Pitfield, Alexander Fraser MD, FRCP(C); Carroll, Allison B. MD, FRCPC; Kissoon, Niranjan MD, FRCP(C), FAAP, FCCM, FACPE Show
Staff Physician (Pitfield), Fellow (Carroll), Associate Head, Professor, and Vice President, Medical Affairs (Kissoon), Division of Critical Care, Department of Pediatrics, British Columbia Children’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada. All authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity. Reprints: Niranjan Kissoon, MD, FRCP(C), FAAP, FCCM, FACPE, Division of Critical Care, Department of Pediatrics, British Columbia Children’s Hospital, The University of British Columbia, 4480 Oak St, Rm B245, Vancouver, British Columbia, Canada V6H 3V4 (e-mail: [email protected]). Pediatric Emergency Care 28(2):p 200-204, February 2012. | DOI: 10.1097/PEC.0b013e318243fb72
AbstractPrimary neurological injury in children can be induced by diverse intrinsic and extrinsic factors including brain trauma, tumors, and intracranial infections. Regardless of etiology, increased intracranial pressure (ICP) as a result of the primary injury or delays in treatment may lead to secondary (preventable) brain injury. Therefore, early diagnosis and aggressive treatment of increased ICP is vital in preventing or limiting secondary brain injury in children with a neurological insult. Present management strategies to improve survival and neurological outcome focus on reducing ICP while optimizing cerebral perfusion and meeting cerebral metabolic demands. Targeted therapies for increased ICP must be considered and implemented as early as possible during and after the initial stabilization of the child. Thus, the emergency physician has a critical role to play in early identification and treatment of increased ICP. This article intends to identify those patients at risk of intracranial hypertension and present a framework for the emergency department investigation and treatment, in keeping with contemporary guidelines. Intensive care management and the treatment of refractory increases in ICP are also outlined. Children suffer a significant number of head injuries as a result of their high activity levels, immature developmental skills and increased head-to-body mass ratio. Primary brain injury is irreversible, but secondary insults can be limited. Central to this is the management of raised intracranial pressure (ICP). The pathophysiology of head injury can explain some of the causes of raised ICP. Monitoring of ICP is important and this is closely linked to the maintenance of an adequate cerebral perfusion pressure and the importance of normovolaemia. Other interventions that have been shown to limit rises in ICP are appropriate use of positioning, mechanical ventilation and drug therapy. Less common therapies include jugular venous bulb oxygen saturation monitoring and the use of trometamol (THAM). Most nursing interventions do not actively reduce ICP, but they are central to its management. Reducing stimuli, avoiding cluster care, manual hyperinflation and limiting routine endotracheal suction may prevent an accumulative rise in ICP. Based on this literature review, it is possible to divide these interventions into first and second tier treatments, as shown in the protocol. Much of the suggested management will occur simultaneously, but it is important to assess the child’s own response to each intervention and thus tailor treatment to minimize secondary brain injury. References (53)
Management of paediatric neurologic emergencies in intensive careCare of the Critically III(1998) Induced hypothermia for head injuryNursing in Critical Care(1999) The role of secondary brain injury in determining outcome from severe head injuryThe Journal of Trauma(1993) Hyperventilation in traumatic brain injury: friend or foe?Critical Care Medicine(1997) Intracranial pressure monitoringCare of the Critically III(1998) The effect of nursing activities on intracranial pressureBritish Journal of Nursing(1994) Cerebrovascular response of closed head-injured patients to a standardized endotracheal tube suctioning and manual hyperventilation procedureJournal of Neuroscience Nursing(1992) Electrolytes, Body Fluids and Acid Base Balance.(1993) Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patientsJournal of Neurosurgery(1992) Pediatric traumatic brain injuryCritical Care Nursing Quarterly(1997) Intracranial pressure monitoring in the 1990sCritical Care Nursing Quarterly(1994) Survey of critical care management of comatose, head-injured patients in the United StatesCritical Care Medicine(1995) Making sense of … external ventricular drainageNursing Times(1995) Neurologic DisordersIntracranial pressure changes and family presenceJournal of Neuroscience Nursing(1987) 2022, Radiology Case Reports Show abstractNavigate Down Diabetic ketoacidosis (DKA) is a well-known complication of type 1 diabetes mellitus. Diabetic ketoacidosis predisposes patients into devastating neurological complications. The most common neurologic complication is cerebral edema. Stroke either ischemic or hemorrhagic are uncommon complications of DKA with worse patient's outcome. Hemorrhagic stroke can manifest as subarachnoid or intraparenchymal hemorrhage. We present a 14-year-girl presented with DKA and complicated with both subarachnoid and intraparenchymal hemorrhages. Owing to early diagnosis and prompt treatment the patient had good outcome. 2007, Physiotherapy for Children 2006, Heart and Lung: Journal of Acute and Critical Care Show abstractNavigate Down Backrest elevation, defined as the angle of the backrest height above the horizontal position, is a common nursing intervention that is often used by subjective visual estimation in critically ill patients. The aim of the study was to describe the magnitude of error during the subjective assessment of backrest elevation. This prospective study was conducted in a sample of 160 subjects: 97 registered nurses, 48 undergraduate nursing students, and 15 nursing assistants. Data were collected by recording the degrees of backrest elevation identified by the subjects through an individual random presentation of the selected study angles of 20 degrees, 30 degrees, 35 degrees, 40 degrees, and 45 degrees. A measurement instrument was developed for determination of the angles. Of the 800 investigated angles, 14.9% were estimated accurately, 61.6% were overestimated, and 23.5% were underestimated, with an error average of 8 degrees (±13.5 degrees). It was determined that the larger the angle estimated, the greater the average error. A statically significant difference (P ≤ .001) was found between the actual degree of backrest elevation and the estimated backrest elevation for 20 degrees, 40 degrees, and 45 degrees with the exception of 30 degrees and 35 degrees, which had similar averages of error. Years of critical care experience did not significantly influence the magnitude of error. The results indicate that the subjective assessment of backrest angle may result in errors that may potentially compromise the patient’s condition and supports the need for a more objective method for determining backrest angle. 2002, Neuroscience Letters Show abstractNavigate Down The experiment entails surgically placing two subarachnoid bolts and a subdural balloon through the skull of white New Zealand rabbits. One bolt is used to raise the intracranial pressure (ICP) by continuously infusing lactated Ringer's solution (LRS) into the subarachnoid space to maintain the desired level of ICPs, and the second bolt is to monitor the ICP. A subdural balloon is inflated with a known volume of LRS to simulate a subdural hematoma condition. Using various levels of ICP and/or different sizes of balloons, auditory evoked potentials (AEPs) were recorded from a rabbit. The results indicate that a major correlation of changes in AEP peak latencies is due to mechanical forces of a mass (inflated balloon simulating a hematoma) on the brain matter rather than increased ICP. The AEP peak latencies are relatively insensitive to an increase in ICP without the simulated intracranial hematoma. This study provides evidence that oxygen deficit to the cerebral blood flow caused by deformation of certain parts of the brain could be identified using AEPs. Intracranial Pressure Forecasting in Children Using Dynamic Averaging of Time Series Data2019, Forecasting Effects of hemodilution after traumatic brain injury in juvenile rats2011, Paediatric Anaesthesia Research article International Journal of Cardiology, Volume 221, 2016, pp. 886-891 Show abstractNavigate Down Surgical repair of coarctation of the aorta (CoA) is a safe procedure in children, however the condition is known for its potential recurrence and other related complications. The available evidence shows abnormal intrinsic properties of the aorta in CoA, thus suggesting additional effect, even after CoA repair, on left ventricular (LV) function. Accordingly, we sought to obtain a better understanding of LV myocardial mechanics in very early-corrected CoA using two-dimensional STE. We retrospectively studied 21 patients with corrected CoA at a median age of 9 (2–53) days at three time points: 1) just before intervention, 2) at short-term follow-up and 3) at medium-term follow-up after intervention and compared them with normal values. Speckle tracking analysis was conducted via vendor independent software, Tomtec. After intervention, LV function significantly improved (from − 12.8 ± 3.9 to − 16.7 ± 1.7; p < 0.001), however normal values were not reached even at medium term follow-up (− 18.3 ± 1.7 vs. − 20 ± 1.6; p = 0.002). Medium term longitudinal strain correlated with pre intervention EF (r = 0.58, p = 0.006). Moreover, medium term subnormal values were more frequently associated with bicuspid aortic valve (33.3% vs. 66.6%; p < 0.05). LV myocardial function in neonates with CoA can be feasibly evaluated and followed up by speckle tracking echocardiography. LV subendocardial dysfunction however, remains in early infancy coarctation long after repair. Long-term follow-up through adulthood using myocardial deformation measurements should shed light on the natural history and consequences of this anomaly. Research article Pediatric Neurology, Volume 93, 2019, p. 68 Research article Revue d'Épidémiologie et de Santé Publique, Volume 63, Issue 5, 2015, pp. 299-303 Show abstractNavigate Down The associated factors contributing to a delay in mandatory tuberculosis notification in the Somme department, France, are not yet known. The objective of this study was to analyze these factors. All reported cases of tuberculosis between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to investigate the factors associated with a short time to notification, i.e., ≤48 h. Between 2007 and 2011, a total of 175 cases of tuberculosis were reported to the Somme Regional Health Agency. Of the 145 (83.8%) cases of tuberculosis with at least one pulmonary location, 57.7% had a positive sputum smear. The mean time between the diagnosis of tuberculosis and mandatory notification was 6.1 days. It was 2.6 days for tuberculosis cases with a positive sputum smear versus 8.3 days for cases with a negative sputum smear; 2.0 days for severe cases and 6.3 days for simpler forms. In multivariate analysis, only a positive sputum smear was significantly associated with a short time to mandatory notification (OR 2.44; 95%CI 1.18–5.00; P = 0.02). The time to mandatory notification is longer than recommended. Better collaboration between the parties involved in tuberculosis control and their continuing medical education could reduce this delay in the Somme department. Les facteurs associés au délai de déclaration obligatoire de la tuberculose ne sont pas encore connus. L’objectif de cette étude est d’analyser les facteurs associés au délai de déclaration obligatoire de la tuberculose dans le département de la Somme. Tous les cas déclarés de tuberculose entre 2007 et 2011 ont été rétrospectivement inclus. Une analyse univariée puis multivariée ont été menées pour rechercher les facteurs associés à un court délai de déclaration, soit ≤ 48 h. Entre 2007 et 2011, un total de 175 cas de tuberculose a été signalé à l’agence régionale de santé de la Somme. Parmi les 145 (83,8 %) cas de tuberculose avec au moins une localisation pulmonaire, 57,7 % avaient un examen microscopique direct positif. Le délai moyen entre le diagnostic de la tuberculose et la déclaration obligatoire était de 6,1 jours. Il était de 2,6 jours pour les cas de tuberculose avec une microscopie positive contre 8,3 jours pour les cas avec une microscopie négative ; 2,0 jours pour les formes graves et 6,3 jours pour les formes simples. En analyse multivariée, seul un examen microscopique direct positif était significativement associé à un délai de déclaration obligatoire court (OR 2,44 ; IC à 95 % 1,18–5,00 ; p = 0,02). Le délai de déclaration obligatoire de la tuberculose est supérieur à celui recommandé. Une meilleure collaboration entre les acteurs de la lutte antituberculeuse et leur formation continue permettraient de réduire ce délai dans le département de la Somme. Research article Long-term ventilation in childrenPaediatrics and Child Health, Volume 29, Issue 4, 2019, pp. 167-171 Show abstractNavigate Down Long-term ventilation (LTV) is now an accepted treatment for children with a wide variety of conditions. Respiratory support can be delivered via a mask or a tracheostomy and can range from CPAP to treat obstructive sleep apnoea, to 24 hour a day sophisticated invasive ventilation. Patient numbers are increasing out of proportion to population growth, suggesting that more children are being supported due to changes in societal expectation, improved survival in PICU, and the availability of more advanced ventilators. LTV can enable a child with a complex medical condition to thrive at home surrounded by their family and ultimately be liberated from ventilation as they grow. Alternatively, it can represent a lifelong burden of increasing dependency, accumulating co-morbidities and vanishing independence. In this review the indications for LTV, the processes required to achieve successful discharge, and the outcome for children receiving this treatment are discussed. Future directions for LTV services are also considered. Research article The Relationship Between Intracranial Pressure and Age—Chasing Age-Related Reference ValuesWorld Neurosurgery, Volume 110, 2018, pp. e119-e123 Show abstractNavigate Down No true reference values for intracranial pressure (ICP) in humans exist; current values are estimated from measurements in adults who undergo treatment in order to correct ICP. We report ICP values in a “pseudonormal” group of children and adults to examine if age affects ICP. We analyzed data from all nonshunted patients undergoing a 24-hour ICP monitoring as part of a diagnostic work-up and included patients with no subsequent suspicion of increased ICP and no need for pressure-relieving treatment with a minimum follow-up period of 3 years. From February 2008 to November 2014, a 24-hour ICP monitoring was performed in 221 patients. Of these patients, 35 (14 children, 21 adults) met the inclusion criteria. Follow-up time to confirm absence of ICP-related disease was 3–9 years. Daytime ICP was 2.8 mmHg ± 2.2 in children and 1.9 mmHg ± 4.2 in adults (P = 0.39). Of 35 patients, 32 had higher nighttime ICP. The difference between daytime and nighttime ICP was similar in children (ΔICP = 5.8 mmHg ± 4.0, P < 0.0001) and adults (ΔICP = 6.1 mm Hg ± 3.3, P < 0.0001). ICP could be described as a decreasing function of age, with an ICP decrement of 0.69 mmHg per decade (P = 0.015). We found similar differences in daytime and nighttime ICP between children and adults with no ICP-related disease. ICP seems to decrease with age across all ages. This has implications for therapeutic interventions (e.g., shunt valve selection or resistance in external ventricular drainage). What should be included in the nursing care of a child with increased intracranial pressure?Nursing Interventions
Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload. The patient must be stabilized before transport to radiology for brain imaging.
What are the key treatment options to manage increased ICP?Medical options for treating elevated ICP include head of bed elevation, IV mannitol, hypertonic saline, transient hyperventilation, barbiturates, and, if ICP remains refractory, sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis.
What is increased intracranial pressure in children?In children, increased ICP is most often a complication of traumatic brain injury; it may also occur in children who have hydrocephalus, brain tumors, intracranial infections, hepatic encephalopathy, or impaired central nervous system venous outflow (table 1).
What is the best position for patients with increased ICP?In most patients with intracranial hypertension, head and trunk elevation up to 30 degrees is useful in helping to decrease ICP, providing that a safe CPP of at least 70 mmHg or even 80 mmHg is maintained.
|
