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Severe Head Trauma in a child
Marie Angele Theard MD
22 kg child transferred from OSH with head trauma, CT sig for open depressed skull fracture with large left parietal/occipital hematoma and midline shift. Tonic-Clonic seizure noted at OSH (except the right side).
Arrived intubated, unresponsive, with mannitol 0.5g/kg just having been completed as well as a dose of Keppra. Blood hanging for Hct of 25, Na 139, urine output -copious.
BP upon arrival 135/80, HR 135, Temp 36.0 C. In the OR patient on Sevoflurane, Propofol, fentanyl and muscle relaxation. Surgery commenced while A-line placed. Upon opening dura, HR to 140’s followed by PEA arrest. Responded to resuscitation with Epi, and 2 rounds CPR and Additional blood products given as surgery proceeded with rapid decompression and removal of bone flap.

Planned half volatile agent and half IV in order to limit any additional increases in ICP (presumed was high). Any ideas of other anesthetic agents in the management of this case? Dex? Propofol alone?
Any other thoughts on the reason for the PEA arrest? Are there reports of herniation causing PEA?
Would you give additional mannitol as case got started in OR?

Dec 7, 2018 12:55 AM
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Shobana Rajan MD
A tough challenge indeed!
I do feel that the PEA arrest could have been due to herniation. Other reasons- VAE?
Did you hyperventilate soon after induction? In retrospect one option could have been to stick to TIVA? Could hypertonic saline have been started?
Look forward to other experts weigh in on this.
Dec 7, 2018 10:30 AM
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Deepali Garg MD
Thanks for sharing this challenging case.
I have a few questions- What was the EtCO2 at the beginning of case and how much was it maintained throughout?
Also, was the brain bulging after opening of dura? If yes probably converting to TIVA completely would be a good option.
Cause for PEA arrest could have been herniation. Herniation is known to cause various types of arrythmias and arrest.
I would give additional hypertonic saline intraop if the surgeon complained of tight brain.
Dec 7, 2018 12:43 PM
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Hemanshu Prabhakar MD, PhD
Thanks for sharing this case.
A few queries -
What was the age of the child?
What were the ABG values at the time of PEA?
Not really sure if PEA could be due to brain herniation but several parameters in ABG could give a clue - Common causes for PEA are acidosis, hypoxia, hyper- and hypokalemia, hypoglycemia. Hypothermia and hypovolemia could be the causes too.
Dec 9, 2018 9:54 PM
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Marie Angele Theard MD
Thanks for some great questions!

The child arrived into the OR and as the surgeon began craniotomy there was a request made for hypertonic saline.
ETC02 was 30-33, lytes, gasses were normal except for Hct.
The brain was bulging and as hypertonic saline started, PEA arrest
I agree that the PEA arrest was due to herniation and a TIVA may have been a better base anesthetic from the beginning.
This child was 5 and sadly had multiple extremity injuries as well

Those who would have chosen TIVA... ? Propofol and fentanyl, or ? Dex, Propofol? ...? would love to hear any thoughts as to anesthetic choices for TIVA
Dec 11, 2018 12:40 AM
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