negative inspiratory force, swallow | IVIG/PLEX + ventilatory support |
Neurosurgery, Spinal Fusion, and Pediatric Spinal Cord Injury
After craniotomy or tumor resection, nursing care centers on neurologic trend detection, ICP and CSF drain management when present, seizure prophylaxis as ordered, and prevention of secondary injury from hypoxia, hypotension, hyperthermia, and hyponatremia. External ventricular drains require leveled transducers, sterile technique, ordered drainage height, and immediate recognition of over-drainage or obstruction. Position and activity restrictions are surgeon-specific; sudden deterioration suggests bleed, edema, seizure, or hydrocephalus.
Posterior spinal fusion for neuromuscular or idiopathic scoliosis is a major PICU pathway. Anticipated issues include significant blood loss, ileus, pain, pulmonary compromise, and neurologic deficit from cord or root injury. Wake-up tests or neuromonitoring changes in the OR should hand off clearly to the PICU team. Monitor hemoglobin, coagulation, urine output, motor/sensory exams distal to the fusion, and respiratory status — especially in children with baseline neuromuscular weakness.
Pediatric spinal cord injury may follow MVC, sports, falls, or non-accidental trauma. Because the pediatric spine is more elastic, children can sustain SCIWORA — cord injury with normal plain films/CT. Persistent neurologic deficit after trauma mandates immobilization, MRI when feasible, and serial exams. High cervical injuries threaten the phrenic nerve roots (C3–C5) and ventilation. Neurogenic shock (hypotension with bradycardia and warm skin after high thoracic/cervical injury) differs from hypovolemic shock and needs volume plus vasopressors with careful attention to concurrent bleeding. Autonomic dysreflexia is less common in very young children but can appear in older children with injuries at or above T6 once spinal shock resolves: sit upright, loosen clothing, and relieve the noxious trigger (usually bladder or bowel).
Bedside priorities after neurosurgery or SCI
- Protect airway and oxygenation before detailed exams.
- Maintain spinal precautions until cleared by the trauma/spine team.
- Trend motor, sensory, pupil, and mentation findings with the same examiner language each hour.
- Treat hypotension aggressively to preserve cord and brain perfusion.
- Coordinate rehab, child life, and family teaching early — functional recovery planning starts in the PICU.
An 8-month-old with fever, poor feeding, and a bulging fontanelle is being admitted to the PICU for suspected bacterial meningitis. Which finding should the nurse recognize as more reliable than neck stiffness in this age group?
A school-age child with Guillain-Barré syndrome has a falling forced vital capacity and a weak cough with retained secretions. What is the priority nursing action?
A child is brought to the PICU after a high-speed MVC with lower-extremity paralysis, yet cervical spine plain films and CT are normal. Which concept best explains this presentation?