Paediatric Neurosurgical Paediatric Neurosurgical

EmergenciesEmergencies

Kate ParkinsKate Parkins

Consultant Paediatric IntensivistConsultant Paediatric Intensivist

Alder HeyAlder Hey

Level of consciousnessLevel of consciousness

–– AVPUAVPU

–– GCSGCS

Pupillary reaction to lightPupillary reaction to light

Limb movementsLimb movements

HistoryHistory

DD……

Neurological AssessmentNeurological Assessment

Definition of ComaDefinition of Coma

GCS 8 or lessGCS 8 or less

–– No eye openingNo eye opening

–– Does not speakDoes not speak

–– Does not obey commandsDoes not obey commands

Airway at riskAirway at risk

–– Go back to ABCGo back to ABC

Pupillary ChangesPupillary Changes

Tentorial herniationTentorial herniation

–– Unilateral fixed pupilUnilateral fixed pupil

Seizures, 3rd nerveSeizures, 3rd nerve

–– Bilateral fixed pupilBilateral fixed pupil

Hypoxia, drugs, Hypoxia, drugs,

seizuresseizures

Central HerniationCentral Herniation

–– Small unreactiveSmall unreactive

–– MidMid--sized fixedsized fixed

–– Fixed dilatedFixed dilated

Regardless of age beware..Regardless of age beware..

–– Abnormal breathing patternsAbnormal breathing patterns

Hyperventilation, periodic, apnoeaHyperventilation, periodic, apnoea

–– CushingCushing’’s Triads Triad

Bradycardia, hypertension, breathing abnormalitiesBradycardia, hypertension, breathing abnormalities

–– Opisthotonic posturing (hydrocephalic Opisthotonic posturing (hydrocephalic

attacks)attacks)

Symptoms and signs of Symptoms and signs of ↑↑ICPICP

Symptoms and signs of Symptoms and signs of ↑↑ICPICP

In the infant and young child– Irritable, ↓level of consciousness

– vomiting, failure to thrive, poor feeding

– developmental delay

– ↑head circumference, tense AF

– dilated scalp veins

– ‘setting sun’ sign (the combination of upper eye-lid retraction and failure of up-gaze)

– ophthalmoplegia

In the older child and young adult

– Headache, vomiting, drowsiness

– diplopia, blurred vision,

– neck pain

– worsened seizure control

– Impaired consciousness and coma

– impaired upgaze

– papilloedema, ophthalmoplegia

Symptoms and signs of Symptoms and signs of ↑↑ICPICP

Management of acute Management of acute ↑↑ICPICP

Regardless of aetiologyRegardless of aetiology

–– A, B, CA, B, C

Acute tentorial herniationAcute tentorial herniation

–– Mannitol (1g per kg) Mannitol (1g per kg)

1g = 5ml of 20% solution1g = 5ml of 20% solution

–– Hypertonic saline 3%Hypertonic saline 3%

33--5 ml/kg5 ml/kg

–– until plasma osmolality 310until plasma osmolality 310--320 mOsm320 mOsm

–– Maintain circulating volumeMaintain circulating volume

Tap ShuntTap Shunt

Management A, B, CManagement A, B, C

Essential to reduce 2ry brain injuryEssential to reduce 2ry brain injury

–– Adequate oxygenationAdequate oxygenation

–– High normal BP to ensure adequate CPPHigh normal BP to ensure adequate CPP

Intubate & ventilate GCS < 8Intubate & ventilate GCS < 8

–– RSIRSI

–– Thiopentone/Propofol + suxamethoniumThiopentone/Propofol + suxamethonium

–– Ongoing: Morphine + midazolamOngoing: Morphine + midazolam

–– Oral ETTOral ETT

–– Orogastric tubeOrogastric tube

Management A, BManagement A, B

VentilationVentilation –– watch carefullywatch carefully

Aims = pCOAims = pCO22 3535--37 mmHg, pO37 mmHg, pO22 >100 mmHg, SpO>100 mmHg, SpO22 >96%>96%

–– Blood gas 6hrly minimumBlood gas 6hrly minimum

–– Suction 6 hrly to maintain ETT patencySuction 6 hrly to maintain ETT patency

PrePre--oxygenate 1min, bolus sedation/analgesia, +/oxygenate 1min, bolus sedation/analgesia, +/-- ETT ETT

lignocaine (2mls 1%, leave 2 mins); suction quicklylignocaine (2mls 1%, leave 2 mins); suction quickly

–– Ensure no abdominal distension Ensure no abdominal distension

eg blocked urinary catheter, abdo traumaeg blocked urinary catheter, abdo trauma

–– Screen for sepsis if pt develops fever (blood, urine, Screen for sepsis if pt develops fever (blood, urine,

sputum +/sputum +/-- CSF cultures)CSF cultures)

CirculationCirculation

Min 2 large bore cannulaeMin 2 large bore cannulae

Maintain BP to ensure adequate CPPMaintain BP to ensure adequate CPP–– CPP = BP CPP = BP –– ICPICP

–– Aim CPP:0Aim CPP:0--2 yrs 2 yrs ≥≥ 40; 240; 2--6 yrs 6 yrs ≥≥ 55; 755; 7--16 yrs 16 yrs ≥≥ 65 mmHg65 mmHg

–– fluid bolus 10 ml/kg (0.9% saline) if neededfluid bolus 10 ml/kg (0.9% saline) if needed

–– use noradrenaline (+/use noradrenaline (+/-- other inotrope as needed)other inotrope as needed)

Check for evidence Check for evidence pain or distresspain or distress–– Treat/remove cause pain/distressTreat/remove cause pain/distress

–– Exclude abdo distension, urinary retension etcExclude abdo distension, urinary retension etc

–– Give bolus sedation/analgesia/paralysis Give bolus sedation/analgesia/paralysis

Confirm no evidence ofConfirm no evidence of seizureseizure (treat if present)(treat if present)–– dilated pupils/dilated pupils/↑↑HR/HR/↑↑BP +/BP +/-- abnormal movementsabnormal movements

Other PICU bitsOther PICU bits……....

PositionPosition –– tilt bed tilt bed →→ Head up 30Head up 30°°

–– head midline (neck not turned), sandbags + tapehead midline (neck not turned), sandbags + tape

–– Always log roll (not straight lift) Always log roll (not straight lift) –– NB cervical collar on for rollNB cervical collar on for roll

Neurology Neurology –– keep ICP <20keep ICP <20

–– Treat drops in CPP rapidlyTreat drops in CPP rapidly

–– Assess pupils/GCS hrly (if not paralysed/heavily sedated)Assess pupils/GCS hrly (if not paralysed/heavily sedated)

–– Do not let pt develop fever! Keep 36.5 Do not let pt develop fever! Keep 36.5 –– 37.537.5°°CC

OtherOther

–– Keep Na 140Keep Na 140--150 150 –– maintenance 0.9% NaClmaintenance 0.9% NaCl

Full maintenance (NOT restriction)Full maintenance (NOT restriction)

–– Watch blood glucose Watch blood glucose –– if >8 mmol/l start insulin infusionif >8 mmol/l start insulin infusion

Aim = glucose 4Aim = glucose 4--7 mmol/l7 mmol/l

–– Minimal handlingMinimal handling

–– DVT prophylaxis DVT prophylaxis –– TEDS if >40 kg +/TEDS if >40 kg +/-- LMW heparinLMW heparin

22ndnd line management line management ↑↑ICPICP

HyperventilationHyperventilation -- aim pCOaim pCO22 3030--35 mmHg35 mmHg

ThiopentoneThiopentone

–– Bolus dose 1Bolus dose 1--5 mg/kg (NB may cause 5 mg/kg (NB may cause ↓↓BP)BP)

–– (Infusion 3(Infusion 3--5 mg/kg/hr)5 mg/kg/hr)

Decompressive craniotomyDecompressive craniotomy

As last resort onlyAs last resort only

–– Hyperventilate Hyperventilate

–– Consider cooling pt ie 35 Consider cooling pt ie 35 °°CC

DISABILITY & EXPOSUREDISABILITY & EXPOSURE

Wrap them upWrap them up–– Expose linesExpose lines

–– Under/over wrapUnder/over wrap

–– HatHat

TraumaTrauma–– CT scans, CXR, AXR, CCT scans, CXR, AXR, C--spine, pelvis spine, pelvis

–– Log rollLog roll

–– Spinal board or vac mattress + scoopSpinal board or vac mattress + scoop

–– Immobilise #Immobilise #

HydrocephalusHydrocephalus

Relative excess of CSF in the cranium Relative excess of CSF in the cranium

resulting in raised pressureresulting in raised pressure

Pressure is the ultimate arbiterPressure is the ultimate arbiter

Small ventricles Small ventricles ≠≠ normal pressurenormal pressure

–– egeg Stiff slit ventricle syndromeStiff slit ventricle syndrome

Radiology reassures onlyRadiology reassures only

Treatment of hydrocephalusTreatment of hydrocephalus

Surgical disorderSurgical disorder

–– Caveats: infection, weight, age, comorbidityCaveats: infection, weight, age, comorbidity

TreatmentTreatment……

–– Divert temporarily and treat causeDivert temporarily and treat cause

–– Divert permanentlyDivert permanently

Diversions used depend on where block isDiversions used depend on where block is

Shunt ComplicationsShunt Complications

Blockage (30% first year)Blockage (30% first year)–– InIn--growth of choroid, poor placement, ventricular growth of choroid, poor placement, ventricular

collapsecollapse

–– Listen to the parentsListen to the parents

Breakage/disconnectionBreakage/disconnection–– XX--ray the shuntray the shunt

Infection Infection --6%6%–– Normal peripheral WC, CRP up in 90%Normal peripheral WC, CRP up in 90%

Subdurals, seizures, over drainageSubdurals, seizures, over drainage–– Stiff slit ventricle syndromeStiff slit ventricle syndrome

Managing potential blocked Managing potential blocked

shuntshuntRecognise potentialRecognise potential

–– ie any child with previously treated ie any child with previously treated hydrocephalushydrocephalus

–– Beware spina bifida, long term shunts, Beware spina bifida, long term shunts, aqueductal stenosisaqueductal stenosis

–– Listen to the parentsListen to the parents

Manage ABCDManage ABCD

Scan earlyScan early

Speak to neurosurgeons/PICUSpeak to neurosurgeons/PICU

Tapping shuntsTapping shunts

All modern shunts have reservoirAll modern shunts have reservoir

Child Child in extremisin extremis

–– Prep skin 2% chlorhexidenePrep skin 2% chlorhexidene

–– Insert butterflyInsert butterfly

–– Measure pressure Measure pressure Stiff extension set + tape measureStiff extension set + tape measure

–– Drain 20 mlDrain 20 ml

–– Observe and repeat if necessaryObserve and repeat if necessary

Find burr holeFind burr hole

–– Insert spinal needleInsert spinal needle

TransferTransfer

Time critical transferTime critical transfer

–– cranial trauma with clotcranial trauma with clot

Urgent/time criticalUrgent/time critical

–– shunt/bleed/tumourshunt/bleed/tumour

Time is of the essence, transfer team may Time is of the essence, transfer team may

miss the boatmiss the boat

ABC then transfer quicklyABC then transfer quickly

SummarySummary

Most neurosurgical emergencies are Most neurosurgical emergencies are

emergencies of acutely raised ICPemergencies of acutely raised ICP

–– Manage ABCDManage ABCD

–– React to changesReact to changes

–– Scan earlyScan early

–– Contact neurosurgeons/PICU earlyContact neurosurgeons/PICU early

–– Contact Contact neurosurgeonsneurosurgeons if concernedif concerned