quoteThis is a, a, a pretty classic, uh, case, and considering that we've already have a CT scan and we've identified a small epidural, I think it's, it behooves us to immediately call our neurosurgical colleagues to ensure that this epidural bleed does not require surgical evacuation.↗
▶Ep 3 · 1:08
clinicalFor a patient with small epidural hematoma, immediate neurosurgical consultation is needed to determine if surgical evacuation is required.↗
▶Ep 3 · 1:25
clinicalSmall epidurals may be managed with repeat CT in several hours or clinical observation for deterioration before operating.↗
▶Ep 3 · 1:40
clinicalICP monitoring should be discussed with neurosurgeons for patients being managed for potential intracranial pressure issues.↗
▶Ep 3 · 1:58
clinicalInvasive blood pressure monitoring is needed for accurate blood pressure identification in patients with intracranial hypertension.↗
▶Ep 3 · 2:10
quoteSo remembering that cerebral perfusion pressure is your mean arterial pressure minus your intracranial pressure.↗
▶Ep 3 · 2:10
clinicalCerebral perfusion pressure equals mean arterial pressure minus intracranial pressure.↗
▶Ep 3 · 2:40
clinicalICP above 20 may require ongoing treatment and/or reevaluation with imaging.↗
▶Ep 3 · 2:55
clinicalAcute intracranial hypertension may first manifest as dilation of the ipsilateral pupil or progressive bradycardia with hypertension.↗
▶Ep 3 · 3:15
clinicalAcute ICP management includes raising the head of bed to improve venous drainage, providing oxygen, and bag valve masking.↗
▶Ep 3 · 3:35
clinicalHyperventilation to PCO2 of around 35 helps vasoconstrict the brain and create space in acute ICP crisis.↗
▶Ep 3 · 3:55
clinicalIf an ICP drain is present, opening it to evacuate fluid and reduce pressure is a first-line intervention.↗
▶Ep 3 · 4:10
clinical3% normal saline at 5 mL per kilogram will generally increase serum sodium by 3 to 5 mEq per liter.↗
▶Ep 3 · 4:10
quoteThe reason why I like 2% normal saline, uh, actually, there's, there are several reasons. One, it's easy to give. Two, it keeps your sodium a little bit higher, so, therefore, um, you actually will have some some, some long-lasting ability to reduce cerebral swelling. Three, it has a much higher osmolarity limit, uh, compared to Mannitol.↗
▶Ep 3 · 4:30
clinical3% normal saline has an osmolarity limit of 360 millimoles compared to Mannitol's 320 millimoles.↗
▶Ep 3 · 4:45
clinicalHypotension in the context of closed head injury is a very poor prognosticator and should be avoided at all costs.↗
▶Ep 3 · 5:00
clinicalIn older children and teenagers, systolic blood pressure should be kept above 90 or 95; younger children should use age-appropriate norms.↗
▶Ep 3 · 5:20
clinicalNorepinephrine can be used to drive up blood pressure to maintain cerebral perfusion.↗
▶Ep 3 · 5:45
clinicalMannitol's diuretic effect can be difficult to control and may lead to hypotension.↗
▶Ep 3 · 5:55
quoteIt's actual first effect, which is within the first, 15 to 20 minutes of providing it is, it changes the rheology of the blood vessels. And by doing that, it allows the blood vessels to pass more freely through the cerebral circulation and therefore improve, um, oxygen delivery.↗
▶Ep 3 · 5:55
clinicalMannitol's first effect within 15 to 20 minutes is changing blood vessel rheology to allow freer passage through cerebral circulation and improve oxygen delivery; the diuretic effect is secondary and occurs afterwards.↗
▶Ep 3 · 6:13
clinicalThe dose of Mannitol is 0.5 g to 1 g per kilogram.↗
▶Ep 3 · 6:33
quoteNo, uh, at present, there is no role for steroids, uh, in these kids.↗
▶Ep 3 · 6:33
guidelineThere is no role for steroids in pediatric traumatic brain injury.↗
▶Ep 3 · 6:42
guidelineSteroids are no longer considered effective therapy for suspected spinal cord injury and may cause detriment.↗
▶Ep 3 · 7:01
clinicalDecompressive craniectomy is an emerging option for patients with diffuse axonal injury and very difficult to control ICP where there is no true surgical lesion to decompress.↗
▶Ep 3 · 7:30
clinicalPatients with persistently elevated ICP above 20 with higher spikes will slowly deteriorate to the point where they are not salvageable.↗
▶Ep 3 · 7:30
quoteIf you're persistently measuring ICPs above 20 and having, uh, higher spikes, you know that that patient is going to slowly deteriorate to the point where they're not going to be salvageable.↗
▶Ep 3 · 7:50
clinicalIn decompressive craniectomy, the bone is preserved and can be replaced after things settle down.↗
▶Ep 3 · 8:40
opinionMajor trauma centers across North America are using decompressive craniectomy more frequently.↗
▶Ep 3 · 9:08
clinicalCT scan is preferred in acute situations with very acute presentation of increased ICP because it provides the best information for determining need for OR or drain placement.↗
▶Ep 3 · 9:30
clinicalMRI is used after the first 48 hours once the patient is stable and ICP spikes are controlled, primarily as a prognosticator.↗
▶Ep 3 · 9:50
clinicalMRI provides useful information for counseling families and directing care plans when injury is very severe.↗
▶Ep 3 · 10:05
clinicalRepeat MRI in a week's time gives the true extent of injury and allows more meaningful discussions about level of disability.↗
▶Ep 3 · 10:17
clinicalCT head scan can be completed in 5 minutes versus 20-30 minutes for MRI, making CT preferable for critical patients.↗
▶Ep 3 · 10:55
clinicalSympathetic storming is thought to occur because of an imbalance of the sympathetic and parasympathetic nervous systems as a result of head injury.↗
▶Ep 3 · 11:15
clinicalUntreated sympathetic storming can lead to secondary brain injury or potentiate ongoing injury.↗
▶Ep 3 · 11:30
clinicalHyperventilation during sympathetic storming leads to vasoconstriction which could lead to cerebral hypoxia and further cellular injury.↗
▶Ep 3 · 11:50
clinicalHypertension during sympathetic storming could lead to hemorrhage within areas of the brain.↗
▶Ep 3 · 12:05
clinicalArrhythmias during sympathetic storming can lead to hemodynamic instability and hypoperfusion, worsening head injury.↗
▶Ep 3 · 12:20
clinicalNeurogenic pulmonary edema is sometimes common in patients with sympathetic storming, leading to hypoxia and difficult ventilation.↗
▶Ep 3 · 12:40
clinicalThe cornerstone of sympathetic storming treatment is sedation and pain control, usually accomplished with narcotics and/or benzodiazepines as first-line medications.↗
▶Ep 3 · 12:55
clinicalBromocriptine acts on the hypothalamus to help reduce hyperthermia, diaphoresis, and blood pressure in sympathetic storming.↗
▶Ep 3 · 13:08
clinicalClonidine is an alpha-2 agonist that can reduce levels of catecholamines throughout the body and reduce ongoing sympathetic storm.↗
▶Ep 3 · 13:08
clinicalPropranolol can help control arrhythmias and lower blood pressure in sympathetic storming.↗
▶Ep 3 · 13:08
clinicalOxycodone has been used for its longer-acting effect for pain control in sympathetic storming.↗
Summaries Pramod gave as host
· 3 summaries
Recaps of other experts' statements, not Pramod's own clinical position.
Summaries Pramod gave as host · Traumatic Brain Injury3 summaries
host summaryPramod Pulaamba summarizing a resource: Most guidelines suggest keeping CPP greater than 45 as the minimal acceptable, sometimes 55 in children.↗
▶Ep 3 · 5:30
host summaryPramod Pulaamba summarizing a resource: Based on the most recent guidelines in Pediatric Critical Care Medicine, there is no evidence that 3% saline is better than Mannitol or vice versa.↗
▶Ep 3 · 8:15
host summaryPramod Pulaamba summarizing a resource: Based on the 3rd iteration of Management of Traumatic Brain Injury in Children published in Pediatric Critical Care Medicine, there is still no clear consensus that decompressive craniectomy improves outcomes.↗
