Paediatric Neuro Flashcards
Signs and symptoms of elevated ICP in peds
Poor feeding Loss of appetite vomiting irritability lethargy seizures ALOC Full/tense fontenells 3/6 nerve palsy, pupil dilation Brady, HTN, ventilation abnormalities
Coagulation goals for TBI in pediatrics
INR <1.5 PTT < 40 (consider FFP) Platlets > 100 Fibrinogen >1 (if < 1 use cyroprecpite) TXA if within 3 hours Dont allow permissive hypotension
ICP mgmt principles
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
Brain Tumors in children may present with
Very typical clinical presentations is headache, exacerbated by postural changes, coughing and shivering. these strongly suggest elevated ICP
BP to maintain in TBI
90 + age x 2
Describe briefly the theory of autoregulation
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
Neuroexam:
When you open eyes it tells you which CN are working
CN2 and CN3
Neuroexam:
Corneal reflex assess which CN’s
CN 5 and 7
Neuro exam:
Doll eyes assess which CN?
CN 8
Neuroexam:
Cough and gag assess which cranial nerves
CN 9 and 10
Neuro exam:
How do you assess the pons?
Check CN 4, 5, 6, 7 and 8
Neuro exam:
How do you examine midbrain
Check CN 3
Neuro exam:
How do you examine medulla oblongata
CN 9 and 10 - gag reflex
Monro-Kellie doctorine percentage of contents in the skull
80% Paranechymal
10% CSF
10% Blood
Mannitol dosing for herniation
1g/kg
Hypertonic Saline 3% herniation dose
5ml/kg
Differences in paediatric CNS than adults
Fontanelles (Closure of posterior 1 month and closure of anterior 6-9months)
Spinal cord is longer, goes. to L3
Why is SCIWORA more common in infants
The fulcrum is located at C1/C2, rather than C5-C6 in adults
Atlanto-axial dissociation is more frequent and is fatal.
Why is propofol not used for sedation in pediatrics beyond 24 hours ?
Children are at increased risk of PRIS due to increase fat distribution and increase dose requirement of effect
Pillars of TBI mgmt
- Resuscitation
- Dc and tx surgical lesions
- Prevention of 2nd injury
- control of ICP
Primary drivers of secondary injury
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
Electrolyte disturbances that may cause complications in TBI
Osmotic diuresis, DI, CSW, and SIADH all of which may complicate neurologic injury.
Metabolic issues which may accelerate secondary brain injury that can be easily treated and dx
Hyperglycemia, hypoglycaemia and other lyte disturbances.
What is flow metabolic coupling and how can you help achieve it?
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
What does OSMOTHERAPY provide
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
