Trauma in the pediatric patient Flashcards
What is pseudotumor cerebri?
idiopathic intracranial hypertension (IIH), is defined as intracranial hypertension (usually >
20 mmHg) that is associated with normal CSF composition, normal sensorium, and the
absence of a mass lesion.
Normally in obese women, but can happen in children. Can cause headache, visual disturbances and even blindness
Treatment for pseudotumor cerebri:
includes: (1) carbonic anhydrase inhibitors (i.e. acetazolamide) to
decrease CSF production; (2) furosemide (used when carbonic anhydrase inhibitors or not
tolerated or are ineffective); (3) corticosteroids to reduce ICP when symptoms are severe
(mechanism unknown); (4) serial lumbar punctures to remove CSF; (5) insertion ofa
ventriculoperitoneal shunt,
You can’t get access in pedi pt: wyd?
If I were unable to obtain access through the anticubital fossa or by direct
percutaneous cannulation of the femoral veins, I would consider placing an intraosseous
infusion device in the tibial plateau. You could also have surgeon cut down to femoral or saphenous vein .
remember-if pt has c collar you clearly can’t place IV in neck
Pedi pt GCS is 8 (head trauma). How are you handling the airway?
ensure the presence of the appropriate airway equipment (the presence of a C-
collar and the need for cricoid pressure and inline stabilization may make intubation more difficult-this is how you’re saying you want a glide or FOB)(2) position the patient in 30° reverse-trendelenburg, if hemodynamically toleratedpre-oxygenate the patient with
100% oxygen; ( 4) apply manual in-line stabilization of the cervical spine (traumatic brain
injury with C-collar in place); (5) administer fentanyl and/or lidocaine to reduce the effects of
laryngoscopy on ICP; (6) provide atropine to avoid reflex-induced bradycardia during
laryngoscopy (should also be considered when utilizing succinylcholine); (7) and perform a
rapid sequence induction utilizing etomidate (improved hemodynamic stability; decreased
CMR02 and CBF) and high dose rocuronium (succinylcholine would be less desirable due to
risk of hyperkalemia in male children< 8 years of age).
What bothers you about somnolence in neuro pts?
DDX:
altered mental state places him at increased risk for aspiration and inadequate ventilation,
with the latter potentially resulting in further increases in ICP (secondary to hypercarbia
and/or hypoxia).
DDX:(1) trauma-induced cerebral hemorrhage and/or edema (significant enough to overwhelm the
ability of the shunt to compensate); (2) ventriculoperitoneal shunt malfunction (i.e. partial or
complete obstruction); (3) seizure (postictal state); (4) significant anemia secondary to occult
bleeding that has not yet been identified (i.e. thoracic, abdominal, or long bone fracture); (5)
hyponatremia; and ( 6) hypoglycemia.
Let’s do this again: with elevated ICP, what are you going to do to reduce ICP?
Secure airway and ensure adequate oxygenation and ventilation ensuring that there is no venous obstruction (especially with a C-
collar in place);elevating his head 15-30 degrees to facilitate venous drainage (if
hemodynamically tolerated); (4) verifying that his ventriculoperitoneal shunt is functioning
properly (function can sometimes be assessed when the device includes an extracranial
subcutaneous compressible bulb); (5) administering analgesics (i.e. opioids) and sedatives
(i.e. benzodiazepines) to reduce the elaboration of excitory neurotransmitters; (6) giving
mannitol and a diuretic (i.e. furosemide) to reduce the fluid in the brain also emergent crani
Why is hyperventilation not a first line thing in TBI?
While hyperventilation would reduce his ICP by inducing cerebral vasoconstriction, this
is no longer recommended in the setting of traumatic brain injury due to the risk of
inducing cerebral ischemia (patients with head trauma often experience a reduction in
cerebral blood flow during the first 24 hours following the injury).
Since he has pseudotumor cerebri, would you just perform a lumbar puncture to
remove some CSF?
While the drainage of CSF via lumbar puncture is often utilized to treat
symptomatic pseudotumor cerebri, it would be inappropriate in a patient with recent head
trauma and an altered level of consciousness without first obtaining a CT of the head to
identify the presence of unequal pressures between the supratentorial and infratentorial
compartments. My concern is that, in the presence of a space-occupying lesion (i.e.
expanding hematoma), the creation of a low resistance outlet for CSF in the lumbar spine
may lead to a dangerous pressure gradient between the cerebral and spinal compartments,
placing the patient at risk for trans-tentorial or uncal herniation. Moreover, ifl believed that
the patient was at increased risk for coagulopathy, I would want to order additional lab work
and perform a careful physical exam to rule out this condition.
Trauma (head) pt bp drops from 107/76 to 68/42
(1) hemorrhagic shock, secondary to unrecognized occult
bleeding (i.e. thoracic, abdominal, or extremity injury); (2) neurogenic shock, secondary to
cervical spinal cord injury; (3) tension pneumothorax, secondary to trauma or central line
placement (potentially worsened with mechanical ventilation); (4) cardiac tamponade,
secondary to his traumatic fall; (5) fat embolism, secondary to an unrecognized long bone
fracture; and (6) anaphylaxis.
What is the FAST exam?
Focused Assessment with Sonography for Trauma (FAST)ultrasound examination utilized primarily in hemodynamically unstable blunt trauma patients
to quickly determine whether there is blood present within the peritoneum, pericardium, and
thorax. While the exam provides a safe, rapid, inexpensive, noninvasive, and radiation-free
method for evaluation of the abdomen, it is more user-dependent than CT fails to identify retroperitoneal and diaphragmatic injuries, CT preferred in hemodynamically stable patient
abdominal compartment syndrome and what it does to the liver? What can it lead to as far as ventilation, cardiovascular, and ICP?
Reduced perfusion of the liver can lead to an inability to metabolize
lactate, altered drug metabolism (delayed), and impaired synthesis of coagulation factors.Furthermore, increased abdominal pressures can lead to: (1) impaired ventilation, secondary
to cephalad displacement of the diaphragm and decreased functional residual capacity; (2)
cardiovascular depression, secondary to decreased venous returnincreased ICP in association with
decreased cerebral perfusion (the increase in ICP is possibly secondary to decreased cerebral
venous outflow
Diagnosis of abdominal compartment syndrome:
abdominal pain and distention are commonly present (not always),
dyspnea and reduced urine output are often the earliest signs of developing intra-abdominal
hypertension.intra-abdominal pressure, which can be
indirectly measured via a nasogastric tube in the stomach or a Foley catheter in the bladder
(intravesicular pressure). Intra-abdominal pressures exceeding 20-25 mm Hg are considered
to be critical, but abdominal compartment syndrome may occur at pressures above 10 mm
So, surgeon wants to go back for ab compartment syndrome-what workup do you want? (trauma pt)
KIM that occult bleeding may be the cause of his condition. and can cause electrolyte imbalances and fluid losses as well as end organ damage. complete blood count, blood
type and cross match, basic metabolic profile, liver and renal function tests, and a
coagulation profile. Given the significant risk of cardiopulmonary compromise and
worsening hemodynamic instability during surgery, I would take the following steps as time
allowed: (1) administer blood and fluids to replace losses and correct any electrolyte
imbalances, keeping in mind that overaggressive fluid administration could potentially
exacerbate the abdominal compartment syndrome (consider using colloids, rather than
crystalloids to reduce the risk of exacerbating abdominal compartment syndrome); (2) ensure
adequate muscle relaxation (abdominal muscle tone may contribute to increased abdominal
compartment pressures); (3) order a chest radiograph, to better evaluate the severity of any
pulmonary compromise; (4) order an echocardiogram to assess his cardiac contractility and
volume status; and (5) ensure that additional blood products, vasopressors, and inotropes
were available in the operating room prior to induction.
What measurement is falsely elevated in abdominal compartment syndrome?
CVP-so, KIM when evaluating this value in the presence of abdominal compartment syndrome
Can you use TEE in children?
Yes-to monitor cardiac function, and aid in fluid mgmt