{"id":7336,"date":"2024-05-28T17:27:03","date_gmt":"2024-05-28T17:27:03","guid":{"rendered":"https:\/\/neuropediatoolkit.org\/?p=7336"},"modified":"2024-06-03T16:21:38","modified_gmt":"2024-06-03T16:21:38","slug":"exploracion-neurologica-del-nino-critico","status":"publish","type":"post","link":"https:\/\/neuropediatoolkit.org\/en\/exploracion-neurologica-del-nino-critico\/","title":{"rendered":"Exploraci\u00f3n neurol\u00f3gica del ni\u00f1o cr\u00edtico."},"content":{"rendered":"\n<p>El ni\u00f1o ingresado en cuidados intensivos es un escenario dificultoso para la exploraci\u00f3n neurol\u00f3gica, que se ve limitada por las especiales circustancias que impone este entorno. Podemos encontrar 3 escenarios principales: <\/p>\n\n\n\n<div id=\"wp-block-themeisle-blocks-accordion-5c1308bc\" class=\"wp-block-themeisle-blocks-accordion exclusive\">\n<details class=\"wp-block-themeisle-blocks-accordion-item\"><summary class=\"wp-block-themeisle-blocks-accordion-item__title\"><div>Exploraci\u00f3n neurol\u00f3gica en el ni\u00f1o sedoanalgesiado y intubado. <\/div><\/summary><div class=\"wp-block-themeisle-blocks-accordion-item__content\">\n<p>Las principales limitaciones son: <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>No es abordable la valoraci\u00f3n del nivel de consciencia, la cognici\u00f3n, la atenci\u00f3n, el lenguaje, ni ninguna estrategia de exploraci\u00f3n que requiera de la colaboraci\u00f3n del paciente (como la sensibilidad).<\/li>\n\n\n\n<li>Tampoco pueden valorarse los pares craneales bajos por la presencia del tubo lar\u00edngeo.<\/li>\n\n\n\n<li>No suele poderse movilizar la cabeza para valorar el reflejo oculocef\u00e1lico por el riesgo de extubaci\u00f3n.<\/li>\n\n\n\n<li>Es necesario tener en cuenta el uso de tratamientos farmacol\u00f3gicos que afectan a la funci\u00f3n pupilar (m\u00f3rficos) o la uni\u00f3n neuromuscular (rocuronio, etc.).<\/li>\n<\/ul>\n\n\n\n<p>En cualquier caso podr\u00e1 valorarse:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Apertura ocular forzada y <a href=\"https:\/\/neuropediatoolkit.org\/test-de-hirschberg\/\" title=\"\">test de Hirschberg<\/a>. Los efectos de los f\u00e1rmacos y la ausencia de fijaci\u00f3n visual hacen poco \u00fatil su valoraci\u00f3n, excepto ante oftalmoparesias muy evidentes (III pc completo, por ejemplo).<\/li>\n\n\n\n<li>Asimetr\u00eda facial.<\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/semiologia-del-movimiento-pediatricos\/\" title=\"\">Exploraci\u00f3n del sistema motor<\/a>, incluyendo: \n<ul class=\"wp-block-list\">\n<li>Trofismo muscular (a interpretar en el contexto del tiempo de estancia y la atrofia por desuso).<\/li>\n\n\n\n<li>Tono muscular y reflejos osteomusculares (dependiendo de la presencia de f\u00e1rmacos que afectan a la uni\u00f3n neuromuscular). <\/li>\n\n\n\n<li>Signos de afectaci\u00f3n de vias largas (Babinski, Hoffmann, Rossolimo), con las mismas limitaciones que las anteriores. <\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/exploracion-neurocutanea\/\" title=\"\">Exploraci\u00f3n neurocut\u00e1nea.<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/exploracion-dismorfologica\/\" title=\"\">Exploraci\u00f3n dismorfol\u00f3gica.<\/a><\/li>\n<\/ul>\n\n\n\n<p>Existen algunos dispositivos espec\u00edficos del neurocr\u00edtico que debemos conocer, y que podemos encontrar en esta situaci\u00f3n: <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Sensor de PIC. <\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/bis\/\" title=\"\">Monitor BIS.<\/a><\/li>\n<\/ul>\n<\/div><\/details>\n\n\n\n<details class=\"wp-block-themeisle-blocks-accordion-item\"><summary class=\"wp-block-themeisle-blocks-accordion-item__title\"><div>Exploraci\u00f3n neurol\u00f3gica del ni\u00f1o con disminuci\u00f3n del nivel de consciencia no farmacol\u00f3gica. <\/div><\/summary><div class=\"wp-block-themeisle-blocks-accordion-item__content\">\n<p>En ni\u00f1o que se presenta con disminuci\u00f3n del nivel de consciencia en la UCIP, la exploraci\u00f3n neurol\u00f3gica busca principalmente diferenciar la presencia de una causa estructural frente a la presencia de causas t\u00f3xicometab\u00f3licas que justifiquen su situaci\u00f3n. Es pr\u00e1ctico diferenciar entre 2 situaciones:<\/p>\n\n\n\n<p>Ojos cerrados. <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Aplicaremos la GCS con el objetivo de evaluar el nivel de consciencia mediante la respuesta al dolor, si existen fluctuaciones en este, y si es posible abordar la exploraci\u00f3n de alguna funci\u00f3n cognitiva. <\/li>\n\n\n\n<li>Si no se consigue la apertura ocular, se puede abrir artificialmente con el objetivo de evaluar la integridad del tronco del enc\u00e9falo. \n<ul class=\"wp-block-list\">\n<li>Campimetr\u00eda por amenaza. <\/li>\n\n\n\n<li>Pupilas.<\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/test-de-hirschberg\/\" title=\"\">Hirschberg.<\/a><\/li>\n\n\n\n<li>Reflejo corneal. <\/li>\n\n\n\n<li>Reflejo oculocef\u00e1lico. <\/li>\n\n\n\n<li><a href=\"https:\/\/play.google.com\/store\/apps\/details?id=com.smartoptometry.smartoptometry.full&amp;hl=es\" title=\"\">Reflejo optocin\u00e9tico.<\/a><\/li>\n\n\n\n<li>Mueca al dolor (simetr\u00eda o asimetr\u00eda).<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><a href=\"https:\/\/neuropediatoolkit.org\/semiologia-del-movimiento-pediatricos\/\" title=\"\">Exploraci\u00f3n del sistema motor<\/a>: Tono muscular, trofismo, reflejos osteomusculares y signos de disfunci\u00f3n de vias largas (Hoffmann, Babinski, Rossolimo).<\/li>\n\n\n\n<li>No suele ser aplicable la exploraci\u00f3n de la sensibilidad, la coordinaci\u00f3n y la motricidad voluntaria. <\/li>\n<\/ul>\n\n\n\n<p>Ojos abiertos. <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Valoraremos la respuesta a la \u00f3rden verbal, y en funci\u00f3n de \u00e9sta y de la observaci\u00f3n de la conducta espont\u00e1nea, inferiremos la situaci\u00f3n de la consciencia realizando diagn\u00f3stico diferencial entre las siguientes situaciones:  <\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img fetchpriority=\"high\" decoding=\"async\" width=\"463\" height=\"504\" src=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/image.png\" alt=\"\" class=\"wp-image-7337\" srcset=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/image.png 463w, https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/image-276x300.png 276w, https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/image-11x12.png 11w\" sizes=\"(max-width: 463px) 100vw, 463px\" \/><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Es importante tener presente que ser\u00e1 necesario realizar m\u00faltiples valoraciones en el tiempo, ya que el nivel de consciencia puede fluctuar. Puede ser de utilidad disponer de una c\u00e1mara de videograbaci\u00f3n. <\/li>\n\n\n\n<li>En situaciones de locked-in o estados de minima consciencia en el ni\u00f1o mayor, puede ser utilizado alg\u00fan sistema de comunicaci\u00f3n aumentativo y alternativo como los <a href=\"https:\/\/qinera.com\/es\/otros-formatos\/106-comunicador-tipo-etran.html\" title=\"\">tableros tipo ETRAN<\/a>.<\/li>\n\n\n\n<li>En caso de necesitar realizar un diagn\u00f3stico de muerte cerebral, ser\u00e1 necesario utilizar t\u00e9cnicas complementarias, aunque ninguna de ellas otorga el diagn\u00f3stico por si misma.\n<ul class=\"wp-block-list\">\n<li>EEG.<\/li>\n\n\n\n<li>Doppler transcraneal. <\/li>\n\n\n\n<li>Neuroimagen. <\/li>\n\n\n\n<li>Medicina nuclear (SPECT cerebral). <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/details>\n\n\n\n<details class=\"wp-block-themeisle-blocks-accordion-item\"><summary class=\"wp-block-themeisle-blocks-accordion-item__title\"><div>Exploraci\u00f3n neurol\u00f3gica del ni\u00f1o con para o tetraparesia aguda. <\/div><\/summary><div class=\"wp-block-themeisle-blocks-accordion-item__content\">\n<p>Este escenario suele plantear el diagn\u00f3stico diferencial entre las neuropat\u00edas motoras agudas (neuronopat\u00edas y polirradiculopat\u00edas) y las mielopat\u00edas agudas. Los signos de uso m\u00e1s frecuente para su diferenciaci\u00f3n son: <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Reflejo cutaneoabdominal.<\/li>\n\n\n\n<li>Reflejo cremasterino. <\/li>\n\n\n\n<li>Nivel sensitivo.<\/li>\n\n\n\n<li>Iodine-starch test para la valoraci\u00f3n de la disautonom\u00eda. <\/li>\n<\/ul>\n<\/div><\/details>\n\n\n\n<details class=\"wp-block-themeisle-blocks-accordion-item\"><summary class=\"wp-block-themeisle-blocks-accordion-item__title\"><div>Valoraci\u00f3n de la muerte cerebral. <\/div><\/summary><div class=\"wp-block-themeisle-blocks-accordion-item__content\">\n<p>Una situaci\u00f3n particularmente compleja es la valoraci\u00f3n de muerte cerebral seg\u00fan criterios neurol\u00f3gicos. <\/p>\n\n\n\n<p>Existen unas gu\u00edas de consenso internacional al respecto. <\/p>\n\n\n<div id=\"zotpress-35b6d5730a44f10008be9321b6f7d0e1\" class=\"zp-Zotpress zp-Zotpress-Bib wp-block-group\">\n\n\t\t<span class=\"ZP_API_USER_ID ZP_ATTR\">332710<\/span>\n\t\t<span 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Pediatric and Adult Brain Death\/Death by Neurologic Criteria Consensus Guideline. Neurology [Internet]. 2023 Dec 12 [cited 2024 May 29];101(24):1112\u201332. Available from: <a class='zp-ItemURL' href='https:\/\/www.neurology.org\/doi\/10.1212\/WNL.0000000000207740'>https:\/\/www.neurology.org\/doi\/10.1212\/WNL.0000000000207740<\/a><\/div>\n  <\/div>\n<\/div>\n\t\t\t\t<\/div><!-- .zp-Entry .zpSearchResultsItem -->\n\t\t\t<\/div><!-- .zp-zp-SEO-Content -->\n\t\t<\/div><!-- .zp-List -->\n\t<\/div><!--.zp-Zotpress-->\n\n\n\n\n\n<div data-wp-interactive=\"core\/file\" class=\"wp-block-file\"><object data-wp-bind--hidden=\"!state.hasPdfPreview\" hidden class=\"wp-block-file__embed\" data=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Checklist-Brain-Death.pdf\" type=\"application\/pdf\" style=\"width:100%;height:600px\" aria-label=\"Embed of Checklist-Brain-Death.\"><\/object><a id=\"wp-block-file--media-30253c7b-0793-461d-9ae9-b161de11a60d\" href=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Checklist-Brain-Death.pdf\">Checklist-Brain-Death<\/a><a href=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Checklist-Brain-Death.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-30253c7b-0793-461d-9ae9-b161de11a60d\">Descarga<\/a><\/div>\n\n\n\n<div data-wp-interactive=\"core\/file\" class=\"wp-block-file\"><object data-wp-bind--hidden=\"!state.hasPdfPreview\" hidden class=\"wp-block-file__embed\" data=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Workflow-Brain-Death.pdf\" type=\"application\/pdf\" style=\"width:100%;height:600px\" aria-label=\"Embed of Workflow-Brain-Death.\"><\/object><a id=\"wp-block-file--media-5df11931-3118-4552-96a0-4f896e3634a2\" href=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Workflow-Brain-Death.pdf\">Workflow-Brain-Death<\/a><a href=\"https:\/\/neuropediatoolkit.org\/wp-content\/uploads\/2024\/05\/Workflow-Brain-Death.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-5df11931-3118-4552-96a0-4f896e3634a2\">Descarga<\/a><\/div>\n<\/div><\/details>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>El ni\u00f1o ingresado en cuidados intensivos es un escenario dificultoso para la exploraci\u00f3n neurol\u00f3gica, que se ve limitada por las especiales circustancias que impone este entorno. Podemos encontrar 3 escenarios principales:<\/p>","protected":false},"author":1,"featured_media":7340,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_themeisle_gutenberg_block_has_review":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-7336","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized","entry"],"_links":{"self":[{"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/posts\/7336","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/comments?post=7336"}],"version-history":[{"count":10,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/posts\/7336\/revisions"}],"predecessor-version":[{"id":7382,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/posts\/7336\/revisions\/7382"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/media\/7340"}],"wp:attachment":[{"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/media?parent=7336"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/categories?post=7336"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/neuropediatoolkit.org\/en\/wp-json\/wp\/v2\/tags?post=7336"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}