Treatment of severe pediatric head injury: Evidence-based practice
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Hypertonic saline (3% saline) creates an osmolar gradient across the blood–brain barrier, which helps reduce cerebral edema and ICP. In addition, the high sodium load can improve rheology in the cerebral vasculature, as well as inhibit inflammation and enhance cardiac output. The side effects include a rebound in intracranial hypertension, high urinary water losses, and hyperchloremic acidosis [16]. In addition to treating intracranial hypertension, hypertonic saline can be used to correct hyponatremia resulting from cerebral salt wasting. This is an important cause of morbidity in pediatric severe TBI and if untreated can contribute to mortality. The presence of natriuresis combined with polyuria and hypovolemia characterizes cerebral salt wasting, which can develop 2–11 days after the injury. Studies have shown improved ICP control and maintenance of cerebral perfusion from using hypertonic saline in pediatric TBI [17]. However, the optimal timing of therapy, safety profile, and target serum osmolality have not been defined in the pediatric population. Current guidelines provide level II recommendations on the use of hypertonic saline for severe pediatric TBI with the effective doses for acute use ranging from 6.5 and 10 mL/kg. Level III recommendations include effective doses as a continuous infusion of 3% saline (0.1–1 mL/kg/h) administered on a sliding scale, while maintaining serum osmolarity below 360 mOsm/L.
Head and Neck
Bobby Krishnachetty, Abdul Syed, Harriet Scott in Applied Anatomy for the FRCA, 2020
Systemic complications Cardiovascular – brain injury results in a massive catecholamine release with increased sympathetic outflow and dysfunction of the autonomic nervous system. This results in a hyperdynamic circulation with increased myocardial oxygen demand and workload leading to transient myocardial ischaemia and failure.Pulmonary – 80% of patients may have impaired oxygenation due to aspiration pneumonitis, neurogenic or cardiogenic pulmonary oedema, pneumonia, acute lung injury or ARDS.Metabolic – hyperglycaemia is a marker of the severity of SAH and is associated with a worse outcome. However, tight glycaemic control may be detrimental because of the risk of hypoglycaemia.Electrolytes – hyponatraemia may be due to administration of excessive hypotonic fluids, cerebral salt wasting syndrome, or the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Traumatic brain injury
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie in Bailey & Love's Short Practice of Surgery, 2018
Electrolyte imbalance is common in TBI, and contributes to brain swelling and to causing seizures. Diverse mechanisms are involved. Cerebral salt wasting, a poorly understood form of excretory dysregulation in association with brain insult, leads to volume depletion and hyponatraemia. The syndrome of inappropriate antidiuretic hormone (SIADH) leads to a water retention and hyponatraemia in the context of pituitary damage. This is of particular concern in head injury since low serum osmotic pressure can contribute to brain swelling, so hypotonic fluids are avoided in this setting. Conversely, ADH secretion may be compromised in the context of trauma, producing diabetes insipidus resulting in hypernatraemia.
Strategies for the diagnosis and management of meningitis in HIV-infected adults in resource limited settings
Published in Expert Opinion on Pharmacotherapy, 2021
Marise Bremer, Yakub E Kadernani, Sean Wasserman, Robert J Wilkinson, Angharad G Davis
Hyponatremia presents in 44% of TM cases, with cerebral salt wasting syndrome more frequently the underlying cause and relating to severity of the condition, than the syndrome of inappropriate secretion of antidiuretic hormone [151]. Distinction between these two causes is critical and clinical estimation of intravascular fluid volume can guide the diagnosis [152]. Fever in TBM increases 1 year mortality, but aggressive temperature control still requires further investigation [153].
Related Knowledge Centers
- Dehydration
- Endocrine Disease
- Neurosurgery
- Syndrome of Inappropriate Antidiuretic Hormone Secretion
- Hyponatremia
- Brain
- Rare Disease
- Neurology
- Nephrology
- Intensive Care Medicine
- Syndrome of Inappropriate Antidiuretic Hormone Secretion