Cerebral Edema Therapy

• Those at increased risk include younger age (<5 y/o), new onset diabetes, and longer duration of symptoms.

• Additional risk factors at diagnosis or during treatment include - more severe acidosis or very elevated BUN at presentation, use of bicarbonate for treatment of acidosis, greater volumes of fluid given in the first 4 hours of treatment, administration of short acting insulin in the first hour of fluid treatment.

• Signs and symptoms - headache, slowing or irregular heart rate, change in neurologic status (restlessness, irritability, increased drowsiness, incontinence), cranial nerve palsies or other specific neurologic signs, increasing blood pressure, decreased oxygen saturation.

• One diagnostic criterion, 2 major criteria, or one major and 2 minor criteria have a sensitivity of 92% and a false positive rate of only 4% for detecting cerebral edema.

  • Diagnostic criteria - abnormal motor or verbal response to pain, decorticate or decerebrate posture, cranial nerve palsy, abnormal neurogenic respiratory pattern (grunting, tachypnea).

  • Major criteria - altered mental status, fluctuating level of consciousness, sustained heart rate deceleration (decrease more than 20 beats per minute) not attributable to improved hydration or sleep, age-inappropriate incontinence.

  • Minor criteria - vomiting, headache, lethargy, diastolic BP >90 mm Hg, age <5 years.

Treatment:

• Begin immediate transfer to pediatric intensive care unit if patient is currently on a medical/surgical unit.

  • Elevate head of bed.

  • Reduce fluid rate by 1/3.

  • Hypertonic saline (3%), 3 - 5 mL/kg over 30 minutes.

  • Obtain CT head after treatment has been started to rule out other possible intracerebral causes of neurologic deterioration (thrombosis or hemorrhage).