Neurological and Neurodevelopmental Assessment
What to assess
In neonates, tone, posture, spontaneous movement, primitive reflexes, and suture/fontanelle findings convey more than a formal coma score. In older children use the pediatric Glasgow Coma Scale (verbal and motor scales differ under age 2) and trend it rather than relying on a single value. Assess pupils, fontanelle, glucose, and seizure activity; neonatal seizures are often subtle - lip smacking, cycling movements, apnea, eye deviation - and may be invisible without EEG.
Neuroprotection
Prevent secondary injury by avoiding hypoxia, hypotension, hypercarbia, hyperthermia, and hypoglycemia. For suspected hypoxic-ischemic encephalopathy, therapeutic hypothermia must begin within 6 hours of birth, so the transport team initiates passive cooling per protocol while avoiding overcooling below target. Keep the head midline, avoid constricting tape that impairs venous drainage, and position for developmental care.
Seizures, pain, and sedation
Benzodiazepines treat acute seizures, followed by a second-line agent (levetiracetam, phenytoin, or phenobarbital - phenobarbital remains first-line in neonates). Provide analgesia and sedation during transport, especially after neuromuscular blockade; use validated scales such as N-PASS or FLACC and reassess.
Traps
Routine hyperventilation to "shrink" the brain reduces cerebral blood flow and is not recommended. Apnea may be the only seizure sign in a neonate. A normal Apgar score does not exclude encephalopathy.
Rule of thumb
The 6-hour cooling window is measured from birth, not from arrival - document initiation time and verify temperature with a low-reading thermometer.