Management of Increased Intracranial Pressure in the Critically Ill Child With an Acute Neurological Injury

Nursing Interventions and Intracranial Pressure Change in Pediatric Patients With Severe Traumatic Brain Injury

BACKGROUND

Nursing interventions in the care of pediatric patients with severe traumatic brain injury (TBI) can have a direct effect on intracranial pressure (ICP), yet they have been largely underexplored. Early evidence is therefore needed to describe these relationships and to determine intervention that promotes neuroprotection and recovery.

OBJECTIVES

The aim of this study was to examine nursing interventions within the first 72 hours of pediatric severe TBI and their effects on ICP.

METHOD

This is a retrospective review of pediatric patients admitted for severe TBI using a quasi-experimental approach to assess nursing interventions and their association with the patients' ICP values prior to and after each intervention.

RESULTS

Of the 56 patients who met the inclusion criteria, 3392 intervention events (range, 31-138 events per patient) were reported. Paired t tests conducted for each intervention type found a statistically significant relationship with suctioning and percent change in ICP values (P = .045). All other interventions showed no significant differences.

DISCUSSION

Standard nursing interventions, specifically suctioning, in pediatric severe TBI may affect ICP and therefore neuroprotection. Further work is needed to better understand the role and timing of nursing interventions and their influence on cerebral hemodynamics so that future TBI guidelines consider nursing care and their impact on brain injury recovery.

Lifesaving Decompressive Craniectomy for High Intracranial Pressure Attributed to Deep-Seated Meningioma: Emergency Management

Objects:

As the most common intracranial extra-axial tumor among adults who tend to grow slowly with minimal clinical manifestation, the patients with meningioma could also fall in neurological emergency and even life-threatening status due to high intracranial pressure (ICP). In those circumstances, decompressive craniectomy (DC) without definitive tumor resection might offer an alternative treatment to alleviate acute increasing of ICP. The current report defines criteria for the indications of lifesaving DC for high ICP caused by deep-seated meningioma as an emergency management.

Patients and Methods:

This study collected the candidates from 2012 to 2018 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The sample included all meningioma patients who came to our ER who fulfilled the clinical (life-threatening decrease in Glasgow Coma Scale [GCS]) and radiography (deep-seated meningioma, midline shift in brain computed tomography [CT] >0.5 cm, and diameter of tumor >4 cm or tumor that involves the temporal lobe) criteria for emergency DC as a lifesaving procedure. GCS, midline shift, tumor diameter, and volume based on CT were evaluated before DC. Immediate postoperative GCS, time to tumor resection, and Glasgow Outcome Scale (GOS) were also assessed postoperation.

Results:

The study enrolled 14 patients, with an average preoperative GCS being 9.29 ± 1.38, whereas the mean midline shift was 15.84 ± 7.02 mm. The average of number of tumor's diameter and volume was 5.59 ± 1.44 cm and 66.76 ± 49.44 cc, respectively. Postoperation, the average time interval between DC and definitive tumor resection surgery was 5.07 ± 3.12 days. The average immediate of GCS postoperation was 10.07 ± 2.97, and the average GOS was 3.93 ± 1.27.

Conclusion:

When emergency tumor resection could not be performed due to some limitation, as in developing countries, DC without tumor resection possibly offers lifesaving procedure in order to alleviate acute increasing ICP before the definitive surgical procedure is carried out. DC might also prevent a higher risk of morbidity and postoperative complications caused by peritumoral brain edema.

Select topics in the management of critically ill children

PURPOSE

The purpose of this review article is to discuss considerations for the critically ill child presenting to an emergency department (ED) with pharmacists who have minimal to no pediatric training.

SUMMARY

In 2015, 17% of all children visited an ED, constituting 30 million visits. The majority of these children were treated at community hospitals where pediatric care resources, including a pediatric-trained pharmacist, may be limited. Because of the complex array of ages and disease states, the care of critically ill children in the ED creates many concerns for adult and community hospitals. This article will focus on several common disease states seen in the pediatric ED, including septic shock, trauma, status epilepticus, and diabetic ketoacidosis.

CONCLUSION

Critically ill children admitted to a community or adult ED provide therapeutic dilemmas and medication safety concerns. A pharmacist with training or experience in pediatrics can have a major impact in patient outcomes in many of the disease states seen in these pediatric patients. This article highlights several key differences between critically ill pediatric and adult patients to better prepare all pharmacists to care for these vulnerable patients.

Management of Intracranial Pressure Part II: Nonpharmacologic Interventions

Pharmacologic and nonpharmacologic interventions are available to treat patients who experience serious elevations in intracranial pressure (ICP). In some cases, patients may experience ICP that is refractory to treatment. Significant negative effects on cerebral blood flow, tissue oxygenation, and cerebral metabolism occur as a result of intracranial hypertension, leading to secondary brain injury. In part 2 of this series, nonpharmacologic interventions for ICP and ICP refractory to treatment are discussed. Interventions include neurologic monitoring (bedside assessment and multimodal monitoring), ventilatory support, fluid and electrolyte maintenance, targeted temperature management, and surgical intervention. Technology is always evolving, and the focus of multimodal monitoring here includes devices to monitor ICP, brain tissue oxygen tension, and cerebral blood flow and cerebral microdialysis monitors. Nursing care of these patients includes perspicacious assessment and integration of data, monitoring ventilatory and hemodynamic functioning, and appropriate patient positioning. Nurses must collaborate with the interprofessional care team to ensure favorable patient outcomes while utilizing an evidence-based guideline for the management of ICP.

Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study

OBJECTIVES

Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning.

DESIGN

Prospective randomized controlled crossover study.

SETTING

PICU of a tertiary hospital.

PATIENTS

Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8) INTERVENTIONS:: Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment efficacy MEASUREMENTS AND MAIN RESULTS:: The time course of intracranial pressure was different throughout the study in both treatment groups, with a significant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although patients treated with lidocaine had no significant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1.

CONCLUSIONS

This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without significant hemodynamic and ventilatory changes.

Management of Intracranial Pressure: Part I: Pharmacologic Interventions

Dangerous, sustained elevation in intracranial pressure (ICP) is a risk for any patient following severe brain injury. Intracranial pressure elevations that do not respond to initial management are considered refractory to treatment, or rICP. Patients are at significant risk of secondary brain injury and permanent loss of function resulting from rICP. Both nonpharmacologic and pharmacologic interventions are utilized to intervene when a patient experiences either elevation in ICP or rICP. In part 1 of this 2-part series, pharmacologic interventions are discussed. Opioids, sedatives, osmotic diuretics, hypertonic saline solutions, and barbiturates are drug classes that may be used in an attempt to normalize ICP and prevent secondary injury. Nursing care of these patients includes collaboration with an interprofessional team and is directed toward patient and family comfort. The utilization of an evidence-based guideline for the management of rICP is strongly encouraged to improve patient outcomes.

Pathophysiology and Treatment of Severe Traumatic Brain Injuries in Children

Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.

Pediatric trauma BIG score: Predicting mortality in polytraumatized pediatric patients

BACKGROUND

Trauma is a worldwide health problem and the major cause of death and disability, particularly affecting the young population. It is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children.

AIM OF THE WORK

This study aimed at evaluation of pediatric trauma BIG score in comparison with New Injury Severity Score (NISS) and Pediatric Trauma Score (PTS) in Tanta University Emergency Hospital.

MATERIALS AND METHODS

The study was conducted in Tanta University Emergency Hospital to all multiple trauma pediatric patients attended to the Emergency Department for 1 year. Pediatric trauma BIG score, PTS, and NISS scores were calculated and results compared to each other and to observed mortality.

RESULTS

BIG score ≥12.7 has sensitivity 86.7% and specificity 71.4%, whereas PTS at value ≤3.5 has sensitivity 63.3% and specificity 68.6% and NISS at value ≥39.5 has sensitivity 53.3% and specificity 54.3%. There was a significant positive correlation between BIG score value and mortality rate.

CONCLUSION

The pediatric BIG score is a reliable mortality-prediction score for children with traumatic injuries; it uses international normalization ratio (INR), Base Excess (BE), and Glasgow Coma Scale (GCS) values that can be measured within a few minutes of sampling, so it can be readily applied in the Pediatric Emergency Department, but it cannot be applied on patients with chronic diseases that affect INR, BE, or GCS.

The predictive value of resting heart rate following osmotherapy in brain injury: back to basics

Background

The importance of resting heart rate as a prognostic factor was described in several studies. An elevated heart rate is an independent risk factor for adverse cardiovascular events and total mortality in patients with coronary artery disease, chronic heart failure, and the general population. Also heart rate is elevated in the Multi Organ Dysfunction Syndrome (MODS) and the mortality due to MODS is highly correlated with inadequate sinus tachycardia.

To evaluate the value of resting heart rate in predicting mortality in patients with traumatic brain injury along scoring systems like Acute Physiology and Chronic Health Evaluation(APACHE II), Sequential Organ Failure Assessment (SOFA) and Glasgow Coma Score (GCS).

Method

By analyzing data which was collected from an open labeled randomized clinical trial that compared the different means of osmotherapy (mannitol vs bolus or infusion hypertonic saline), heart rate, GCS, APACHE II and SOFA score were measured at baseline and daily for 7 days up to 60 days and the relationship between elevated heart rate and mortality during the first 7 days and 60th day were assessed.

Results

After adjustments for confounding factors, although there was no difference in mean heart rate between either groups of alive and expired patients, however, we have found a relative correlation between 60th day mortality rate and resting heart rate (P=0.07).

Conclusion

Heart rate can be a prognostic factor for estimating mortality rate in brain injury patients along with APACHE II and SOFA scores in patients with brain injury.

Do children with Glasgow 13/14 could be identified as mild traumatic brain injury?

OBJECTIVE

To identify in mild head injured children the major differences between those with a Glasgow Coma Scale (GCS) 15 and GCS 13/14.

METHOD

Cross-sectional study accomplished through information derived from medical records of mild head injured children presented in the emergency room of a Pediatric Trauma Centre level I, between May 2007 and May 2008.

RESULTS

1888 patients were included. The mean age was 7.6 + or - 5.4 years; 93.7% had GCS 15; among children with GCS 13/14, 46.2% (p<0.001) suffered multiple traumas and 52.1% (p<0.001) had abnormal cranial computed tomography (CCT) scan. In those with GCS 13/14, neurosurgery was performed in 6.7% and 9.2% (p=0.001) had neurological disabilities.

CONCLUSION

Those with GCS 13/14 had frequently association with multiple traumas, abnormalities in CCT scan, require of neurosurgical procedure and Intensive Care Unit admission. We must be cautious in classified children with GCS 13/14 as mild head trauma victims.

Management of raised intracranial pressure

Appropriate management of raised intracranial pressure begins with stabilization of the patient and simultaneous assessment of the level of sensorium and the cause of raised intracranial pressure. Stabilization is initiated with securing the airway, ventilation and circulatory function. The identification of surgically remediable conditions is a priority. Emergent use of external ventricular drain or ventriculo-peritoneal shunt may be lifesaving in selected patients. In children with severe coma, signs of herniation or acutely elevated intracranial pressure, treatment should be started prior to imaging or invasive monitoring. Emergent use of hyperventilation and mannitol are life saving in such situations. Medical management involves careful use of head elevation, osmotic agents, and avoiding hypotonic fluids. Appropriate care also includes avoidance of aggravating factors. For refractory intracranial hypertension, barbiturate coma, hypothermia, or decompressive craniectomy should be considered.

Traumatic brain injury in children

This article provides a clinical overview of traumatic brain injury in children. It concentrates on the current management guidelines from initial assessment in the accident and emergency department through to specialist critical care.

Hyperglycemia in pediatric head trauma patients: a cross-sectional study

OBJECTIVE

To verify the prevalence of acute hyperglycemia in children with head trauma stratified by the Glasgow coma scale (GCS).

METHOD

A prospective cross-sectional study carried out with information from medical records of pediatric patients presenting with head injury in the emergency room of a referral emergency hospital during a one year period. We considered the cut-off value of 150 mg/dL to define hyperglycemia.

RESULTS

A total of 340 children were included and 60 (17.6%) had admission hyperglycemia. Hyperglycemia was present in 9% of mild head trauma cases; 30.4% of those with moderate head trauma and 49% of severe head trauma. We observed that among children with higher blood glucose levels, 85% had abnormal findings on cranial computed tomography scans.

CONCLUSION

Hyperglycemia was more prevalent in patients with severe head trauma (GCS <8), regardless if they had or not multiple traumas and in children with abnormal findings on head computed tomography scans.

Controversies of prophylactic hypothermia and the emerging use of brain tissue oxygen tension monitoring and decompressive craniectomy in traumatic brain-injured children

BACKGROUND

Despite being the leading cause of death and disability in the paediatric population, traumatic brain injury (TBI) in this group is largely understudied. Clinical practice within the paediatric intensive care unit (PICU) has been based upon adult guidelines however children are significantly different in terms of mechanism, pathophysiology and consequence of injury.

AIM

To review TBI management in the PICU and gain insight into potential management strategies.

METHOD

To conduct this review, a literature search was conducted using MEDLINE, PUBMED and The Cochrane Library using the following key words; traumatic brain injury; paediatric; hypothermia. There were no date restrictions applied to ensure that past studies, whose principles remain current were not excluded.

RESULTS

Three areas were identified from the literature search and will be discussed against current acknowledged treatment strategies: Prophylactic hypothermia, brain tissue oxygen tension monitoring and decompressive craniectomy.

CONCLUSION

Previous literature has failed to fully address paediatric specific management protocols and we therefore have little evidence-based guidance. This review has shown that there is an emerging and ongoing trend towards paediatric specific TBI research in particular the area of moderate prophylactic hypothermia (MPH).

Defenestration in children younger than 6 years old: mortality predictors in severe head trauma

PURPOSE

This study aims to describe the characteristics of severe head injuries in children less than 6 years old, victims of falls from windows, and identify the main predictive factors of mortality in this population.

PATIENTS AND METHODS

A cross-sectional study was designed through data derived from medical records of less than 6-year-old children victims of falls from windows presenting with a severe head injury defined by an initial Glasgow coma scale (GCS) < or =8, hospitalized at a Pediatric Trauma center level III, between January 2000 and December 2005. Statistical analysis used univariate analysis and multiple logistic regressions.

RESULTS

We identified 58 severe head injuries in children victims of falls from windows. The mean age was 2.8 +/- 1.4 years, with a male prevalence (64%); 48% of patients had a GCS < or =5; 62.1% had a Pediatric Trauma Score (PTS) < or =3 at hospital admission. The mortality rate was 41% (24/58) and most of them (88%; 21/24) died within 48 h. An increased death rate was noted in children admitted with hypoxemia (p = 0.001), low systolic blood pressure (p = 0.002), hypothermia (p = 0.0001), GCS < or =5 (p = 10(-5)), PTS < or =3 (p = 0.008), hyperglycemia (p = 0.023), coagulation disorders (p = 0.02), and initial intracranial pressure > or =20 mmHg (p = 0.03). Initial hypothermia, hyperglycemia, and coagulation disorders were the only independent predictive factors of mortality.

CONCLUSION

Severe head injuries resulting from falls from windows carry a high risk of mortality in less than 6-year-old children. Hypothermia, hyperglycemia, and coagulation's disorders are independent predictive factors of mortality. Early deaths could be considered as direct consequences of uncontrollable brain lesions.

Diagnosis of childhood astrocytomas

BACKGROUND

Astrocytomas are the most common brain tumours, accounting for 28 - 50% of all primary CNS tumours. Diagnosis of CNS tumours remains difficult because the varied and nonspecific presentations of CNS tumours in childhood. Objectives/method: The clinical presentations of CNS astrocytomas vary with their sites of location; therefore, a period of uncertainty often precedes diagnosis, and approximately 42% of patients with an intracranial process make several visits to various physicians between the onset and diagnosis. However, on clinical suspicion of a brain tumour, a wide range of neuroimaging techniques may be used to assess the diagnosis of paediatric brain lesions. In this review the authors, for ease of presentation, describe the clinical presentations of supratentorial, infratentorial and spinal cord astrocytomas as well as their radiological and pathological features, and discuss their differential diagnoses.

RESULTS/CONCLUSIONS

Understanding and mastering the numerous imaging features of several subtypes of primary brain tumours affecting children, in addition to radiological features of non-tumoural disorders, remains a significant challenge and demands increased awareness of the paediatric brain diseases.

Management of critically ill children with traumatic brain injury

The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra-cranial injuries. Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans-cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure - intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age-related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation-analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first-tier ICP-specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second-tier therapy (profound hyperventilation with P(a)CO(2) < 35 mmHg, high-dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan.