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Case Presentation

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Case Presentation

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    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 Presentation Lincoln ER Intubated, unresponsive, pulseless, FS: 332 CPR for about 10 min. 11:22 - 2.5 ml epinephrine, ET 11:25 - Pulse noted 11:35 - NS bolus 11:41 - 25 meq NaHCO3 11:49 - Foley catheter 11:52 - Reintubated

    3. CBC: 12.9>13.8/40.5<517/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 Case Presentation Lincoln ER

    4. ABG pH pCO2 pO2 lac BE 12:16: 7.13 56.1 20 9.27 -10 12:28: 7.25 27.5 70 9.21 -15 13:23: 7.27 33.5 67 5.36 -12 15:29: 7.28 37.8 90 3.33 -9 Case Presentation Lincoln ER

    5. Case Presentation CHAM-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. CBC: WBC 46.5 no significant change BMP: no significant change LFT: wnl CPK: 225 LDH: 294 Troponin: 1.14 Urine toxicology: negative Case Presentation CHAM-PICU

    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 >13 Moderate: GCS 9-12 Severe: GCS <8

    11. Anoxic-Ischemic Brain Injury Nomenclature 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 Injury Nomenclature 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

    14. Anoxic-Ischemic Brain Injury Prognosis type of injury CPR: 4-6 min ffed by ACLS w/in 10-12 min. length of CPR: >15 min. poorer prognosis GCS: <4 in 48*, poorer prognosis drug/medication use metabolic derangements PE: D3: (-) extensor motor response/ pupillary or corneal reflexes Seizures

    15. Anoxic-Ischemic Brain Injury Prognosis 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 Injury Management A irway GCS <8 - intubated; cervical spine stabilized B reathing mod. hyperventilation (PaCO2 30 to 35 mm Hg) arterial constriction & ICP WOF hyperventilation (PaCO2<30) brain ischemia C irculation fluids & inotropes - to deliver O2, metabolic substrates & remove toxic metabolites

    17. 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 (32-36*C) Anoxic-Ischemic Brain Injury Management

    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 >32*C

    20. 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 Anoxic-Ischemic Brain Injury Clinical Criteria of Brain Death

    21. Anoxic-Ischemic Brain Injury Apnea Test performed after all other criteria for brain death have been met core temperature =36.5C or 97F systolic blood pressure =90 mmHg euvolemic status no respiratory response to a PaCO2 >60 mmHg and a final arterial pH of <7.28

    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 34-36*C Fosphenytoin and Keppra

    23. Case Presentation: CHAM-PICU EEG (HD#3): generalized background slowing MRI (HD#5): multiple infarcts in cerebrum and cerebellum ECHO (HD#6): no structural Abnties; mildly dilated LV w/ mildly depressed systolic function

    24. Case Presentation: CHAM-PICU HD#2-4: Pupils 3-4mm, SRTL; RR: breathing > vent. HD# 5: Pupils 5mm NRTL; RR: 20 :pronounced Brain dead : Organ donor contacted HD#8: failed Apnea test HD#9: (+) Apnea test

    25. Case Presentation: CHAM-PICU Apnea 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. doi:10.1016/0735-6757(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; 67:203. Zandbergen, EG, de Haan, RJ, Stoutenbeek, CP, et al. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet 1998; 352:1808. 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

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