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2yo s/p ground level fall with head injury. period of AMS while in ed. however after iv placment now agitated.
sedation of choice for head ct?
sedation of choice for head ct?
Ketamine and Versed?
ketamine increases ICP
I'm by no means a sedation expert yet, but some of the newer literature refutes the claim of ketamine increasing ICP
IM ketamine.
I like to start fights with nursing that I can't win.
Which increases ICP more, the ketamine or the kid fighting on the table and being restrained?ketamine is contraindicated in head injury. at least this is what i thought.
Disclaimer: I don't necessarily know what I'm talking about, so take this post with a grain of salt.
IMHO, Ketamine's the best choice for peds sedation even with suspected head injury unless there's already elevated ICP due to hemorrhage, which you should be able to identify via ophtho exam (papilledema, swollen optic nerve). If not, Ketamine's rapid onset should make it a go-to in this instance. Just my 2¢.
If the kid herniates, you've probably missed some pretty major warning signs, indicative of an insufficiently thorough physical exam (optho exam, head trauma→raised ICP via hematoma or contusions→Cushing's triad?). It's unlikely that the Ketamine would've caused it. Critically elevated ICP is a physical diagnosis; if the signs are there, you treat it, but it's very unlikely (IMHO, which once again, may easily be wrong) that Ketamine would push a ped with ≤10-20mmHg to ≥35mmHg at a 1mg/kg slow push.the thing with using ketamine in head trauma is that it isn't standard of care. standard of care usually lags these new studies finding no basis in what was thought to be common sense.
worse case scenario u give ketamine for ct sedation in a kid that herniates or develops neuro deficits. the ketamine likely had nothing to do with the outcome but there won't be a shortage of lawyers ready to take you for all of what your worth, including the shirt on your back.
the problem at my place is that i can't use pentobarb.
anyone use etomidate?
Disclaimer: I don't necessarily know what I'm talking about, so take this post with a grain of salt.
IMHO, Ketamine's the best choice for peds sedation even with suspected head injury unless there's already elevated ICP due to hemorrhage, which you should be able to identify via ophtho exam (papilledema, swollen optic nerve). If not, Ketamine's rapid onset should make it a go-to in this instance. Just my 2¢.
If the kid herniates, you've probably missed some pretty major warning signs, indicative of an insufficiently thorough physical exam (optho exam, head trauma→raised ICP via hematoma or contusions→Cushing's triad?). It's unlikely that the Ketamine would've caused it. Critically elevated ICP is a physical diagnosis; if the signs are there, you treat it, but it's very unlikely (IMHO, which once again, may easily be wrong) that Ketamine would push a ped with ≤10-20mmHg to ≥35mmHg at a 1mg/kg slow push.
I think etomidate would be overkill for rads sedation; perhaps methohexital if you can get the pt in quickly enough? Or if you're worried about ICP, thiopental (although have to watch for that long-acting effect)?
OP stated that pt didn't get agitated until after IV placement. Couldn't anyone have gotten eye impressions during triage or in EMS? What about bp, etc? What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?The only question I have is if the kid is awake (assuming they are if you are trying to sedate them) and young, how do you keep them still enough to do a thorough ophtho exam? Assuming you can hold them down and still, that would increase the ICP if they fight, so that kind of defeats the purpose.
So is acute ICP spiking always your concern for any head injury +AMS (on a 2yo) -LoC (I assume since OP didn't mention that) that is otherwise asymptomatic for any further evidence of ICP? If mass effect-induced ICP is a concern for you, why wasn't there a NSGY consult (in which case, no sedation until pt is seen by NSGY)? If there's M&M due to ICP and you didn't follow ICP protocols from the getgo, you can still get slammed for that as well. The head CT really shouldn't be precluding the physical exam. (Once again, disclaimer, I may easily be wrong and am not an expert, so don't make any clinical decisions based on this post)While I agree that ketamine would not push the kid to increased ICP, increased ICP can still happen down the line, and if you used ketamine, people will look for someone to blame. It's easier to blame the doctor, even if the ketamine wasnyoure' wrong, than to blame the accident. Gotta wait until most docs are ok with ketamine in head trauma.
OP stated that pt didn't get agitated until after IV placement. Couldn't anyone have gotten eye impressions during triage or in EMS? What about bp, etc? What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?
Finally if you haven't read the PECARN study on head CTs in children you should. We have it up on all our computers to reference the flow chart, and it's definitely cut down on the number of scans we do.
Now, some facilities may be different, but I get looked at like I have 3 arms when I ask the nurses for the ophthalmoscope head. They certainly don't have the training to perform a fundoscopic exam, and if they did one, I wouldn't trust it. It certainly isn't something EMS would perform.Couldn't anyone have gotten eye impressions during triage or in EMS?
Valid, if you have a cuff that fits correctlyWhat about bp, etc?
Lots of IVs are placed without us ordering them. Less frequently on kids, but still, nursing likes to take charge frequently.What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?
By "eye impressions", I'm just referring to basic things such as dilation, reactivity, palsy, etc. that should be within the scope of EMS and Triage Nurses with penlights. If you were about to see a ped c/o head injury from fall with AMS, wouldn't someone have a GCS for you? If there is CHI concern though, someone qualified to check for fluid and nerve inflammation should probably do one before a head ct (unless your facility has portable ct).Now, some facilities may be different, but I get looked at like I have 3 arms when I ask the nurses for the ophthalmoscope head. They certainly don't have the training to perform a fundoscopic exam, and if they did one, I wouldn't trust it. It certainly isn't something EMS would perform.
Dude, I'm not sure if I understood you correctly; what's a facility without the ability to get the bp of a ped doing with accreditation for seeing peds?Valid, if you have a cuff that fits correctly
I agree, but Head Injury+AMS+Ped, wouldn't you want to at least have a look before or while a nurse is trying to get a line? Also, wouldn't certain factors such as GCS, vomiting, etc. also help you determine whether you would be calling consults?Lots of IVs are placed without us ordering them. Less frequently on kids, but still, nursing likes to take charge frequently.
I'm certainly not saying it would be easy, especially on a 2yo, but if the circumstances warrant suspicion of pathologies that raise ICP, someone's going to have to do one.Also, getting a kid to be calm is one thing, getting them to follow commands during an eye exam (or to not move their eyes, or keep them open while you shine a bright light in there) is another.
I'm certainly not saying it would be easy, especially on a 2yo, but if the circumstances warrant suspicion of pathologies that raise ICP, someone's going to have to do one.
Have you ever done or attempted to do a fundoscopic exam on a 2 year old? If so, how do you do it? I like to do eye exams when I can for practice, but I've never been able to see a fundus on anyone under maybe 8 years old before due to lack of cooperation?
Have you ever done or attempted to do a fundoscopic exam on a 2 year old? If so, how do you do it? I like to do eye exams when I can for practice, but I've never been able to see a fundus on anyone under maybe 8 years old before due to lack of cooperation?
I agree, but Head Injury+AMS+Ped, wouldn't you want to at least have a look before or while a nurse is trying to get a line? Also, wouldn't certain factors such as GCS, vomiting, etc. also help you determine whether you would be calling consults?
Just so we're all on the same page (for those of you who don't read the whole thread! ), I'm not advocating an optho exam on every single pt in every single case. I was referring to this particular instance posted by the OP, where there could have been ICP concerns (only because some people were mentioning that they'd avoid Ketamine because it may cause morbidity if ICP was elevated), and the pt presented with AMS, accompanied potentially with a low enough GCS where ICP-raising pathology was suspected, I posited that an optho exam would be appropriate because it could demonstrate presence of ICP, which would potentially change management. The exam, on this particular pt, if ICP was suspected, would be appropriate, and at that point should have been done prior to when the pt became agitated, at which point it may've made more sense to do. I'm in no way saying that an Optho exam is necessary on any ped that hits their head, but if you reasonably suspect ICP issues, the optho exam is one of the best ways to check for it if conditions permit.
If you have successfully done this before, I would love to know your trick.
Me too. I'm actually not sure why this topic has become such a talking point, and I suspect you (Dimoak) are putting a bit too much faith in a fundal exam, even if you could get one. It's unlikely to change your management even if you could get it (which neither you nor anyone else will be able to). It's really not going to change your management, as these decisions should be made clinically. Based on the presentation, this kid deserves some radiation.
Moreover I've seen a number of kids without papilledema who had significant intracranial pathology, including a midline shift. Papilledema takes some time to show itself. I don't know if that's a kid thing or not, but overall a 'normal' fundal exam, by me, not an ophthalmologist, wouldn't make me not scan this kid who has AMS, agitation or any other sign of trouble. In fact, if you look at the PCARN study (and thank you southerndoc for fixing my link!) which reviewed 44,000 cases of head trauma, they don't even mention ophthalmic exams.
No, I have never done one, nor do I have the expertise to do one effectively on a 2 year old. But someone with that ability can do it if the patient is in a state where ICP is suspected. Don't forget the above connotation of my posts, which involved a level of distress where the ICP is high enough to contraindicate Ketamine (which would have to be quite high), and at that point, the patient is probably not going to be easily agitatable. Also, at that point, a successful ophtho exam would probably show edema and optic nerve inflammation to demonstrate the presence of the ICP. If you can't get the ophtho exam, as Stitch alluded to, you probably don't need one. At which point, the patient's ICP levels, as I mentioned earlier in this thread, would not warrant eliminating Ketamine from potential sedatives.Again, though, how do you do a fundoscopic exam on a 2 year old? That is why I ask if you've ever done one before in this age group because with the exception of checking for a red reflex, reactivity, and extraocular movements, I don't know how to do a full opthalmologic exam on any 2 year old kid, forget an agitated one (since the purpose in this case is to look for papilledema). If you have successfully done this before, I would love to know your trick.
Once again, I'm not discussing whether or not this patient should or should not have been imaged (they should). The entire point of my posts was that if the patient is indeed in a situation of severe enough distress where the ICP is so elevated that Ketamine should not be used, this would be evident in an optho exam because by then most likely the papilledema and swelling of the optic nerve would be present, as well as other signs such as Cushing's triad. At no point was I arguing that the ophtho exam is an appropriate avenue instead of imaging this patient! My point, simply, was that nothing about the presentation of this patient suggested that Ketamine should not be used to sedate this patient for a head CT; because if the contraindications (highly elevated ICP) were present, there would potentially be a multitude of clinical identifiers prior to the head CT findings, which would have demonstrated a need to address it immediately.Me too. I'm actually not sure why this topic has become such a talking point, and I suspect you (Dimoak) are putting a bit too much faith in a fundal exam, even if you could get one. It's unlikely to change your management even if you could get it (which neither you nor anyone else will be able to). It's really not going to change your management, as these decisions should be made clinically. Based on the presentation, this kid deserves some radiation.
Moreover I've seen a number of kids without papilledema who had significant intracranial pathology, including a midline shift. Papilledema takes some time to show itself. I don't know if that's a kid thing or not, but overall a 'normal' fundal exam, by me, not an ophthalmologist, wouldn't make me not scan this kid who has AMS, agitation or any other sign of trouble. In fact, if you look at the PCARN study (and thank you southerndoc for fixing my link!) which reviewed 44,000 cases of head trauma, they don't even mention ophthalmic exams.
Dude, I'm not sure if I understood you correctly; what's a facility without the ability to get the bp of a ped doing with accreditation for seeing peds?
This thread made me think WTF would I do for corneal/conjuctival FB in a raging child. I wonder if the nystagmus from IM ketamine would be too significant....
Ah thanks, I didn't realize that's what Ninja may've meant. I was just confused about why it would be difficult to get a ped's bp if necessary.Blood pressure is not part of the routine vital signs our facility gets on young pediatric cases. I do not recall the age cutoff. It can be requested on an as-needed basis.
This thread made me think WTF would I do for corneal/conjuctival FB in a raging child. I wonder if the nystagmus from IM ketamine would be too significant....
I'm surprised nobody has yet mentioned Propofol, if the child already has an IV. If you want quick on/off to facilitate neuro exam, its pretty hard to beat, and no ICP concerns. With a 64 (or even 16)-slice scanner, if you're just doing the head, it should be 1-2 minutes, tops, with a good tech. Go to CT, push the propofol, do the scan, and come back. Child is awake again minutes after you get back. Of course, anesthesia at my shop says I can't use propofol, which makes me
Anyone else with thoughts on propofol?
IM ketamine.
I like to start fights with nursing that I can't win.
What do you mean? Are your nurses refusing to give ketamine?
They refuse to give it IM.
We have a testy bunch here.
They refuse to give it IM.
We have a testy bunch here.
Pediatric Patients: Most patients aged 3 years through 16 years and classified ASA-PS I or II require 2.5 to 3.5 mg/kg of DIPRIVAN Injectable Emulsion for induction when unpremedicated or when lightly premedicated with oral benzodiazepines or intramuscular opioids. Within this dosage range, younger pediatric patients may require higher induction doses than older pediatric patients. As with other sedative-hypnotic agents, the amount of intravenous opioid and/or benzodiazepine premedication will influence the response of the patient to an induction dose of DIPRIVAN Injectable Emulsion. A lower dosage is recommended for pediatric patients classified as ASA-PS III or IV. Attention should be paid to minimize pain on injection when administering DIPRIVAN Injectable Emulsion to pediatric patients. Boluses of DIPRIVAN Injectable Emulsion may be administered via small veins if pretreated with lidocaine or via antecubital or larger veins
http://www.rxlist.com/diprivan-drug.htmIndication Approved Patient Population
Initiation and maintenance of Monitored Anesthesia Care (MAC) sedation Adults only
Combined sedation and regional anesthesia Adults only
Induction of General Anesthesia Patients ≥ 3 years of age
Mainenance of General Anesthesia Patients ≥ 2 months of age
Intensive Care Unit (ICU) sedation of intubated, mechanically ventilated patients Adults only
Refuse to give based on a few patients with CSF shunts who had elevated ICP after being given ketamine? Or just refuse because "somebody told me ketamine was bad with head injuries?"
Yeah, I was just providing that data as a possible point of reference; I'm not familiar with the literature regarding its dosing beyond that. I wonder though, if something did go wrong with the induction dose, couldn't you get slammed at trial with this by an expert witness testifying that it's not indicated for induction of pts younger than 3yo (especially with the high profile of Propofol in the general public)?Dimoak, You are correct that is what the drug is "approved" for. However, pediatric intensivists use it for maintanance with ventilated pts for up to 24 hrs to facilitate extubation. It is commonly used as an induction agent in pediatric anesthesia. Many EDs use it for procedural sedation. Off label use of meds is common.
Yeah, I was just providing that data as a possible point of reference; I'm not familiar with the literature regarding its dosing beyond that. I wonder though, if something did go wrong with the induction dose, couldn't you get slammed at trial with this by an expert witness testifying that it's not indicated for induction of pts younger than 3yo (especially with the high profile of Propofol in the general public)?