Chapter 58

• Cerebral palsy (CP) is a common condition associated with “special needs” children who require care in emergency departments.
• The major abnormality in all forms of CP is abnormal muscle tone.
• Breakthrough seizures are common.
• Respiratory problems, often resulting from chronic aspiration, commonly result in emergency department visits in CP victims.
• Severely impaired patients may require a multidisciplinary approach in the emergency department.

Cerebral palsy (CP) is a nonprogressive motor disorder reported to occur in 1.2 to 2.5 per 1000 children. It is usually evident within the first 3 to 4 years of life.1 The injury that results in CP can occur during the antepartum, peripartum, or postnatal period. Prematurity remains the most important risk factor, but there is also a higher risk of CP with multiple births, even those not born prematurely.1 The Task Force on Neonatal Encephalopathy has developed four essential criteria for asphyxial CP. Evidence of metabolic acidosis (umbilical artery pH < 7 and base deficit ≥ 12 mmol/L at delivery), early onset of severe or moderate neonatal encephalopathy in infants older than 34 weeks gestation, CP of the spastic quadriplegia or dyskinetic type, and exclusion of other identifiable etiologies.2 They have also developed a list of peripartum events that may be related to the development of CP, but are not specifically asphyxial in nature: a sentinel hypoxic event occurring immediately before or after delivery, a sudden and sustained fetal bradycardia or absence of fetal heart rate variability, Apgar score of 0 to 5 at 5 minutes, onset of multisystem involvement within 72 hours, early imaging studies showing evidence of an acute nonfocal cerebral abnormality.2 Other etiologies include congenital abnormalities, brain malformations, stroke in the perinatal period, intracranial hemorrhage, intrauterine infection, premature birth, genetic abnormalities, metabolic abnormalities, and kernicterus.1,3

Although the disorder is not in itself an emergency department diagnosis, children with CP have associated problems that often result in emergency department visits. The emergency department physician must realize that each child with CP has different abilities and problems and that each family has different parent–child relationships and coping mechanisms.

There are several forms of CP, with the classification systems based on the extremities involved, tone, and the ability to perform normal activity. The major disorder is of muscle tone, but there can also be neurologic disorders such as seizures, vision disturbances, and impaired intelligence.

Spastic CP includes several variants: spastic quadriplegia, spastic diplegia, and spastic hemiplegia. Spastic CP is the most common variant, with 70% to 80% of children with CP in one of these groups.

Spastic quadriplegia is characterized by a generalized increase in muscle tone, deep tendon reflexes, and rigidity of the limbs on both flexion and extension. Although the lower extremities are generally more severely affected, in severe forms the child is stiff and assumes a posture of decerebrate rigidity. Many children have pseudobulbar involvement, resulting in swallowing difficulties and recurrent aspiration. Intellectual impairment is severe, and half have a tonic–clonic seizure disorder.1,4

Spastic diplegia is characterized by bilateral spasticity, with greater involvement of the lower extremities than the upper. It is ...

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