This is from our director of PICU.
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>Date: Mon, 31 Aug 1998 10:53:30 +1000
>To: Peter Barnett <[log in to unmask]>
>From: Frank Shann <[log in to unmask]>
>Subject: Re: mechanisms of braindeath
>>Date: Sun, 30 Aug 1998 02:55:32 +0000
>>From: "Dr. Nikolaus Lutz-Dettinger" <[log in to unmask]>
>>To: [log in to unmask]
>>Subject: mechanisms of braindeath
>>Message-ID: <[log in to unmask]>
>>LP shows 130 WBC, elevated protein and gram neg. diplococci.
>>In the following hour, the neurologic situation of the child is
>>described in varying terms, from "passive" to "not reacting to pain",
>>but there is no clear evolution from better to worse. Temperature is
>>39.7 C, blood-pressure is rising in the course of that hour from
>>normal to 180/110 mmHg, while pulse rate is remaining quite constant at
>>105/min; the child is breathing spontaneously (in room air ?).
>>It is decided to do a CT of the brain, but ,while on the CT-table
>>(about 3 pm), the child becomes apneic and is intubated without the use of
>>medication; seemingly no circulatory instability even at that moment.
>>The CT is interpreted as normal, although one could argue, the the
>>ventricles where a little smaller than average (certainly not
>>slitlike) and that corticomedullary differentiation was a bit less
>>clear than usual.
>>After the CT it becomes apparent, that the pupils are dilated and
>>not reactive, while they where normal before. The elevated
>>blood-pressure quickly returns to normal.
>>Transfer to our institution is asked.
>>From that moment to the eventual termination of intensive care about
>>21h later the general situation of the child remains perfectly
>>stable, without a hint of circulatory disturbance (even without
>>diabetes insipidus). The child remains flaccid with al signs of brain
>>death. Because the child was very stable, we decided on arrival, to go
>>immediately to the MRI-department (at about 5 pm). MRI showed some
>>swelling of the mesencephalon (not impressive, the highest intensity
>>on T2-weighted images symmetrically in the posterior parts of the
>>thalamus) and possibly some sign of herniation
>>through the foramen magnum; MR-angio confirmed absence of brain
>>circulation (Doppler of the a. cerebri media next morning showed the
>>picture of negative diastolic flow equalling positive systolic flow).
>>During the discussions of this case in our service, the following
>>questions remained unresolved or contentious:
>We reviewed our experience with cerebral herniation in meningitis in Br Med
>J 1993;306:953-5. We found that herniation was much more likely to occur
>after lumbar puncture (suggesing that LP increases the risk of herniation),
>and that the CT was normal in 36% of the children who had a scan at about
>the time of herniation (ie a normal CT does NOT exclude raised intracranial
>Our practice is NOT to do an LP on children with decerebrate or decorticate
>posturing, focal neurological signs, or no response to pain - we treat with
>a aciclovir and a cephalosporin, and do an LP in 1-3 days when the child
>has recovered consciousness. The key question: is the child so sick that
>you will give antibiotics even if the LP is normal - if you will give
>antibiotics anyway, do NOT do an LP (even if the CT is normal). It is
>still a good idea to do a CT, after stabilsation, to exclude cerebral
>neoplasm, abscess or haemorrhage.
>>1) in the absence of systemic instability or other (toxic) systemic
>>oxygen transport and delivery problems, is there another mechanism than
>>herniation, that can result in brain death (i.e. cessation of
>>bloodflow to any part of the brain?
>No. I have no doubt that this child died from herniation. The story is
>typical of the cases in our series.
>>2) It seems very probable, that the patient suffered brain death on
>>the CT-table; why was the CT so unimpressive, merely hinting at some
>>early signs of edema.
>See above. CT shows structure, not pressure, and shows herniation poorly.
>>3) The rising blood-pressure before the CT seems most likely a sign of
>>increasing ICP, but why than was this not associated by any reduction
>>in pulse frequency.
>Bradycardia is a late sign of HERNIATION, and is a very unreliable guide to
>ICP (if you monitor ICP in traumatic or infectious brain injury, you will
>know that patients can have a very high ICP without bradycardia).
>Here is our management plan for this situation. It was designed to give
>our medical staff permission NOT to do an LP and NOT to give aciclovir or a
>cephalosporin in certain cases:
>ACUTE IMPAIRMENT OF CONSCIOUSNESS IN A CHILD OVER 60 DAYS OLD, NOT CAUSED
>BY A KNOWN UNDERLYING DISEASE
>CONSIDER: post-ictal state, infection (meningitis, encephalitis), trauma
>(including non-accidental), poisoning (drugs, toxins), matabolic,
>hydrocephalus, hypertension, hepatic or renal failure, Reye syndrome.
>LOOK FOR: bruises, fundal hge, blood pressure, urinalysis, blood sugar.
>INITIAL INVESTIGATIONS MAY INCLUDE: full blood examination, urea and
>electrolytes, glucose, liver function tests, arterial blood gas, drug
>screen, urine antigens, culture blood and urine, ammonia.
>PAPILLOEDEMA -> Yes -> Yes -> No LP. Give aciclovir + cefotaxime.
> | | | Consider CT or MRI.
> No | |
> | | |
>FOCAL SIGNS ---> FEVER - No -> No LP. Do CT/MRI; consider EEG.
>OR FOCAL FIT | Aciclovir + cefotaxime if infctn likely.
> | |
> | |------------<----------------------<--------
> | | |
> | | |
> No No No
> | | |
>PRESENTATION ---> Yes --> Paracetamol -----> IMPROVED -- Yes -> FULLY
>JUST AFTER FIT 20mg/kg if CONSCIOUS CONSCIOUS
> | fever STATE EACH WITHIN 6H
> | HOUR |
> | Yes
> No |
> | |
>ROUSABLE TO FULL CONSCIOUSNESS ---- Yes -> Do LP. No LP.
>(SQUEEZE EARLOBE AS HARD AS YOU CAN Give aciclovir No aciclovir
>FOR UP TO 1 MIN IF NO RESPONSE; or cefotaxime or cefotaxime.
>CHILDREN OVER 12 MONTHS SHOULD depending on
>LOCALISE RESPONSE AND SEEK A PARENT) results.
>AGE > 2 YR WITH DEFINITE NECK STIFFNESS -- Yes -> No LP. Give cefotaxime.
>(NECK STIFNESS UNRELIABLE UNDER 2 YR) Do LP when conscious.
>No LP. Give cefotaxime and aciclovir.
>Consider CT or MRI, and EEG.
>Do LP when conscious.
>Prof Frank Shann
>Professor of Critical Care Medicine, University of Melbourne.
>Director of Intensive Care, Royal Children's Hospital,
>Flemington Road, Parkville, Victoria 3052, Australia.
>Tel: +61 3 9345 5220 Fax: +61 3 9345 6239
>Email: [log in to unmask]
Dr. Peter Barnett MBBS FRACP MSc(epid) FACEM
Department of Emergency Medicine
Royal Children's Hospital
Telephone + 61 3 9345.6592
Facsimile + 61 3 9345-5938
E-mail [log in to unmask]
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