sedative of choice for head ct after pediatric head trauma?

[southerndoc]

Nate, there are new CMS guidelines which we are currently reviewing which are confusing, but from the interpretation of our CMO and lawyers, seems to suggest that ED physicians using propofol for deep sedation must follow protocols developed by anesthesiology and supervised by anesthesiology. We haven't found a definitive answer on it yet, but I can email you a copy of it if you like.

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[TeleoDeum]

I am a Peds EM Attending in an academic institution. I also work on the Peds Sedation Service doing MRI sedation with mostly propofol. Concerning propofol and elevated ICP (or CHI with potential/concern for elevated ICP) - I tend to be wary of propofol for sedation on physiologic reasons. If the patient does have a significant bleed with high ICP/swelling or mass lesion, they need to keep adequate systemic BP to maintain cerebral blood flow. Sometimes in the PICU, these patients end up on pressors to elevate their systemic BP/mean arterial pressures. Propofol can and does drop your systemic BP by 30-40%. So, my concern here is if, I drop their systemic BP with my sedation (prop), then I can cause even more injury or damage, ischemic due to decreased cerebral blood flow.
That being said, the PICU I trained in used propofol regularly in intubated CHI kids with ICP monitors/elevated ICP to allow them to wake up from their chemical paralysis for q AM neuro checks.
For what my opinion is worth (not much, according to my wife!!!): look at the PECARN study and try to minimize radiation exposure/CT scans unless you have a good reasonto get one. Document that you have discussed the risk of CT/radiation exposure with parents to cover yourself against future law-suits. I personally think we will be seeing seperate CT/radiation consent forms soon!
And in this hypothetical kid, for a quick 1-2 min non-contrast brain to r/o skull fracture or ICH, I would likely try distraction/music/swadling, comforting by parents. When that fails - versed (PO, IV, IM, intranasal).

 

[TeleoDeum]

So, my previous post and propofol fears for ICP prompted me to do a quick lit search on propofol, ICP, and pediatric patients.
There is ample evidence in adult populations and neuro ICU care, that despite propofol dropping systemic BP, it also drops ICP, thus having a net positive effect on management of ICP. So, no fears of worsening ischemic injury from Prop use in adults.
In kids, there is this one case report of 2 patients in PICU who responded to Prop tx to help drop ICP where other sedation did not work well.

http://content.karger.com/ProdukteD...oduktNr=224273&Ausgabe=226501&ArtikelNr=28861

So, you be the judge...

 

[NateintheED]

Nate, there are new CMS guidelines which we are currently reviewing which are confusing, but from the interpretation of our CMO and lawyers, seems to suggest that ED physicians using propofol for deep sedation must follow protocols developed by anesthesiology and supervised by anesthesiology. We haven't found a definitive answer on it yet, but I can email you a copy of it if you like.

That's interesting and frustrating at the same time. I know I'm not the only one who really takes issue with other specialties defining our scope of practice.

I'm curious, but at the same time, I've pretty much given up the fight here, since our anesthesia chief and hospital commander seem almost completely unwilling to listen to evidence-based reason. Luckily I'm outta here in 3 months. Hopefully the next place will be a little more EM-friendly.

 

[pratik7]

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.

Papilledema is rarely seen in the acute setting. It is more for the brain tumors and intercranial hypertension. There was a little discussion in the journal of peds about this issue. The finding is low sensitivity/neg predicitve value and not usually seen in the first 24 hours


http://pediatrics.aappublications.org/cgi/content/full/107/5/1231

 

[Dimoak]

Papilledema is rarely seen in the acute setting. It is more for the brain tumors and intercranial hypertension. There was a little discussion in the journal of peds about this issue. The finding is low sensitivity/neg predicitve value and not usually seen in the first 24 hours
http://pediatrics.aappublications.org/cgi/content/full/107/5/1231

The point of that statement (I assume you didn't read the entire thread) was that it's unlikely for there to be a severe enough ICP level (without some big warning signs) to warrant elimination of Ketamine from consideration due to fears that it would cause ICP-related morbidity from Ketamine-induced ICP increases.

 

[roja]

I like Brevital. Amazing sedation drug in kids. of course ther eis a weight limit becasue of the IM load. (I dont' use it IV)

 

[deleted65604]

If a kid is not cooperative enough to stay still for 45 seconds for a CT scan, they won't stay still long enough for you to find papilledema.

How long does brevital take to kick-in and how long does it last Roja? I've never used it.

 

[Dimoak]

If a kid is not cooperative enough to stay still for 45 seconds for a CT scan, they won't stay still long enough for you to find papilledema.

Seriously, what is with everyone and papilledema? Yes, you won't see papilledema unless the ICP is way up there. Coincidentally, that's what it would take to contraindicate Ketamine.

 

[tkim]

Seriously, what is with everyone and papilledema? Yes, you won't see papilledema unless the ICP is way up there. Coincidentally, that's what it would take to contraindicate Ketamine.

I forget, what are you - med student, resident, or attending? Just curious.

 

[Dimoak]

I forget, what are you - med student, resident, or attending? Just curious.

I don't like to answer that question, but your point is taken. I'll leave this thread alone if required.

 

[tkim]

I don't like to answer that question, but your point is taken. I'll leave this thread alone if required.

I didn't really mean for you to take it that way, but it certainly helps to see where you get your information from - i.e., from a book, or from experience.

Not wanting to answer what level of training you have makes you look shifty, dude.

 

[Apollyon]

Not wanting to answer what level of training you have makes you look shifty, dude.

Seriously. I mean, even if you say you're a resident, you're one of about 4000 EM residents (if you are). I can't say that I can divine any information from a username like "Dimoak".

"tkim", on the other hand - now there's some sketch.

 

[Dimoak]

I didn't really mean for you to take it that way, but it certainly helps to see where you get your information from - i.e., from a book, or from experience.

Not wanting to answer what level of training you have makes you look shifty, dude.

I wasn't offended or anything, but I also post in the SPF, and so I'm almost borderline paranoid about keeping my identity as "un-identifiable" as possible since I'd prefer my opinions on various issues remain as anonymous as possible. I've been called out on other forums before about not answering this question before, so I'll usually just leave a thread alone if it bothers other posters. I do frequently post about things that I'm far from an expert on (as I mentioned earlier in this thread), which is usually based on my own attempt at EBM.

 

[Apollyon]

I wasn't offended or anything, but I also post in the SPF, and so I'm almost borderline paranoid about keeping my identity as "un-identifiable" as possible since I'd prefer my opinions on various issues remain as anonymous as possible. I've been called out on other forums before about not answering this question before, so I'll usually just leave a thread alone if it bothers other posters. I do frequently post about things that I'm far from an expert on (as I mentioned earlier in this thread), which is usually based on my own attempt at EBM.

And, yet, you list your location as "Chicagoland". Either that shows a fundamental lack of grasping the idea of anonymity, or it's a red herring.

 

[tkim]

"tkim", on the other hand - now there's some sketch.

I cut you.

 

[tkim]

And, yet, you list your location as "Chicagoland". Either that shows a fundamental lack of grasping the idea of anonymity, or it's a red herring.

QFT.

Just using username and stated location, I was able to find another user with same username and location, who plays trumpet, had his comcast pages with [first initial][lastname] web url posted.

Using that, I cross-referenced that with another trumpet website, I now have a first name, IL school he attended, and an alternate email addy from a trauma mailing list.

It's all downhill from there, dude.

Bottom line, use a different goddamn username with every site.

EDIT: Thanks to an old Facebook link, I now know *everything* about you - where you work, the name of your girlfriend, what you majored in college. The internets is a scary place.

 

[Dimoak]

QFT.

Just using username and stated location, I was able to find another user with same username and location, who plays trumpet, had his comcast pages with [first initial][lastname] web url posted.

Using that, I cross-referenced that with another trumpet website, I now have a first name, IL school he attended, and an alternate email addy from a trauma mailing list.

It's all downhill from there, dude.

Bottom line, use a different goddamn username with every site.

EDIT: Thanks to an old Facebook link, I now know *everything* about you - where you work, the name of your girlfriend, what you majored in college. The internets is a scary place.

Sure, but here's the rub. "Dimoak", which I derived from a weapon name in the game Diablo II (pretty popular). I assume you googled the name "Dimoak", and found a user on the "Trumpet Herald" (I googled my user name) website, which is where you inferred that I played trumpet from? Also, location, how do you know that's not a red herring as Apollyon said? Third, if someone's trying to keep private, wouldn't they keep their facebook private? I assume someone who doesn't care wouldn't, whereas some who cared would. The fact that this person went to school in Illinois and may actually be from Illinois is pretty interesting. So basically, you assumed that only one person on the entire internet uses the name "Dimoak", and by simply googling it, you can automatically make the connection? Really, that's fine by me. If you had my IP (and were able to demonstrate it as a known Comcast IP), you'd probably make a more convincing case, but really, it'd take a little more than googling around.

 

[tkim]

Sure, but here's the rub. "Dimoak", which I derived from a weapon name in the game Diablo II (pretty popular). I assume you googled the name "Dimoak", and found a user on the "Trumpet Herald" (I googled my user name) website, which is where you inferred that I played trumpet from? Also, location, how do you know that's not a red herring as Apollyon said? Third, if someone's trying to keep private, wouldn't they keep their facebook private? I assume someone who doesn't care wouldn't, whereas some who cared would. The fact that this person went to school in Illinois and may actually be from Illinois is pretty interesting. So basically, you assumed that only one person on the entire internet uses the name "Dimoak", and by simply googling it, you can automatically make the connection? Really, that's fine by me. If you had my IP (and were able to demonstrate it as a known Comcast IP), you'd probably make a more convincing case, but really, it'd take a little more than googling around.

Of course, your post could be a red herring to lead me away from your true info.

I suppose, though, that if this person is indeed not you, then you wouldn't mind if I post all the info I have for everyone to see. I mean, it's not you, right?

 

[Dimoak]

Of course, your post could be a red herring to lead me away from your true info.

I suppose, though, that if this person is indeed not you, then you wouldn't mind if I post all the info I have for everyone to see. I mean, it's not you, right?

That's fine as long as it's not violating the ToS (people were banned from SPF for that before). I PM'ed you as well.

 

[tkim]

That's fine as long as it's not violating the ToS (people were banned from SPF for that before). I PM'ed you as well.

I mean if it's you, then you've given me permission. If it's not you, then you couldn't give me permission anyway.

 

[Dimoak]

I mean if it's you, then you've given me permission. If it's not you, then you couldn't give me permission anyway.

I'm not well-versed enough with the ToS, but feel free to post whatever you wish to post.

 

[roja]

If a kid is not cooperative enough to stay still for 45 seconds for a CT scan, they won't stay still long enough for you to find papilledema.

How long does brevital take to kick-in and how long does it last Roja? I've never used it.

I had never used it either till I got to where I am now. The only limiting factor is the weight based limit due to the IM injection volume.

When you use it IM, it takes about 10 minutes to reach the maximum sedation (really about 5-7 but our protocol is to have an MD obs them for 10 minutes, then they can go to wherever with a pulse ox and a nurse). It lasts about 45-an hour. The other nice thing is they don't move around (like ketamine). Its really safe, it requires less monitoring overall, and they wake up nicely.

I now use it on all my <5 sedations.

b

 

[tkim]

.

 

[12R34Y]

pentobarb 2mg/kg with two doses available. works almost every single time, never seen an adverse event/outcome, our nurses give it.

its protocol at the children's ED.

later

 

[Dimoak]

.

You were right, I was wrong, but I didn't want to disrupt the thread.

 

[deleted109597]

You were right, I was wrong, but I didn't want to disrupt the thread.

Uh, no more than you did by giving examples for something you've never actually done.





Anyway, I wonder if I can get the nurses here to actually use Brevital. I need some articles on that.

 

[tkim]

You were right, I was wrong, but I didn't want to disrupt the thread.

It's not about being right or wrong. For a person who is self-professed paranoid about revealing their identity, playing the bluff/chicken game when you know the info I have is solid is just plain stupid. Maybe revealing who you are also reveals your level of medical training or lack thereof, and that's why you don't want to go there, which is fine.

But you need to deal with the fact that when you offer medical opinion or discussion, people are going to always ask what your medical background is in order to assess the quality of your opinion, and sometimes it's better to say 'none' or 'little' instead of 'I'd rather not say'.

 

[Dimoak]

I did mention earlier that I was not an expert and did not have experience with this (the paranoia bit was a bit of a jab at the SPF stereotype), but I suppose either way it was inappropriate for me to participate in the discussion so I'll leave it alone.

 

[deleted65604]

you guys are using all kinds of abbreviations...

SPF?
ToS?
QFT?

enlighten me

 

[tkim]

you guys are using all kinds of abbreviations...

SPF?
ToS?
QFT?

enlighten me

Sociopolitical Forum - rough place
ToS - Terms of Service - the reason people get banned
QFT - 'quoted for truth' - 'can I get an Amen'?

 

[doctorFred]