Peds Case

[CodeBlu]

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Alright fellow gas passers... I've been rotating through pediatrics and I've had a wild time.

I've got a whole slew cases for you guys that I've found interesting and educational. Curious to hear your thoughts. Will start with this one though... as my first night on call, this blew my mind.

7 year old male, presents to ED via EMS for altered LOC. Was running around in gym class and got side swiped and hit head on wall pretty hard. Brief loss of consciousness. Regained consciousness and business as usual. Parents pick kid up with intent of coming to hospital to get looked at. They get stuck in traffic. Patient becomes increasingly lethargic and unresponsive. Parents call EMS. GCS 8 when they arrive. HR 70's, BP 120/90.

By the time kid arrives to the ED. They call a pediatric trauma code. Anesthesia shows up. The heart rate is not going from 38-45 bpm, and the BP is 146/100. Left pupil is blown. GCS is 6 now. ED decides they need to secure airway before CT scan. Their plan? Etomidate and succinylcholine, glidescope.

Thoughts?

 

[deleted171991]

Haven't done one of these ever, and I don't do neuro emergencies or peds. But let's exercise the oral board cells...

Textbook epidural hematoma. This kid is herniating or getting there. It's not the airway that will kill him (although hypercarbia and/or aspiration won't help). This is a neurosurgical emergency, and I would ask the surgeon what he needs before the OR (he may want to put in an EVD stat before CT/intubation/OR). I wouldn't delay the CT scan/EVD securing the airway unless the patient can't protect it, or is hypoventilating (check a VBG stat). I would literally run with this kid to the scanner and then directly to the OR. With impending brain herniation, he may code during an RSI, so I would love having some form of CSF/hematoma drainage first.

When needed, a modified (gentle) RSI with atropine/propofol/remi/roc with a Mac blade. I would put in an A-line/IVs when I have a chance.

He will need some manitol/lasix in the meanwhile, with head elevation.

What am I missing?

 

[btbam]

Cushing's Reflex. Intubate, hyperventilate, start mannitol/3% saline and go to scanner.

I've seen it several times in kids with obstructed hydrocephalus when their VP shunt fails. Massive head with brady/hypertension/erratic breathing.

 

[Hoya11]

Alright fellow gas passers... I've been rotating through pediatrics and I've had a wild time.

I've got a whole slew cases for you guys that I've found interesting and educational. Curious to hear your thoughts. Will start with this one though... as my first night on call, this blew my mind.

7 year old male, presents to ED via EMS for altered LOC. Was running around in gym class and got side swiped and hit head on wall pretty hard. Brief loss of consciousness. Regained consciousness and business as usual. Parents pick kid up with intent of coming to hospital to get looked at. They get stuck in traffic. Patient becomes increasingly lethargic and unresponsive. Parents call EMS. GCS 8 when they arrive. HR 70's, BP 120/90.

By the time kid arrives to the ED. They call a pediatric trauma code. Anesthesia shows up. The heart rate is not going from 38-45 bpm, and the BP is 146/100. Left pupil is blown. GCS is 6 now. ED decides they need to secure airway before CT scan. Their plan? Etomidate and succinylcholine, glidescope.

Thoughts?

it sounds like they did the right thing

I think you are concerned about using SUx with this situation of someone with already increased ICP and Bradycardia, I get that.

The intubation itself will likely help the heart rate. Atropine or Glyco And/or ephedrine would be ideal before intubation, but I think you would probably still be OK without it.

And the increased ICP with SUX thing is risk/benefit argument.

You have GOT to secure this kids airway, hes considered full stomach, needs an RSI. Sux MIGHT cause increased ICP but very unlikely to have clinical significance vs an aspiration.

And the Glidescope is because thats just how they do it in the ER.

And better to intubate the kid now before the scanner, paralyze and control CO2. You dont want to sedate this kid for a CT scan without an ETT. Classic board question, because then CO2 rises with sedation, head bleed worsens. YOu also dont want to have the kid decompensate during transport or scan, so secure the airway in the ER.

 

[T-burglar]

Kid needs simultaneous head up 30 degree neurocritical intubation and a femoral or subclavian central line for HTS followed by adjunctive herniation measures like neutral head position etc and then some kind of neurosurgery

Don’t let the ED intubate him if it doesn’t seem like they’re familiar with this special situation , anesthesia or PICU need to take over immediately. Should be treated like cardiac arrest, the kid is “newly” dead and needs to be resuscitated just like sudden cardiac death.

 

[jeesapeesa]

cushings reflex with the hypertension and bradycardia secondary to increased ICP/midline shift. intubate..propofol and succinylcholine and treat any decrease in BP accordingly. Propofol infusion and hyperventilation. CPP = MAP - ICP. aline. neurosurgery to place ICP monitor and watch ICP carefully. head of bead 30 degrees. mannitol. scan or not scan this pt needs immediate decompression now.

Alright fellow gas passers... I've been rotating through pediatrics and I've had a wild time.

I've got a whole slew cases for you guys that I've found interesting and educational. Curious to hear your thoughts. Will start with this one though... as my first night on call, this blew my mind.

7 year old male, presents to ED via EMS for altered LOC. Was running around in gym class and got side swiped and hit head on wall pretty hard. Brief loss of consciousness. Regained consciousness and business as usual. Parents pick kid up with intent of coming to hospital to get looked at. They get stuck in traffic. Patient becomes increasingly lethargic and unresponsive. Parents call EMS. GCS 8 when they arrive. HR 70's, BP 120/90.

By the time kid arrives to the ED. They call a pediatric trauma code. Anesthesia shows up. The heart rate is not going from 38-45 bpm, and the BP is 146/100. Left pupil is blown. GCS is 6 now. ED decides they need to secure airway before CT scan. Their plan? Etomidate and succinylcholine, glidescope.

Thoughts?

 

[vector2]

Kid needs simultaneous head up 30 degree neurocritical intubation and a femoral or subclavian central line for HTS followed by adjunctive herniation measures like neutral head position etc and then some kind of neurosurgery

Don’t let the ED intubate him if it doesn’t seem like they’re familiar with this special situation , anesthesia or PICU need to take over immediately. Should be treated like cardiac arrest, the kid is “newly” dead and needs to be resuscitated just like sudden cardiac death.

Agreed, please do not let the ED manage this unless they are specifically peds ER trained. These guys literally give etomidate and sux to everyone regardless of the clinical picture. Me, personally, I'm RSI'ing with prop/sux and a squirt of atropine before going to the scanner

 

[coffeebythelake]

Propofol and high dose roc (or suxx)
IV lidocaine may help attenuate ICP response
IV aropine available
Wont waste time on pre induction art line

Hypotension will reduce CBF but wont kill him.
Hypertension and especially bucking may lead to herniation - this will kill him

As others mentioned, hyperventilate, hob up, and other techniques to reduce ICP. And dont let the ER intubate, those cowboys

 

[HLxDrummer]

ED resident here...

Do you guys have any evidence for lidocaine or not using sux in this situation?

I've heard of the lidocaine thing but really doesn't seem to be much data out there for it.

As far as sux in TBI, I've seen one retrospective study they suggests a trend but nothing damning.

Regarding the glidescope I'm not sure if this is relevant, is it? Whatever helps you get the tube the first time sounds good in my book. Probably wouldn't be my go-to, but if they are comfortable with it...

This is very bread and butter EM. Classic EDH. Maybe different at the ivory tower but out in the community this ED doc is going to make the diagnosis, get access, protect the airway, get the CT, start hypertonic, talk to family, and arrange transfer while dealing with an entire ED full of other sick patients. I personally am not going to waste time with stuff not proven to work. I might have some atropine drawn up in case he gets more bradycardic but other than that, just RSI him! I generally like Roc for a variety of reasons but if the neurosurgeon is not at the bedside, sux is nice for giving them an exam. I'd probably do prop/sux. He doesn' need to spend anymore time in the ED than necessary.

I could be missing something obvious which is why I'm asking. Just throwing out some thoughts from the ED side as they seem to be getting beat up on here.

 

[coffeebythelake]

If left pupil is blown he is already herniating. He is in the far right hand side of the cerebral compliance curve. Prognosis is not good even with timely intervention.

 

[itwasalladream]

I don't do this frequently but management sounded ok to me. Do whatever it takes to get them quickly and safely to decompression - they are about to die. Sux is fine. Glide might reduce stimulation and make for a more stable BP. Main goals are stable BP, no bucking, quick placement of tube and quick progression to definitive therapy. Plenty of patients buck if roc hasn't kicked in yet during emergent RSI. Hyperventilation, mannitol, hypertonic saline are all nice but he has pressurized blood squeezing brain matter out of his cranium. I doubt osmosis is saving his life here.

I also don't understand the ER hate here...it's trauma center bread and butter, right?

 

[coffeebythelake]

ED resident here...

Do you guys have any evidence for lidocaine or not using sux in this situation?

I've heard of the lidocaine thing but really doesn't seem to be much data out there for it.

As far as sux in TBI, I've seen one retrospective study they suggests a trend but nothing damning.

Regarding the glidescope I'm not sure if this is relevant, is it? Whatever helps you get the tube the first time sounds good in my book. Probably wouldn't be my go-to, but if they are comfortable with it...

This is very bread and butter EM. Classic EDH. Maybe different at the ivory tower but out in the community this ED doc is going to make the diagnosis, get access, protect the airway, get the CT, start hypertonic, talk to family, and arrange transfer while dealing with an entire ED full of other sick patients. I personally am not going to waste time with stuff not proven to work. I might have some atropine drawn up in case he gets more bradycardic but other than that, just RSI him! I generally like Roc for a variety of reasons but if the neurosurgeon is not at the bedside, sux is nice for giving them an exam. I'd probably do prop/sux. He doesn' need to spend anymore time in the ED than necessary.

I could be missing something obvious which is why I'm asking. Just throwing out some thoughts from the ED side as they seem to be getting beat up on here.

There is a paucity of solid, evidence based studies. Those that exist are often conflicting. Suxx is by far the quickest acting and provides optimal intubating conditions in about 45 seconds. There is a transient increase in ICP but studies have not shown it worsens morbidity and mortality. In addition, bucking with intubation cause massive increases in ICP. For this reason, it is generally considered acceptable to use.

Now don't get me started on the wording of this. "Studies have not shown" is not the same as saying "it is safe". In my mind the former statement is a much lower standard.

I think high dose rocuronium (1.2 mg/kg) is a much better choice than suxx (1 mg/kg) for RSI in TBI. It provides optimal intubating conditions in a similar amount of time (just slightly longer). It does not increase ICP. Roc also increases the apneia time compared to suxx.

There is a fair amount of evidence for IV lidocaine, and I think its use is not considered controversial. Some studies show no effect compared to placebo. No studies show harm, and the risk profile of 1.5 mg/kg IV lidocaine is low.

Also throwing it out there, ketamine has long been vilified but overwhelming evidence support safety profile for TBI w increased ICP. Probably won't change my practice though. I still wouldn't use it except in extenuating circumstances.

Agree that goal is to intubate smoothly and quickly. For reassuring airway, I would expect DL = VL. In fact, in this case, studies show DL is faster than VL. For less straightforward airways, VL would reduce time to intubation and degree of laryngeal stimulation.

I work in one of these ivory towers. My experience in several different hospital systems have definitely tainted my perception of ED intubating skills. On multiple occasions with different ED attendings, I've seen (a) no preoxygenation leading to profound hypoxemia with induction (and they are surprised when it happened), (b) inappropriate choice and dosing of induction drugs, (c) poor positioning, (d) a "rapid sequence intubation" for aspiration risk that is not at all rapid or safe. As others have noted, ED loves etomidate/suxx and use this as a default regardless of patient comorbidities. ED also loves to glidescope everyone.

 

[Robotic Wis-Hipple]

I legitimately have no idea why you wouldn’t use a glidescope. I like to look like the BSD as much as the next guy but imo a glidescope causes far less laryngeal stimulation than a DL even if your view is a grade 1 with minimal lifting. Plus, you’re in an ED etc and everyone can watch it going thru the cords and move on from the “is it possible it’s not in” stage to securing, hyperventilating, and getting definitive treatment.

As far as induction, I’d say Lido,Prop, and either sux or RSI roc I don’t really care but as I’m in the ED and used to getting guff anytime I ask for sux I’d probably just use roc. But keep that etomidate away from me.

 

[coffeebythelake]

I legitimately have no idea why you wouldn’t use a glidescope. I like to look like the BSD as much as the next guy but imo a glidescope causes far less laryngeal stimulation than a DL even if your view is a grade 1 with minimal lifting. Plus, you’re in an ED etc and everyone can watch it going thru the cords and move on from the “is it possible it’s not in” stage to securing, hyperventilating, and getting definitive treatment.

As far as induction, I’d say Lido,Prop, and either sux or RSI roc I don’t really care but as I’m in the ED and used to getting guff anytime I ask for sux I’d probably just use roc. But keep that etomidate away from me.

While theoretically glidescope should reduce laryngeal stimulation, this hasn't been seen in studies. Several explanations have been suggested - longer duration of stimulation, and use of a very curved rigid stylet. IF the patient has an anterior airway or predicted to be difficult I would use it. BUT studies dont support routine use of glidescope over DL as a means to minimize laryngeal stimulation. The most stimulating part of the intubation is getting the tube past the VC

 

[HLxDrummer]

There is a paucity of solid, evidence based studies. Those that exist are often conflicting. Suxx is by far the quickest acting and provides optimal intubating conditions in about 45 seconds. There is a transient increase in ICP but studies have not shown it worsens morbidity and mortality. In addition, bucking with intubation cause massive increases in ICP. For this reason, it is generally considered acceptable to use.

Now don't get me started on the wording of this. "Studies have not shown" is not the same as saying "it is safe". In my mind the former statement is a much lower standard.

I think high dose rocuronium (1.2 mg/kg) is a much better choice than suxx (1 mg/kg) for RSI in TBI. It provides optimal intubating conditions in a similar amount of time (just slightly longer). It does not increase ICP. Roc also increases the apneia time compared to suxx.

There is a fair amount of evidence for IV lidocaine, and I think its use is not considered controversial. Some studies show no effect compared to placebo. No studies show harm, and the risk profile of 1.5 mg/kg IV lidocaine is low.

Also throwing it out there, ketamine has long been vilified but overwhelming evidence support safety profile for TBI w increased ICP. Probably won't change my practice though. I still wouldn't use it except in extenuating circumstances.

Agree that goal is to intubate smoothly and quickly. For reassuring airway, I would expect DL = VL. In fact, in this case, studies show DL is faster than VL. For less straightforward airways, VL would reduce time to intubation and degree of laryngeal stimulation.

I work in one of these ivory towers. My experience in several different hospital systems have definitely tainted my perception of ED intubating skills. On multiple occasions with different ED attendings, I've seen (a) no preoxygenation leading to profound hypoxemia with induction (and they are surprised when it happened), (b) inappropriate choice and dosing of induction drugs, (c) poor positioning, (d) a "rapid sequence intubation" for aspiration risk that is not at all rapid or safe. As others have noted, ED loves etomidate/suxx and use this as a default regardless of patient comorbidities. ED also loves to glidescope everyone.

Good point on the no harm with lido. I/my nurses basically never use lido so it would slow us down in the ED but you guys can probably make it happen lickety split so no loss there.

Regarding ED intubations... I see your point. When I initially got into medicine I wanted to be a CRNA which transformed to wanting to be an anesthesiologist. When I was in med school it was a tough decision between ED and anesthesia. Always had an interest in airway stuff (why I browse here periodically). Not all of my collegaues share this. I have seen some rough intubations/peri-intubations myself. Guess there is variability with everything. Just wish we could all get along and work collaboratively.

 

[vector2]

Good point on the no harm with lido. I/my nurses basically never use lido so it would slow us down in the ED but you guys can probably make it happen lickety split so no loss there.

Regarding ED intubations... I see your point. When I initially got into medicine I wanted to be a CRNA which transformed to wanting to be an anesthesiologist. When I was in med school it was a tough decision between ED and anesthesia. Always had an interest in airway stuff (why I browse here periodically). Not all of my collegaues share this. I have seen some rough intubations/peri-intubations myself. Guess there is variability with everything. Just wish we could all get along and work collaboratively.

I would love to work "collaboratively" with the ED. The problem I have is that I not infrequently get called down to act as backup for their intubation, but yet they get huffy or indignant when I offer advice or take over the intubation when things are clearly going south with their initial attempt.

 

[Robotic Wis-Hipple]

While theoretically glidescope should reduce laryngeal stimulation, this hasn't been seen in studies. Several explanations have been suggested - longer duration of stimulation, and use of a very curved rigid stylet. IF the patient has an anterior airway or predicted to be difficult I would use it. BUT studies dont support routine use of glidescope over DL as a means to minimize laryngeal stimulation. The most stimulating part of the intubation is getting the tube past the VC

I have no doubt there are studies out there that say this. But I disagree it’s the ETT traversing VC that is the most stimulating, I think it’s the laryngoscopy. So maybe the findings are related to length of stimulation or the airway instrumentors skill and hence why they were using the VL. We can agree to disagree here and I’ll acknowledge I’m letting my anecdotal personal opinion overrule the evidence 🙂.

 

[coffeebythelake]

I have no doubt there are studies out there that say this. But I disagree it’s the ETT traversing VC that is the most stimulating, I think it’s the laryngoscopy. So maybe the findings are related to length of stimulation or the airway instrumentors skill and hence why they were using the VL. We can agree to disagree here and I’ll acknowledge I’m letting my anecdotal personal opinion overrule the evidence 🙂.

The literature on this is very strong. I know you have your anecdotes but so do I. And my anecdotes match the evidence. Stable HR during DL then when the tube goes in the HR (and BP) skyrocket. Stimulation of RLN by the tube can cause a very intense hemodynamic response.

I'm talking about routine, straight forward intubation. Not mucking around, changing blades, trying several times to intubate.

 

[AdmiralChz]

If this is the orals, be ready to defend that use of succinylcholine. As others have said it is debatable with respect to ICP but the debate is still very much there and this patient is showing signs of impending or active herniation. If I’m the examiner, I’m definitely asking “so to be clear, you are giving a mediciation that may increase ICP to someone with active herniation?” Or maybe “a colleague suggests taking another approach” - be ready to answer. Plus risk of undiagnosed myalgias, most peds anesthesiologists avoid Sux routinely. You can argue both sides of this argument but be prepared to defend the answer. BEWARE of saying “studies show” because you are opening yourself up to being asked more about it - which studies were they, what it a prospective or retrospective study, how many patients etc... Remember, most oral board examiners are academics and a few may be experts in that field - they can and will grill you on it. Personally I’m giving RSI Roc - you’ll need paralysis anyway and the patient is going to stay intubated after the case. Most important is securing the airway quickly before your ETCO2 creeps up - yes, that means you may even have to mask ventilate a bit. You’ll want an anesthesiologist or PICU person to do this ideally, but that person may not be readily available. Once secured, hyperventilate to ETCO2 30 or so.

For induction agent, I’m going with propofol. An induction dose causes near-if-not-actual burst suppression which decreased CMRO2, thereby helping treat the ICP. Etomidate doesn’t cause as profound a decrease in CMRO2.

Something this bad might merit an EVD or even burr hole in the ED. That’s up to the neurosurgeon and his or her comfort level doing such things on a child.

As others have said - mannitol, hypertonic saline. Avoid colloids like albumin, they have a worse morbidity/mortality risk in TBI. Place a Foley catheter, lasix to draw out all the extra cellular water you can while scans and what not are being obtained. Urgent to emergent operative intervention.

Side note for more oral boards stuff, the intraoperative stuff is fairly routine once started here, but postoperative management questions is where the “meat” can be in terms of difficulty. Know how to work up polyuria as well as treatment, longer term goals for TBI management as well. This is where books like Yao are good as a reference.

 

[Iso4ane]

I have no doubt there are studies out there that say this. But I disagree it’s the ETT traversing VC that is the most stimulating, I think it’s the laryngoscopy. So maybe the findings are related to length of stimulation or the airway instrumentors skill and hence why they were using the VL. We can agree to disagree here and I’ll acknowledge I’m letting my anecdotal personal opinion overrule the evidence 🙂.

According to something I read once, that is correct the intubating portion is the most stimulating, moreso than the laryngoscopes portion. I think this is most evident the bronch suite, they can be just fine, but if the proceduralists hits the sides you get coughing.

 

[Robotic Wis-Hipple]

According to something I read once, that is correct the intubating portion is the most stimulating, moreso than the laryngoscopes portion. I think this is most evident the bronch suite, they can be just fine, but if the proceduralists hits the sides you get coughing.

Oh, I agree there. But there’s no difference between DL and VL in that regard, either way an ETT is going thru VCs. And we aren’t really discussing bouncing a bronch off of tracheal mucosa or the carina which is clearly stimulating.

 

[deleted162650]

Why do people care about stimulation during intubation??? More BP will only help his CPP. This kid needs a hole in his head like yesterday. A baller neurosurgeon would do it bedside in the ED. The only thing that matters here is doing everything you can to expedite this kid getting drained. Keep up the circle jerk though. It’s entertaining.

Sux/roc/lido/glide/3% . . . none of that matters here.

 

[deleted162650]

Oh, and plastic in airway >>>>> stimulating than DL. Often times they don’t care till the cuff goes up and that’s what they really don’t like.

 

[anbuitachi]

prop, a lot of roc, tube. would DL not VL, as this is a 7 yr old kid with no signs of difficult airway. minimal lifting can probably see the cords... Dl would get the tube in faster in my opinion.

Agree with plastic in airway > DL stimulation

 

[Robotic Wis-Hipple]

Oh, and plastic in airway >>>>> stimulating than DL. Often times they don’t care till the cuff goes up and that’s what they really don’t like.

Lol, I love how this has gotten side tracked and spiraled out of control. Both of your posts are correct of course.

Just to be clear, I never said or meant to imply that plastic in the airway isn’t more stimulating than the laryngoscopy as both methods of intubation result in that :/.

 

[coffeebythelake]

Why do people care about stimulation during intubation??? More BP will only help his CPP.

I would take a brief drop in CPP if it meant not raising ICP further and completing the herniation

 

[deleted162650]

I would take a brief drop in CPP if it meant not raising ICP further and completing the herniation

What are you worried is gonna bump up his ICP? He needs to be fully paralyzed to not buck on the tube. Beyond that I think more BP is better than less here.

 

[deleted171991]

ED resident here...

Do you guys have any evidence for lidocaine or not using sux in this situation?

I've heard of the lidocaine thing but really doesn't seem to be much data out there for it.

As far as sux in TBI, I've seen one retrospective study they suggests a trend but nothing damning.

Regarding the glidescope I'm not sure if this is relevant, is it? Whatever helps you get the tube the first time sounds good in my book. Probably wouldn't be my go-to, but if they are comfortable with it...

This is very bread and butter EM. Classic EDH. Maybe different at the ivory tower but out in the community this ED doc is going to make the diagnosis, get access, protect the airway, get the CT, start hypertonic, talk to family, and arrange transfer while dealing with an entire ED full of other sick patients. I personally am not going to waste time with stuff not proven to work. I might have some atropine drawn up in case he gets more bradycardic but other than that, just RSI him! I generally like Roc for a variety of reasons but if the neurosurgeon is not at the bedside, sux is nice for giving them an exam. I'd probably do prop/sux. He doesn' need to spend anymore time in the ED than necessary.

I could be missing something obvious which is why I'm asking. Just throwing out some thoughts from the ED side as they seem to be getting beat up on here.

In My Opinion: A Debate: Is Succinylcholine Safe for Children? - Anesthesia Patient Safety Foundation

 

[HLxDrummer]

I would love to work "collaboratively" with the ED. The problem I have is that I not infrequently get called down to act as backup for their intubation, but yet they get huffy or indignant when I offer advice or take over the intubation when things are clearly going south with their initial attempt.

Ya that's not cool. I've called twice for difficult cases that had time (angioedema, bloody airway with neck trauma) before we touched it and let anesthesia handle it completely, we were just there to help them. One time I got yelled at because I didn't try first, the other time they were happy to assist and it went great. I learned from watching them and it was good for the patient. Wish I had time for another anesthesia elective, honestly.

 

[HLxDrummer]

In My Opinion: A Debate: Is Succinylcholine Safe for Children? - Anesthesia Patient Safety Foundation

Thanks for the link. I've been taught to avoid sux for real little ones that aren't walking yet in case of undiagnosed neuromuscular issues and obviously MH/hyperK. Wasn't aware of the bradycardia issue, that's good to know. Is that a fairly common/significant thing?

Like I said before the majority of the time my go to is roc unless it's something we need a Neuro exam on (status epilepticus, stroke).

 

[deleted162650]

Brady with sux is more of an issue with infants or with repeat dosing.

 

[coffeebythelake]

What are you worried is gonna bump up his ICP? He needs to be fully paralyzed to not buck on the tube. Beyond that I think more BP is better than less here.

good point

Yes.. CBF = MAP - ICP

but to what effect (if any) do large spikes of hypertension contribute to increases in ICP when cerebral autoregulation is impaired?

 

[anbuitachi]

good point

Yes.. CBF = MAP - ICP

but to what effect (if any) do large spikes of hypertension contribute to increases in ICP when cerebral autoregulation is impaired?

Arrange the equation. ICP = MAP - CBF

 

[deleted59964]

this kid needs a neurosurgeon.

1. call neurosurgeon
2. call CT
3. call OR to be ready
4. prepare induction -- atropine , propofol, roc - I don't need to be medico legally defensive, and think the "avoid sux thing" is BS but I want this kid paralysed for a while anyway.
5. be ready to prevent /treat hypotension -- fluids and pressor of choice
6. QUICK word to parents - who are likely at bedside
7. induce and intubate. (for what it's worth I'd have someone do MILS but I'm a paranoid SOB), ventilate to ETCO2 about 30, urgently transport to CT most likely, then to OR.
8. ask for some mannitol to be brought to the scanner as you walk out the door.
9. call ICU'

 

[coffeebythelake]

Arrange the equation. ICP = MAP - CBF

Sorry, I meant to say CPP = MAP - ICP, so rearranged it becomes ICP = MAP - CPP

We're talking about a patient with an intracranial bleed. Big jumps in BP will increase blood volume from the bleed -> increase ICP further??

 

[dannyboy1]

This kid is obtunded with a blown pupil. Tube him however you would like (I would just do prop, large dose of roc. Prop is good for neurosurgical patients) but do it quickly and open the skull. This case sounds like it might benefit from burr holes in the ED starting on the side of the impact. Nice thing about this case is that it will be hard to blame anesthesia for a bad outcome. Bad part is that it is someone’s kid....

 

[vector2]

CPP = MAP - ICP (or CVP, whichever is greater)

CBF = CPP / CVR

CBF = (MAP - ICP) / CVR

Always remember the Monroe-Kellie hypothesis- intracranial volume is about 90% brain parenchyma, 10% blood (art and ven), 10% CSF. Blood and CSF can be displaced relatively easily. If it remains tight, then you have parenchyma getting displaced which leads to a herniation syndrome.

Most of the time (tumors, swollen parenchyma), you want to press up the blood pressure because if too much blood is displaced by intracranial hypertension then you obviously will get a stroke. eikenhein is correct in this case that HTN is not necessarily desirable because an epidural hematoma is sourced from an arterial bleeder. Best thing to do here (in adults) is get the SBP down to ~140 while keeping CPP around 60-70 (likely very difficult to do without an EVD or evacuating the hematoma).

 

[deleted171991]

good point

Yes.. CBF = MAP - ICP

but to what effect (if any) do large spikes of hypertension contribute to increases in ICP when cerebral autoregulation is impaired?

That equation is very nice (except it's CPP, not CBF), but, once the brain starts herniating, more MAP will cause more increase in ICP and herniation. There is simply zero space inside the neurocranium at this point, so it's a sausage machine. That's why the only (possibly, not probably) lifesaving measure would be to evacuate the hematoma ASAP, even at bedside. Anything that raises the MAP and the amount of blood in the brain will just compress it even more. At least that's what my physiology plaques tell me.

 

[deleted171991]

Thanks for the link. I've been taught to avoid sux for real little ones that aren't walking yet in case of undiagnosed neuromuscular issues and obviously MH/hyperK. Wasn't aware of the bradycardia issue, that's good to know. Is that a fairly common/significant thing?

Like I said before the majority of the time my go to is roc unless it's something we need a Neuro exam on (status epilepticus, stroke).

I've been taught not to use it until after puberty, unless sux is clearly the better choice for RSI (that was before the sugammadex era). The neuromuscular degenerative diseases can show up much later than the walking age.

For most elective pediatric intubations, one doesn't even need a muscle relaxant (difficult airways are very rare in children).

The bradycardia usually happens with repeat sux doses; can be avoided with atropine pre-treatment.

 

[deleted162650]

I think concern for increased BP making the bleed and ICP worse in this case has merit. But dropping the BP with a heavy handed induction will certainly drop the CPP and worsen the herniation induced ischemia. Ideally I’d want to keep the BP in normotensive range. None of this matters though if we can’t drain that hematoma ASAP.

 

[IlDestriero]

I would love to work "collaboratively" with the ED. The problem I have is that I not infrequently get called down to act as backup for their intubation, but yet they get huffy or indignant when I offer advice or take over the intubation when things are clearly going south with their initial attempt.

We solve this problem by assuming control of the airway in a trauma call, or if called to the ED, ICU, etc. When we are called, it’s now our airway. Though we can and do often let them manage it themselves. It is case by case. We also have a policy that an emergency airway page needs to go out with the 3rd attempt (by non anesthesia team). There shouldn’t be a 4th or 5th unless we are doing it. There’s clear data in kids showing that morbidity and mortality increase after 2 attempts. It’s also a good reminder that we should be checking ourselves and looking at plan B, C and D if we are 3 attempts in without a secured airway.

 

[Twiggidy]

His pressure is 146/100 so the kid has already given you room to work. RSI with PROPOFOL and Roc 100 mg (he'll be relaxed) and whatever instrument of intubation that you feel will lead you to success in the fastest manner possible.


Also a little tidbit for residents, I had an attending that said he could go his entire career and not use a vial of etomidate.....as I gain more experience I more and more agree with him.

Also, Admiral is correct. Be careful with how smart you want to appear in front of oral board examiners. If you're going to start quoting studies then be prepared to defend like Deion Sanders, which interestingly enough, you may find yourself backpedaling.

 

[deleted697535]

Terrible situation...

Unfortunately common enough. A straight forward enough exam q really unless you fall into the sux trap. Do you want in real life but in an exam im givin 1.2 per kilo roc with 16 per kilo suggamadex ready also. If you want to spend 3 mins debating sux go for it. I dont want that... Kid needs controlled vent for some time. Roc is a fine choice.

Yo can argue vl or dl here all you want but im not mentioning vl as a first line here. Imo that would raise eyebrows in an exam.

No one has actually mentioned that this is a trauma case yet and no one has mentioned c spine... I think that should be addressed too... MILS for me. Atropine preinduction too.

Someone mentioned going not delay going to scan by securing the airway... I would think its hard to pass with that approach tbh...

 

[T-burglar]

Any of you that place spinal drains: since they are usually placed pre induction you have the opportunity to monitor CSF pressure during intubation and with other physiologic changes. With a balanced induction designed to prevent sympathetic activity the CSF pressure doesn’t rise much. Interestingly I’ve found the largest changes by far in CSF pressure occur with apnea (not just CO2 buildup). Within seconds of turning the vent off the CSF pressure rises sharply.

 

[deleted697535]

Id actually really consider ketamine here in real life... Not in an exam however

Its good to have our emerg colleague chime in on this. Sux and its 8 or 9 s/e are very heavily tested. You really have to know them.

 

[DrZzZz]

His pressure is 146/100 so the kid has already given you room to work. RSI with PROPOFOL and Roc 100 mg (he'll be relaxed) and whateven instrument of intubation that you feel will lead you to success in the fastest manner possible.


Also a little tidbit for residents, I had an attending that said he could go his entire career and not use a vial of etomidate.....as I gain more experience I more and more agree with him.

Also, Admiral is correct. Be careful with how smart you want to appear in front of oral board examiners. If you're going to start quoting studies then be prepared to defend like Deion Sanders, which interestingly enough, you may find yourself backpedaling.

Agree with that attending you had. Not a fan of etomidate and don't see a reason to use it. I can induce an unstable patient with an appropriately decreased dose of prop and if they're truly on the brink, then they don't need prop or etomidate, just some amnestic if I'm feeling generous.

 

[HLxDrummer]

Agree with that attending you had. Not a fan of etomidate and don't see a reason to use it. I can induce an unstable patient with an appropriately decreased dose of prop and if they're truly on the brink, then they don't need prop or etomidate, just some amnestic if I'm feeling generous.

Mind me asking what makes you guys stay away from etomidate? I've noticed you guys love propofol in general... I love propofol for procedural sedations and drips in vented patients but usually shy to induce with it (usually in the ED when intubating they are unstable and I'm hesitant to drop the BP). It seems you guys go for pressors pretty quick so maybe that's the difference? I also feel like it wears off so fast it is easy for them to be paralyze and not sedated in the ED setting (confirming the tube, getting drips setup, resuscitating, other procedures, etc). Just curious what you input is.

 

[vector2]

Etomidate takes forever to work, it doesn’t cause any degree of muscle relaxation or apnea which makes ventilating harder for those who want to do it, it burns just as bad as prop, it causes ponv, adrenal suppression may or may not have some effect.

 

[coffeebythelake]

to sidetrack things a bit further,
i'm not a big fan of etomidate, i think the adrenal suppressant effect is real even from a single dose, but I do use it from time to time
severe PH and severely depressed RV?
septic shock maxed on triple pressors?

i'd take the hemodynamic stability and cardiac stable induction
on par or even better than high dose opiate induction
they can sort the rest later
and if they still crash and burn with induction.. well... pt is just that sick.

 

[chocomorsel]

So.....what happened OP. Lets get the juice please.