Paediatric Neurosurgical Emergencies. Kate Parkins Consultant Paediatric Intensivist Alder Hey

Transcription

1 Paediatric Neurosurgical Emergencies Kate Parkins Consultant Paediatric Intensivist Alder Hey

2 Level of consciousness AVPU GCS D Neurological Assessment Pupillary reaction to light Limb movements History

3 Definition of Coma GCS 8 or less No eye opening Does not speak Does not obey commands Airway at risk Go back to ABC

4 Pupillary Changes Tentorial herniation Unilateral fixed pupil Seizures, 3rd nerve Bilateral fixed pupil Hypoxia, drugs, seizures Central Herniation Small unreactive Mid-sized fixed Fixed dilated

5 Symptoms and signs of ICP Regardless of age beware.. Abnormal breathing patterns Hyperventilation, periodic, apnoea Cushing s s Triad Bradycardia, hypertension, breathing abnormalities Opisthotonic posturing (hydrocephalic attacks)

6 Symptoms and signs of ICP In the infant and young child Irritable, level of consciousness vomiting, failure to thrive, poor feeding developmental delay head circumference, tense AF dilated scalp veins setting sun sign (the combination of upper eye-lid retraction and failure of up-gaze) ophthalmoplegia

7 Symptoms and signs of ICP In the older child and young adult Headache, vomiting, drowsiness diplopia, blurred vision, neck pain worsened seizure control Impaired consciousness and coma impaired upgaze papilloedema, ophthalmoplegia

8 Management of acute ICP Regardless of aetiology A, B, C Acute tentorial herniation Mannitol (1g per kg) 1g = 5ml of 20% solution Hypertonic saline 3% 3-55 ml/kg until plasma osmolality mosm Maintain circulating volume Tap Shunt

9 Management A, B, C Essential to reduce 2ry brain injury Adequate oxygenation High normal BP to ensure adequate CPP Intubate & ventilate GCS < 8 RSI Thiopentone/Propofol + suxamethonium Ongoing: Morphine + midazolam Oral ETT Orogastric tube

10 Management A, B Ventilation watch carefully Aims = pco mmhg, po 2 >100 mmhg, SpO 2 >96% Blood gas 6hrly minimum Suction 6 hrly to maintain ETT patency Pre-oxygenate 1min, bolus sedation/analgesia, +/- ETT lignocaine (2mls 1%, leave 2 mins); suction quickly Ensure no abdominal distension eg blocked urinary catheter, abdo trauma Screen for sepsis if pt develops fever (blood, urine, sputum +/- CSF cultures)

11 Circulation Min 2 large bore cannulae Maintain BP to ensure adequate CPP CPP = BP ICP Aim CPP:0-2 2 yrs 40; yrs 55; yrs 65 mmhg fluid bolus 10 ml/kg (0.9% saline) if needed use noradrenaline (+/- other inotrope as needed) Check for evidence pain or distress Treat/remove cause pain/distress Exclude abdo distension, urinary retension etc Give bolus sedation/analgesia/paralysis Confirm no evidence of seizure (treat if present) dilated pupils/ HR/ HR/ BP +/- abnormal movements

12 Other PICU bits.. Position tilt bed Head up 30 head midline (neck not turned), sandbags + tape Always log roll (not straight lift) NB cervical collar on for roll Neurology keep ICP <20 Treat drops in CPP rapidly Assess pupils/gcs hrly (if not paralysed/heavily sedated) Do not let pt develop fever! Keep C Other Keep Na maintenance 0.9% NaCl Full maintenance (NOT restriction) Watch blood glucose if >8 mmol/l start insulin infusion Aim = glucose mmol/l Minimal handling DVT prophylaxis TEDS if >40 kg +/- LMW heparin

13 2nd line management ICP Hyperventilation - aim pco mmhg Thiopentone Bolus dose mg/kg (NB may cause BP) (Infusion mg/kg/hr) Decompressive craniotomy As last resort only Hyperventilate Consider cooling pt ie 35 C

14 DISABILITY & EXPOSURE Wrap them up Expose lines Under/over wrap Hat Trauma CT scans, CXR, AXR, C-spine, C pelvis Log roll Spinal board or vac mattress + scoop Immobilise #

15 Hydrocephalus Relative excess of CSF in the cranium resulting in raised pressure Pressure is the ultimate arbiter Small ventricles normal pressure eg Stiff slit ventricle syndrome Radiology reassures only

16 Treatment of hydrocephalus Surgical disorder Caveats: infection, weight, age, comorbidity Treatment Divert temporarily and treat cause Divert permanently Diversions used depend on where block is

17 Shunt Complications Blockage (30% first year) In-growth of choroid, poor placement, ventricular collapse Listen to the parents Breakage/disconnection X-ray the shunt Infection -6% Normal peripheral WC, CRP up in 90% Subdurals, seizures, over drainage Stiff slit ventricle syndrome

18 Managing potential blocked Recognise potential shunt ie any child with previously treated hydrocephalus Beware spina bifida, long term shunts, aqueductal stenosis Listen to the parents Manage ABCD Scan early Speak to neurosurgeons/picu

19 Tapping shunts All modern shunts have reservoir Child in extremis Prep skin 2% chlorhexidene Insert butterfly Measure pressure Stiff extension set + tape measure Drain 20 ml Observe and repeat if necessary Find burr hole Insert spinal needle

20 Transfer Time critical transfer cranial trauma with clot Urgent/time critical shunt/bleed/tumour Time is of the essence, transfer team may miss the boat ABC then transfer quickly

21 Summary Most neurosurgical emergencies are emergencies of acutely raised ICP Manage ABCD React to changes Scan early Contact neurosurgeons/picu early Contact neurosurgeons if concerned