CEREBRAL EDEMA PRACTICAL

7/29/2019 CEREBRAL EDEMA PRACTICAL

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Describing the investigativeprocedures,

Preoperative and Post Operative

Assessment and Management forcerebral

oedema.

Dr.A.Sridhar, MPT(Neurology) 1


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Cerebral edema


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Ischaemic stroke and intracerebral haemorrhage

Brain tumours

Meningitis and encephalitis of all etiologies

Other brain infections like cysticercosis, tuberculosisand toxoplasma.

Non-neurological conditions -

Diabetic ketoacidosis, lactic acidoticcoma

Malignant hypertension,hypertensive encephalopathy

Fulminant viral hepatitis, hepatic

encephalopathy, Reyes syndrome

Systemic poisoning (carbonmonoxide and lead)

Hyponatraemia, SIADH

Opioid drug abuse and dependence

Bites of certain reptiles and marineanimals

High altitude cerebral edema (HACO)



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Cysticercosis- Cysticercosis is an infection by a parasite called Taenia solium

(T. solium), a pork tapeworm that creates cysts in different areas in the body



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Consequences of cerebral edema

Compromised regional or global cerebral

blood flow (CBF) and intracranial

compartmental shifts due to intracranial

pressure gradients that result in compression

of vital brain structures



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Management

prevent secondary neuronal injury from

cerebral ischemia



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general measures

optimal head and neck positioning forfacilitating intracranial venous outflow

avoidance of dehydration

systemic hypotension

maintenance of normothermia



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Specific therapeutic interventions

controlled hyperventilation

administration of corticosteroids and diuretics

Osmotherapy

pharmacological cerebral metabolic suppression



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GENERAL OBJECTIVES

Prevention of secondary injury.

Ensure adequate cerebraloxygenation

Clear airway

Consider cervical spine injury Good gas exchange Restore circulating volume

Think about other causes of haemorrhage Scalp lacerations cause significant blood

loss Intracranial bleeds can cause

hypovolaemia in infants but not older

children Intra-thoracic /intra-abdominal bleeding Long bone/pelvic fractures

Maintain arterial pressure Volume resuscitation Inotropes/vasoconstrictors if necessary

Treat suspected raised intracranialpressure (ICP) Suspect if

Lateralising signs Falling conscious level Arrange emergency CT scan and

neurosurgical opinion

Control fits Phenytoin 18mg/kg loading dose. Follow local fit protocol if fits persist.

Ensure adequate analgesia withcarefully titrated doses ofmorphine and morphine infusion if

necessary

Catheterise the bladder if You have volume resuscitated There is a palpable full bladder You have given mannitol

Immobilise long bone fracturesDr.A.Sridhar, MPT(Neurology) 9


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Once intubated (orally):

Immobilise cervical spine (spinal board + sandbags + collar)

Paralyse (Atracurium 0.5 mg/kg bolus then infusion at1mg/kg/hr)

Sedate (Midazolam 0.1 mg/kg bolus then infusion at 6

microg/kg/min and Morphine 0.1 mg/kg bolus theninfusion at 20 microg/kg/hr)

Ventilate to pCO2 4.6 5.3kPa (35 - 40mmHg),

PaO2 10.6 13.3 Kpa (80 100 mmHg), PEEP initially at5cmH2O

Maintain SaO2> 95% Position - 30 head up, head in neutral position.

Site orogastric tube, aspirate and place on free drainage



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Maintain Adequate Blood Pressure

Give further boluses of fluid. (10-20ml/kg

boluses)

Use inotropic support (adrenaline or

noradrenaline) if MAP inadequate despite

fluid resus



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Indications for mannitol prior to

transfer

Lateralising signs

Unequal pupil responses

Falling conscious level

CT showing space occupying lesion, prior todefinitive management in theatre

Use Mannitol 0.5g/kg (2.5 ml/kg of 20% solutionpreferred) over 20 min

Follow Mannitol with human albumin solution orother plasma expander as required to maintainblood pressure



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If you have given diuretics

Catheterise

Watch BP and replace volume if necessary

Assess response of pupils

If pupil responses become unequal or you

suspect herniation (coning) give a further dose of

diuretics mannitol 0.5g/kg iv over 20minutes and

consider moderate hyperventilation, PaCO2 > 3.5kPa (mmHg) with 100% oxygen until scan and

definitive management are possible


O i t b t d d t l


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Once intubated, adequately

ventilated and cardiovascularly

stable: Complete secondary survey and treat findingsas appropriate,

Perform a CT scan of the head and cervical

spine


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CEREBRAL EDEMA PRACTICAL