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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
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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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