Paediatric Neuro

Question 1

Signs and symptoms of elevated ICP in peds

Answer 1

Poor feeding
Loss of appetite 
vomiting
irritability 
lethargy 
seizures
ALOC 
Full/tense fontenells
3/6 nerve palsy, pupil dilation
Brady, HTN, ventilation abnormalities

Question 2

Coagulation goals for TBI in pediatrics

Answer 2

INR <1.5 
PTT < 40 (consider FFP)
Platlets > 100
Fibrinogen >1  (if < 1 use cyroprecpite)
TXA if within 3 hours 
Dont allow permissive hypotension

Question 3

ICP mgmt principles

Answer 3

parachymal:
- sedation (ketamine/prop/m+m)
- osmotherapy (HTS,Mannitol)
- normal temperaturee e

CSF:
- EVD

Vasculature:

• Arterial - PCO2 - 35-40mmHg
• venous: HOB 30, loose collars, tube ties, PEEP <13cmH20, OG tube

other:
craniotomy

Question 4

Brain Tumors in children may present with

Answer 4

Very typical clinical presentations is headache, exacerbated by postural changes, coughing and shivering. these strongly suggest elevated ICP

Question 5

BP to maintain in TBI

Answer 5

90 + age x 2

Question 6

Describe briefly the theory of autoregulation

Answer 6

Refers to the intrinsic ability of an organ to maintain blood flow despite changes in BP

Autoregulation ensures that critical organs such as the brain are adequately perfused within the range of blood pressure values, known as autoregulation limits

Question 7

Neuroexam:

When you open eyes it tells you which CN are working

Answer 7

CN2 and CN3

Question 8

Neuroexam:

Corneal reflex assess which CN’s

Answer 8

CN 5 and 7

Question 9

Neuro exam:

Doll eyes assess which CN?

Answer 9

CN 8

Question 10

Neuroexam:

Cough and gag assess which cranial nerves

Answer 10

CN 9 and 10

Question 11

Neuro exam:

How do you assess the pons?

Answer 11

Check CN 4, 5, 6, 7 and 8

Question 12

Neuro exam:

How do you examine midbrain

Answer 12

Check CN 3

Question 13

Neuro exam:

How do you examine medulla oblongata

Answer 13

CN 9 and 10 - gag reflex

Question 14

Monro-Kellie doctorine percentage of contents in the skull

Answer 14

80% Paranechymal
10% CSF
10% Blood

Question 15

Mannitol dosing for herniation

Answer 15

1g/kg

Question 16

Hypertonic Saline 3% herniation dose

Answer 16

5ml/kg

Question 17

Differences in paediatric CNS than adults

Answer 17

Fontanelles (Closure of posterior 1 month and closure of anterior 6-9months)
Spinal cord is longer, goes. to L3

Question 18

Why is SCIWORA more common in infants

Answer 18

The fulcrum is located at C1/C2, rather than C5-C6 in adults
Atlanto-axial dissociation is more frequent and is fatal.

Question 19

Why is propofol not used for sedation in pediatrics beyond 24 hours ?

Answer 19

Children are at increased risk of PRIS due to increase fat distribution and increase dose requirement of effect

Question 20

Pillars of TBI mgmt

Answer 20

1. Resuscitation
2. Dc and tx surgical lesions
3. Prevention of 2nd injury
4. control of ICP

Question 21

Primary drivers of secondary injury

Answer 21

Decreased oxygen delivery and increase cerebral oxygen consumption are probably the most important.

In the absence of ICP monitoring, assume ICP of 20mmHg and maintain high normal MAP appropriate for age

Question 22

Electrolyte disturbances that may cause complications in TBI

Answer 22

Osmotic diuresis, DI, CSW, and SIADH all of which may complicate neurologic injury.

Question 23

Metabolic issues which may accelerate secondary brain injury that can be easily treated and dx

Answer 23

Hyperglycemia, hypoglycaemia and other lyte disturbances.

Question 24

What is flow metabolic coupling and how can you help achieve it?

Answer 24

Achieve with appropriate sedation.

Sedation helps lowers metabolism in the cortex.
Sedation helps improve flow metabolic coupling, which is the demand for BF increase/decrease when brain activity increases/decreases

Question 25

What does OSMOTHERAPY provide

Answer 25

Administration of hypertonic saline or mannitol creates an osmotic gradient that causes free water to come out of the extracellular space and pass into circulation.
This effect leads to parenchymal shrinkage of brain volume and a reduction in ICP.

Increased tonicity draws water from the brain parenchyma. Threshold to treat should be low, acting on a ONSD of 6mm (which correlates to ICP of 20mmHg) to PREVENT herniation, rather than waiting for herniation to occur