Raised Intracranial Pressure (Case 39)

Chapter 81 Raised Intracranial Pressure (Case 39)



Glenn R. Stryjewski, MD, MPH




Case


A 4-year-old child is brought to the emergency department with vomiting and severe headache. He has an elevated blood pressure and slow irregular heart rate. A CT scan of the head shows signs of raised intracranial pressure.




Differential Diagnosis











Hydrocephalus Tumor/mass and edema
Infection Intracranial hemorrhage


Speaking Intelligently


When I suspect a patient has raised intracranial pressure (ICP), I assess the patient’s clinical status, simultaneously trying to determine the etiology. Knowing the underlying cause helps determine the likely time course of progression and facilitates decisions about possible therapies. Critical patients will require not only treatment of their intracranial pressure but also immediate support of their cardiorespiratory systems. After addressing the airway, breathing, and circulation (ABCs), I position the child with the head elevated to 45 degrees with the neck in midline and with neck stabilization if it appears to be a case of trauma. Next I administer osmotherapy with 3% saline, typically 3 mL/kg as an initial bolus. Mannitol is another option. At the same time I begin marshalling necessary resources such as the CT scan and the neurosurgeon, recognizing that both may require time to become available. If clinical progression of symptoms is rapid, I suspect some type of intracranial hemorrhage. Slower development usually implies hydrocephalus, tumor, or infection. Laboratory work is rarely a priority, but when an intracranial bleed is suspected, it is important to know the patient’s hemoglobin, platelets, and PT/PTT values promptly. Serum electrolyte levels should also be obtained, because disorders of sodium can be both a cause and a consequence of raised ICP.



Patient Care



Clinical Thinking



• Support the ABCs. ICP will worsen if the airway, breathing, and circulation are not supported.

• Is there an obvious problem you can do something about, such as a malfunctioning ventricular drain?


History



• Consider underlying conditions because these are often the contributing etiology, such as hydrocephalus or a mass.

• Fever in an otherwise healthy child with these symptoms may suggest an infectious cause such as meningitis or encephalitis.

• Recent trauma and rapid progression of symptoms is suggestive of intraparenchymal, epidural, subdural, or subarachnoid hemorrhages.

• Consider underlying conditions such as hydrocephalus or mass as possible etiologies.


Physical Examination



• Vital signs: Classic changes associated with a significant rise in ICP are hypertension, bradycardia, and an abnormal respiratory pattern. Early on, however, hypertension with tachycardia may be present. Realize that the normal range for heart rate, blood pressure, and respiratory rate varies with age.

• The first assessment should focus on airway, breathing, and circulation.

• Fontanelle size and character in infants can be helpful but are inconsistent findings.

• Papilledema is a more reliable finding to confirm your suspicions.

• Focal findings such as weakness or paralysis can help localize a lesion.

• Obtundation, posturing, or fixed and dilated pupil examination (unilateral or bilateral) implies impending herniation.


Tests for Consideration



• Complete blood count (CBC): May be useful if hemorrhage is suspected, especially in a young infant; platelet count may be helpful. $110

• Electrolytes: Screening for sodium disorders. $115

• Arterial blood gas (ABG): Checking that respiratory status is adequate. $45

• PT: Both PT and PTT are useful if hemorrhage is suspected because coagulopathy will need to be corrected. $75

• PTT $75


Imaging Considerations


→ Head CT: Provides a rapid assessment for bleeding and hydrocephalus and may detect some masses if normal structures in the brain are displaced $450


→ Shunt series: If a ventriculoperitoneal shunt is in place $275


→ Head ultrasound: Would be appropriate in an infant 6 months or younger with an adequately open anterior fontanelle $350


→ Magnetic resonance imaging (MRI): May be necessary to further delineate lesions; not generally necessary acutely $1800

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Raised Intracranial Pressure (Case 39)

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