2011 neuro1
DESCRIPTION
PPTTRANSCRIPT
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• A 6 year old child fell down from rooftop of a 2 storey building and was brought to the emergency.
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General assessment
Agitated
Rapid breathing
Colour pink
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Primary assessmentAgitated RR
50/min, bilateral air entry equal, no added sounds, SpO2 88%
HR 150/min, peripheral pulses weak, central pulses ++, BP 85/78 (88), CFT 2s
Pupils equal and reacting
Swelling of lt femur with abrasions over chest and abdomen
What is your assessment and intervention?
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What does this picture show?
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• What are the clinical signs suggestive of fracture of base of skull
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• After 20ml /kg saline bolus HR improved to 120/min,warm extremities, NIBP 90/50mmHg
• In next 5 minutes, the child starts having generalised tonic-clonic seizures.
• How will you manage ?
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A. Was given i/v lorazepam B. Convulsions continued.C. What next?
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• What is the role of prophylactic anticonvulsants in TBI?
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• When will you stop Phenytoin which you are starting now?
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B. At this point:• Bloody froth from mouth + • Respiration jerky• Central cyanosis +• Femoral pulse weak, 160/min, regular • What will you do now?
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How will you intubate this child?
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–Started on IMV-PC mode at –60% FiO2, –PIP 20, –PEEP 5, –Ti 0.8 secs–At 18 Breathes / min–How will you select PEEP?
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• ABG: Ph 7.53/PaCO2 30/PaO2 120/sBE 1• What will be your strategy on this blood
Gas?
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Head elevation of 30°
• How does it help?• Why 30 Degrees
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How will you give the prognosis?
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• Child on IMV-PC at 50% FiO2,Pressures of 18/4cmH2O,Ti0.8 sec
• Head at 30 degrees• NIBP is 90/55mmHg• Warm extremities aith CRT < 2 secs• What Next?
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CT scan
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What next?
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• What are different types of ICP monitors?• Which probe will you use in this child?• Why?
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Which is more important ICP OR CPP?
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Label the components of ICP wave
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Interprete the ICP wave
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• In this patient what is the osmotic agent of choice?
• What factors will you look for before choosing the agents?
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• Contraindication to use of mannitol?
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• What are your goals for CPP?
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DAY 1 IN PICU
• Child was noted to have ICP of 42 at 30 min of the time of insertion…….
• What are the things to be looked for?
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O/E• Vitals– HR = 92/min– RR = 50 /min– BP = 130/84 mm Hg–Moving limbs on sound and touch– EEG = no seizure activity– Temp = 36.60 C –Whats your interpretation?
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• Cause: Improper sedation 2 Marks
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• What is your sedation and paralysis strategy in this child?
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How will you optimize the Nursing care?
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AT 6 HRS OF PICU ADMISSION
• ICP = 36 mm Hg• Vitals– HR = 136/min– RR = 40 /min– BP = 130/80 mm Hg– Moving limbs only to deep pain– Temp = 39.80 C – EEG = no seizure activity
•What is the likely precipitating factor for rise in ICP?
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ON DAY 2 OF PICU• ICP = 40 mm Hg• Vitals– HR = 130/min– RR = 46 /min– BP = 130/80 mm Hg– Temp = 36.60 C– Tonic deviation of eyes to the left side
•What is the likely precipitating factor for rise in ICP now? How will you manage it?
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Day 3 of PICU
– ICP of 30 mmHg– CVP = 4 cm– BP = 70/ 36 mm Hg (MAP = 50 mm Hg)– What s the cause?– How will you manage?
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• BP = 78/45 mm Hg ( MAP = 55 mmHg)
• CVP is 12• ICP =26 mm Hg ( CPP =24mmHg)• WHAT IS YOUR NEXT STEP?
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• Choice of Inotrope?
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Role of therapeutic Hypothermia
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Role of Decompressive craniotomy?
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READ THE CT SCAN
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ENUMERATE TWO SIGNS INDICATING POOR PROGNOSIS IN THIS CT SCAN
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Whats the most definitive mode of therapy in this child?
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Identify the Type of waves1 and 2 Mention clinical implication of each of
them
7.5
15
22.5
ICP mmHg
Time (minutes)2010 30 40
ICP mmHg 20
40
60
Time (minutes)10 20
30
30 40
1-
2-
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42
• 1- isType B waves have an amplitude of upto 50mmHg. and a duration of <2 minutes. They also reflect reduced intracranial compliance, but are a less sinister finding than A waves.
• 2 Marks
• 2- Type A (plateau waves) are largest in amplitude (50-100mmHg above baseline ICP) and duration (5-20 minutes). They are thought to be due to cerebral
• vasodilatation in response to critically low cerebral perfusion. This dilatation further raises ICP, compromising cerebral perfusion and increasing the risk of brain herniation.
• 2 Marks
• Lundberg waves occur over a period of time and should not be confused with the three peaks of thenormal intracranial pressure waveform seen in normal individuals andrelated to the arterial waveform.
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DAY 5 OF PICU
• ICP showed no rise even on stimulation and suctioning and spontaneous movements.
• WHAT NEXT?
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• STOP SEDATION AND CONSIDER EXTUBATION
• ICP monitoring was discontinued with removal of ICP catheter…
• 2 MARKS
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THANK YOU
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1) At 6 hours:
• Low BP alarm starts ringing• Five minutes later low SpO2 alarm
also starts ringing
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BP fell to 86/50 Tachycardia increased to 162 min Pupils- R dilated and fixed
L mid size, sluggish reaction
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• What could be the cause for these neurological and hemodynamic changes
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How will you give the prognosis?
• low GCS was most associated with poor outcome• The absence of pupil reactivity is a predictor of
poor outcome.• Radiographically, obliteration of the third
ventricle and midline shift was most likely to be associated with early mortality (14 days), and
• nonevacuated hematoma was most likely to be associated with poor outcome at 6 months.
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• Days 3 Child develops severe polyuriaSerum Na+ = 163 meq/LSerum osmolality = 336Urinary Na+ = 8 meq/LUrinary specific gravity = 1002
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• What is the cause of this polyuria.
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• Day 4 Patient develops fever – 390 C
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• What are the common causes of fever in this situation