• A 6 year old child fell down from rooftop of a 2 storey building and was brought to the emergency.

General assessment

Agitated

Rapid breathing

Colour pink

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?

What does this picture show?

• What are the clinical signs suggestive of fracture of base of skull

• 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 ?

A. Was given i/v lorazepam B. Convulsions continued.C. What next?

• What is the role of prophylactic anticonvulsants in TBI?

• When will you stop Phenytoin which you are starting now?

B. At this point:• Bloody froth from mouth + • Respiration jerky• Central cyanosis +• Femoral pulse weak, 160/min, regular • What will you do now?

How will you intubate this child?

–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?

• ABG: Ph 7.53/PaCO2 30/PaO2 120/sBE 1• What will be your strategy on this blood

Gas?

Head elevation of 30°

• How does it help?• Why 30 Degrees

How will you give the prognosis?

• 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?

CT scan

What next?

• What are different types of ICP monitors?• Which probe will you use in this child?• Why?

Which is more important ICP OR CPP?

Label the components of ICP wave

Interprete the ICP wave

• In this patient what is the osmotic agent of choice?

• What factors will you look for before choosing the agents?

• Contraindication to use of mannitol?

• What are your goals for CPP?

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?

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?

• Cause: Improper sedation 2 Marks

• What is your sedation and paralysis strategy in this child?

How will you optimize the Nursing care?

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?

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?

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?

• BP = 78/45 mm Hg ( MAP = 55 mmHg)

• CVP is 12• ICP =26 mm Hg ( CPP =24mmHg)• WHAT IS YOUR NEXT STEP?

• Choice of Inotrope?

Role of therapeutic Hypothermia

Role of Decompressive craniotomy?

READ THE CT SCAN

ENUMERATE TWO SIGNS INDICATING POOR PROGNOSIS IN THIS CT SCAN

Whats the most definitive mode of therapy in this child?

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-

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.

DAY 5 OF PICU

• ICP showed no rise even on stimulation and suctioning and spontaneous movements.

• WHAT NEXT?

• STOP SEDATION AND CONSIDER EXTUBATION

• ICP monitoring was discontinued with removal of ICP catheter…

• 2 MARKS

THANK YOU

1) At 6 hours:

• Low BP alarm starts ringing• Five minutes later low SpO2 alarm

also starts ringing

BP fell to 86/50 Tachycardia increased to 162 min Pupils- R dilated and fixed

L mid size, sluggish reaction

• What could be the cause for these neurological and hemodynamic changes

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.

• Days 3 Child develops severe polyuriaSerum Na+ = 163 meq/LSerum osmolality = 336Urinary Na+ = 8 meq/LUrinary specific gravity = 1002

• What is the cause of this polyuria.

• Day 4 Patient develops fever – 390 C

• What are the common causes of fever in this situation