Case Presentation

1
Case Presentation

• 7 y.o. male found hanging by a book bag from a
  closet rack
• CPR initiated by mother
• EMS intubated and CPR around 3 min.
• brought to LH in about 6 min.

2
Case PresentationLincoln ER

• Intubated, unresponsive, pulseless, FS 332
• CPR for about 10 min.
• 1122 - 2.5 ml epinephrine, ET
• 1125 - Pulse noted
• 1135 - NS bolus
• 1141 - 25 meq NaHCO3
• 1149 - Foley catheter
• 1152 - Reintubated

3
Case PresentationLincoln ER

• CBC 12.9gt13.8/40.5lt517/N 51.5/L46
• BMP 135/4.2/105/15/glu335/14/0.98/Ca8.6
• PTT 31.5 PT 13.1 (sl. Inc.) INR 1.23 (N)
• UA 1 glu, 2 blood, sp. Gr. 1.024, pH 6.5, neg
  LE NO2, wbc 2-5, rbc 10-15, mod. Bact, fine
  gran. Casts 0-2
• CXR extensive b/l alveolar infiltrates
• Brain and Neck CT normal

4
Case PresentationLincoln ER

• ABG pH pCO2 pO2 lac
  BE
• 1216 7.13 56.1 20 9.27
  -10
• 1228 7.25 27.5 70 9.21 -15
• 1323 7.27 33.5 67 5.36
  -12
• 1529 7.28 37.8 90 3.33
  -9

5
Case PresentationCHAM-PICU

• Intubated with a collar brace
• VS HR 142 BP 100/72, RR 44
• comatose
• 5mm pupils NRTL
• no corneal reflex
• no gag reflex
• no response to deep nailbed pressure
• () muscular twitching on face and ext

6
Case PresentationCHAM-PICU

• CBC WBC 46.5 no significant change
• BMP no significant change
• LFT wnl
• CPK 225
• LDH 294
• Troponin 1.14
• Urine toxicology negative

7
Anoxic Ischemic Brain Injury

• Valerie May G. Sia, M.D.

8
Glasgow Coma Scale
9
Pediatric Glasgow Coma Scale
10
Glasgow Coma Scale

• Brain Injury Classification
• Minor GCS gt13
• Moderate GCS 9-12
• Severe GCS lt8

11
Anoxic-Ischemic Brain InjuryNomenclature

• Coma
• pathologic unconsciousness
• being unaware of the environment
• unarousable
• caused by either
• dysfunction of the RAS above the level of the
  mid-pons
• dysfunction of both cerebral hemispheres.
• Persistent Vegetative State
• unawareness of the environment
• normal sleep-wake cycles and are arousable

12
Anoxic-Ischemic Brain InjuryNomenclature

• Brain Death
• irreversible cessation of cerebral and brain
  stem fxn
• no spontaneous breaths regardless of
  hypercarbia or hypoxemia
• no CN or motor reflexes but spinal reflexes may
  persist (Lazarus sign)

13
Anoxic-Ischemic Brain Injury
Recovery Persistent Vegetative State Coma
Brain Death
14
Anoxic-Ischemic Brain InjuryPrognosis

• type of injury
• CPR 4-6 min ffed by ACLS w/in 10-12 min.
• length of CPR gt15 min. poorer prognosis
• GCS lt4 in 48, poorer prognosis
• drug/medication use
• metabolic derangements
• PE D3 (-) extensor motor response/ pupillary or
  corneal reflexes
• Seizures

15
Anoxic-Ischemic Brain InjuryPrognosis

• Ancillary Testing
• EEG
• Somatosensory evoked potentials
• averaged electrical responses in the central
  nervous system to somatosensory stimulation
• Biochemistry
• Neuron specific enolase, glial S-100 protein
• Neuroimaging
• CT scan, MRI, PET scan

16
Anoxic-Ischemic Brain InjuryManagement

• A irway
• GCS lt8 - intubated cervical spine stabilized
• B reathing
• mod. hyperventilation (PaCO2 30 to 35 mm Hg)
  arterial constriction ICP
• WOF hyperventilation (PaCO2lt30) brain
  ischemia
• C irculation
• fluids inotropes - to deliver O2, metabolic
  substrates remove toxic metabolites

17
Anoxic-Ischemic Brain InjuryManagement

• Glucose 2.5 mL/kg of 10 dextrose solution
• ICP Tx fever, head elevation 30, moderate
  hyperventilation, mannitol
• Seizures fosphenytoin
• Infection empiric antibiotic
• Acid-base electrolyte imbalance
• Antidotes
• Temperature mod. hypothermia (32-36C)

18
Cooling Cap
19
Anoxic-Ischemic Brain Injury Clinical Criteria
of Brain Death

• Clinical or neuroimaging evidence of an acute CNS
  catastrophe
• Confounding medical conditions excluded
• severe electrolyte, acid-base, or endocrine
  disturbance
• No drug intoxication/poisoning
• Core T gt32C

20
Anoxic-Ischemic Brain Injury Clinical Criteria
of Brain Death

• Neurologic Examination
• Coma
• Absent motor response
• Absent pupillary light reflex, (4 to 9 mm)
• Absent corneal reflexes
• Absent oculovestibular reflexes (caloric response)

• Absent jaw jerk
• Absent gag reflex
• Absent cough with tracheal suctioning
• Absent sucking or rooting reflexes
• Apnea via apnea test

21
Anoxic-Ischemic Brain Injury

• Apnea Test
• performed after all other criteria for brain
  death have been met
• core temperature 36.5ºC or 97ºF
• systolic blood pressure 90 mmHg
• euvolemic status
• no respiratory response to a PaCO2 gt60 mmHg and a
  final arterial pH of lt7.28

22
Case Presentation CHAM-PICU

• SIMV TV200, RR 20, PEEP10, FiO2 45
• Central venous access Arterial line, R femoral
• Dopamine 10mcg/kg/min
• Epinephrine 0.3mcg/kg/min
• 3 NaCL
• Cooling blanket 34-36C
• Fosphenytoin and Keppra

23
Case Presentation CHAM-PICU

• EEG (HD3) generalized background slowing
• MRI (HD5) multiple infarcts in cerebrum and
  cerebellum
• ECHO (HD6) no structural Abnties mildly
  dilated LV w/ mildly depressed systolic function

24
Case Presentation CHAM-PICU

• HD2-4 Pupils 3-4mm, SRTL RR breathing gt vent.
• HD 5 Pupils 5mm NRTL RR 20
• pronounced Brain dead
• Organ donor contacted
• HD8 failed Apnea test
• HD9 () Apnea test

25
Case Presentation CHAM-PICUApnea Test

• ABG pH pCO2 pO2
• baseline 7.493 34.6 414
• 5 min 7.3 55.7 249
• 10 min 7.192 71.2 263
• 15 min 7.107 88.9 245

26
Sources

• Cummins, RO Eisenberg MS Hallstrom AP Litwin
  PE (March 1985). "Survival of out-of-hospital
  cardiac arrest with early initiation of
  cardiopulmonary resuscitation". American Journal
  of Emergency Medicine 3 (2) 1149.
  doi10.1016/0735-6757(85)90032-4. PMID 3970766
  3970766.
• Wijdicks, EF, Hijdra, A, Young, GB, et al.
  Practice parameter prediction of outcome in
  comatose survivors after cardiopulmonary
  resuscitation (an evidence-based review) report
  of the Quality Standards Subcommittee of the
  American Academy of Neurology. Neurology 2006
  67203.
• Zandbergen, EG, de Haan, RJ, Stoutenbeek, CP, et
  al. Systematic review of early prediction of poor
  outcome in anoxic-ischaemic coma. Lancet 1998
  3521808.
• Gerald L Weinhouse, MD, G Bryan Young, MD, FRCPC.
  Anoxic-ischemic brain injury Assessment and
  treatment. UpToDate
• G Bryan Young, MD, FRCPC. Diagnosis of brain
  death. UpToDate
• Linda Thompson, MD, Eric Williams, MD. Treatment
  and prognosis of coma in children. UpToDate

27
Thank you