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Episode 106: INSIGHTS - Pediatric Emergencies

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Episode 106 - INSIGHTS: Pediatric Emergencies

Contributors

  • Nikki Miller Ferguson, MD

  • Agnes Kielian, MD

  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  1. 00:00:19
    Hi, everyone and welcome back to the
  2. 00:00:20
    insights podcast, and as a reminder,
  3. 00:00:23
    the insights podcast is based on the
  4. 00:00:25
    material that's published through on
  5. 00:00:29
    -call on -call is the Neuro critical
  6. 00:00:31
    care societies continually updated
  7. 00:00:34
    online textbook which you can find in.
  8. 00:00:38
    It's available on the Ncs website.
  9. 00:00:40
    Under the educational resource Taps.
  10. 00:00:44
    Today, we have a little bit of a
  11. 00:00:45
    different program. We're going to be
  12. 00:00:47
    talking about pediatric nurse
  13. 00:00:49
    emergencies, and we are so lucky to be
  14. 00:00:52
    joined by two guests that Sally and I
  15. 00:00:53
    will introduce, and who are going to
  16. 00:00:55
    talk to us about the two most commonly
  17. 00:00:59
    encountered problem in pediatric neuro
  18. 00:01:01
    critical care, which our status
  19. 00:01:03
    epilepticus and traumatic brain injury,
  20. 00:01:05
    and the approach to these is a little
  21. 00:01:07
    bit different in our pediatric patient
  22. 00:01:08
    population that it is in the adult
  23. 00:01:10
    patient population, so this is a really
  24. 00:01:12
    exciting episode and one that we're
  25. 00:01:14
    really excited to bring to you, and as
  26. 00:01:16
    always, we are very grateful. for our
  27. 00:01:18
    sponsors, Biogen and Cerebell, and now
  28. 00:01:21
    a word from our sponsors. Time is brain
  29. 00:01:24
    when it comes to seizures. Cerebell
  30. 00:01:26
    Point of Care EEG empowers the bedside
  31. 00:01:29
    team to detect or rule out seizure
  32. 00:01:31
    activity in minutes. To learn more,
  33. 00:01:34
    visit Cerebellcom.
  34. 00:01:40
    Hello, everyone. Thank you so much for
  35. 00:01:42
    joining us today and I'm Scalia Froch.
  36. 00:01:45
    I am the narrator clinical pharmacist
  37. 00:01:47
    specialist at Johns Hopkins Hospital.
  38. 00:01:50
    Today, We're super super excited to
  39. 00:01:53
    have Dr. Agnes Killian. She is a
  40. 00:01:58
    pediatric neurologist and she practices
  41. 00:02:02
    and the neuro critical care unit and she
  42. 00:02:04
    is also the director of critical care
  43. 00:02:07
    epilepsy at Boston Children's Hospital.
  44. 00:02:11
    This is a lot. She is very accomplished.
  45. 00:02:13
    We're very excited to have her and Dr.
  46. 00:02:17
    Caroline. Is there anything that I
  47. 00:02:19
    missed that you would like to tell our
  48. 00:02:21
    audience about yourself
  49. 00:02:24
    through. That was a great introduction.
  50. 00:02:25
    Talia. Thanks so much, and I'm happy
  51. 00:02:27
    to be here, awesome, great, so our
  52. 00:02:31
    focus today as art, and as burst, Ah,
  53. 00:02:35
    Pediatric episode. Which is very
  54. 00:02:37
    exciting as the first time we're doing
  55. 00:02:39
    destiny know there is a lot of requests
  56. 00:02:41
    for this episode is that we're gonna
  57. 00:02:44
    focus on status epilepticus beneath the
  58. 00:02:45
    adult version a few months back with
  59. 00:02:49
    Casey Albin, and now we're going to do
  60. 00:02:51
    this for the pediatric population again,
  61. 00:02:53
    very exciting a very popular topic, so
  62. 00:02:58
    and we want to learn from you or from
  63. 00:03:01
    the experts, and what are some of the
  64. 00:03:04
    tips that you have for us that are not
  65. 00:03:08
    no pediatric, trained, or not never
  66. 00:03:10
    critical care trained that we take care
  67. 00:03:12
    of status epilepticus in the Edi and in
  68. 00:03:15
    this specific population are there any
  69. 00:03:17
    specific or three important pearls that
  70. 00:03:20
    you'd say this is what I do in Edi every
  71. 00:03:23
    time I had to take care of a patient and
  72. 00:03:26
    a pediatric patient, who's in status
  73. 00:03:28
    epilepticus
  74. 00:03:31
    Yup, so I her horror chatting by the
  75. 00:03:35
    topic of you guys know. As a blessing,
  76. 00:03:37
    because there's a medical emergency
  77. 00:03:39
    requiring immediate intervention to help
  78. 00:03:41
    the seizure activity. I'm it can lead
  79. 00:03:45
    to a number of Ah. Changes in the
  80. 00:03:47
    central nervous system as well as are a
  81. 00:03:49
    number of physiological changes are
  82. 00:03:52
    which are important to address fast, or
  83. 00:03:55
    so. The first thing that's a. It's
  84. 00:03:57
    important to do is to assess the pay a
  85. 00:04:00
    patient traits of your writing. The
  86. 00:04:01
    eighty on that, make sure that you are
  87. 00:04:04
    assisting airway breathing circulation.
  88. 00:04:06
    Right you're looking, or to make sure
  89. 00:04:08
    that the patient is overall
  90. 00:04:10
    hemodynamically stable, and the second
  91. 00:04:13
    think or you want to do is I'm you want
  92. 00:04:16
    to make sure A A few assess whether the
  93. 00:04:18
    patient continues to be peace in crate.
  94. 00:04:21
    So if Ah excuse was a can present in
  95. 00:04:24
    various different ways, Right, Some
  96. 00:04:26
    have motor presentations with motor
  97. 00:04:28
    movements are, but and the symbology of
  98. 00:04:32
    the seashore at various, right, and
  99. 00:04:34
    sometimes that can. It'd be the science
  100. 00:04:36
    can be much more sought, all right,
  101. 00:04:38
    like gaze, deviation to unsigned, a
  102. 00:04:41
    decreased responsiveness. I'm a, and
  103. 00:04:46
    there are. Of course other signs are as
  104. 00:04:48
    well, Ah, so figuring out what are the
  105. 00:04:51
    patient season or not is very important
  106. 00:04:54
    and a next you'll want to figure out how
  107. 00:04:56
    long has the patient than choosing for
  108. 00:04:59
    right, So if the patient is a seizing,
  109. 00:05:03
    still seizing on arrival, you should
  110. 00:05:05
    assume that the patient is in status
  111. 00:05:07
    epilepticus trait is the patient. If a
  112. 00:05:10
    starts seeping are in a medical setting
  113. 00:05:14
    or you want to make sure that you start
  114. 00:05:16
    timing. The are right because there's a
  115. 00:05:18
    specific duration of time where we
  116. 00:05:21
    initiate treatment of trade, and for
  117. 00:05:24
    convulsive a status epilepticus. It's
  118. 00:05:27
    typically around five minutes of seizure
  119. 00:05:29
    activity where you with one out in the
  120. 00:05:31
    shade, first therapy and four. Other
  121. 00:05:35
    types of Er status epilepticus, It's a
  122. 00:05:37
    little different, so, for example, if
  123. 00:05:40
    a patient is in focal status epilepticus,
  124. 00:05:43
    usually the treatment of initiate at the
  125. 00:05:45
    little later around at about ten minutes
  126. 00:05:48
    of time
  127. 00:05:51
    or so, and as I mentioned, are you,
  128. 00:05:56
    I'm one to assess what are the fees are
  129. 00:05:59
    ongoing, and then at the law and
  130. 00:06:02
    another thing you wanna do is ask your
  131. 00:06:04
    learning. How figure out a little more
  132. 00:06:06
    about patient's history, All right, So
  133. 00:06:08
    Uh, is this what could be the
  134. 00:06:10
    underlying etiology of the future Right
  135. 00:06:13
    Is this a reversible cause? Try if you
  136. 00:06:16
    want to look for a metabolic
  137. 00:06:18
    derangements, Make sure you're checking
  138. 00:06:20
    the spare crates and glucose. Ah. This
  139. 00:06:23
    is one of the first things that you want
  140. 00:06:25
    to do as this can be potentially
  141. 00:06:27
    irreversible cause of the seizure A,
  142. 00:06:29
    and then also figuring out if the
  143. 00:06:31
    patient or someone who has underlying
  144. 00:06:34
    capital. You're right, Epilepsy is not
  145. 00:06:36
    an uncommon pediatric condition A, and
  146. 00:06:40
    it's going to be important to know what
  147. 00:06:43
    are just as someone with underlying
  148. 00:06:44
    disease or disorder or not, or they are
  149. 00:06:46
    on the Any medications, Are there any
  150. 00:06:49
    specific medications that have worked in
  151. 00:06:52
    the past for the patients, or that
  152. 00:06:54
    potentially you could mold with, I'm so
  153. 00:06:57
    those are all the important stuff, and
  154. 00:06:59
    then a initiating treatment early right
  155. 00:07:03
    That's an appropriate time is also
  156. 00:07:05
    important as we know that the longer
  157. 00:07:07
    seizures are the more difficult it
  158. 00:07:10
    becomes to control
  159. 00:07:13
    awesome. Thank you so much. That was
  160. 00:07:15
    really helpful. So either we talked
  161. 00:07:20
    about this about adults and I feel like
  162. 00:07:21
    there is a lot of overlap. We're kind
  163. 00:07:24
    of talking about a lot of things about
  164. 00:07:26
    you know the timeline of that five
  165. 00:07:27
    minute rule is still the same acting
  166. 00:07:30
    early knowing what they're taking at
  167. 00:07:32
    home. knowing what happened to them,
  168. 00:07:35
    how long have they been seizing? Is
  169. 00:07:38
    there anything unique about pediatric
  170. 00:07:40
    patients that you'd say, this is
  171. 00:07:42
    different? Meaning you should really,
  172. 00:07:44
    this is a big distinction between
  173. 00:07:47
    treating adult patients with status
  174. 00:07:49
    versus pediatric patients. And I think
  175. 00:07:51
    you already kind of addressed it a
  176. 00:07:53
    little bit about how pediatric patients
  177. 00:07:57
    may have maybe a different underlying
  178. 00:07:59
    cause that you may not see that in
  179. 00:08:01
    adults We talk about genetic stuff and
  180. 00:08:04
    metabolic complications. But I guess if
  181. 00:08:08
    you had to kind of provide some clinical
  182. 00:08:11
    pros about how this is different from
  183. 00:08:14
    adult patients in status, what would
  184. 00:08:16
    you say?
  185. 00:08:20
    So that's a great question. And
  186. 00:08:24
    I think you could approach it from
  187. 00:08:25
    multiple angles, right? So first, you
  188. 00:08:30
    alluded to it, right? the etiology of
  189. 00:08:33
    pediatrics. is epilepticus may vary
  190. 00:08:35
    from the the the the etiology seen in
  191. 00:08:38
    adults are for example in addition to
  192. 00:08:42
    causes like cerebrovascular diseases CMS
  193. 00:08:45
    infection rate we also want to
  194. 00:08:48
    contribute or things like cortical
  195. 00:08:50
    dysplasia as neurodegenerative
  196. 00:08:52
    conditions or metabolic conditions I'm
  197. 00:08:57
    out or immune disorders of mitochondrial
  198. 00:09:00
    disorders I'm so sold the etiology M May
  199. 00:09:07
    vary slightly in the Pediatric ER
  200. 00:09:09
    patients Ah and AH unfortunately also
  201. 00:09:13
    includes a non accidental trauma in our
  202. 00:09:15
    younger patient population AH so this is
  203. 00:09:19
    something that we are think about four
  204. 00:09:21
    children who also a show signs of a
  205. 00:09:25
    abuse or on on physical exam and a
  206. 00:09:29
    particularly if they are present with
  207. 00:09:31
    altered mental status or not
  208. 00:09:33
    appropriately.
  209. 00:09:37
    Other things that,
  210. 00:09:40
    yeah, please go ahead.
  211. 00:09:44
    Okay, other things that
  212. 00:09:47
    may differ slightly in pediatric
  213. 00:09:50
    population is the use of medications,
  214. 00:09:52
    right? So while typically for generally
  215. 00:09:56
    in pediatric patients, the approach is
  216. 00:09:58
    quite similar to the, to therapy use in
  217. 00:10:01
    adults, meaning that depends on the day
  218. 00:10:03
    at the peak, are still first
  219. 00:10:07
    line of therapy. There are some
  220. 00:10:10
    medications with which we are more
  221. 00:10:12
    cautious with. For example, in
  222. 00:10:15
    children who are younger than two years
  223. 00:10:17
    of age, we are very cautious about
  224. 00:10:19
    using medications such as called prog
  225. 00:10:21
    acid. And this is related to the
  226. 00:10:25
    possibility that the child may have an
  227. 00:10:27
    underlying yet undiscovered
  228. 00:10:30
    mitochondrial disorder, right? So this
  229. 00:10:33
    is a medication that we can still
  230. 00:10:35
    potentially use, but that probably will
  231. 00:10:38
    not be the first in line in the
  232. 00:10:42
    treatment algorithm.
  233. 00:10:46
    Excellent, great. This is actually a
  234. 00:10:49
    good start for our last question about
  235. 00:10:53
    how is pharmacology different in
  236. 00:10:55
    pediatric patients? And I know you
  237. 00:10:58
    already spoke about, you know, what
  238. 00:10:59
    medication maybe they shouldn't use in
  239. 00:11:01
    pediatric patients, you know, as
  240. 00:11:03
    opposed to adult patients. But when we
  241. 00:11:05
    talked about status in adult patients,
  242. 00:11:07
    we had a lot of, I think, new and
  243. 00:11:10
    exciting conversation about the dosing
  244. 00:11:11
    has to be aggressive. You know,
  245. 00:11:14
    we talked about
  246. 00:11:18
    how at Kepra or Levatrazotam, we're
  247. 00:11:19
    doing 60 McPhercake, we're, you know,
  248. 00:11:19
    maxing or loading dose to 45
  249. 00:11:25
    grams. And how you really don't need to
  250. 00:11:29
    worry about renal and hematics function
  251. 00:11:31
    with you loads. Patients in status and
  252. 00:11:34
    then you kind of take care of that later,
  253. 00:11:37
    Obviously, If a dragon is not the right
  254. 00:11:39
    age, and if someone is full full -blown
  255. 00:11:41
    hepatic failure, we're not going to use
  256. 00:11:43
    Valproic acid for it, cause there's
  257. 00:11:45
    really no sense of doing that, but if
  258. 00:11:47
    someone has a mild Ak, I do we think
  259. 00:11:49
    that Capra is the next best agent. We
  260. 00:11:51
    kind of load them, and in one figure
  261. 00:11:54
    out all the dose adjustments afterwards,
  262. 00:11:57
    and I guess, especially for mean as the
  263. 00:12:01
    neuroses premises who has done only
  264. 00:12:03
    adults, you know kind of farm
  265. 00:12:06
    management are the same clinical pearls
  266. 00:12:10
    apply for pediatrics meeting, Are you
  267. 00:12:13
    guys are very aggressive with a
  268. 00:12:16
    medication dosing in pediatric patients,
  269. 00:12:19
    and and and again, Like are there any
  270. 00:12:22
    specifics Not you care about that made
  271. 00:12:25
    him Don't think of it think about in
  272. 00:12:27
    adult patients when it comes to
  273. 00:12:28
    medication dosing. monitoring, even
  274. 00:12:31
    long-term, is there anything that you
  275. 00:12:34
    have in mind that we may or may not
  276. 00:12:37
    think about in the adult kind of world's
  277. 00:12:40
    first status epileptic is?
  278. 00:12:44
    I think the approach is overall quite
  279. 00:12:49
    similar to the adult
  280. 00:12:52
    treatment algorithm. The one thing to
  281. 00:12:56
    keep in mind for pediatric patients,
  282. 00:12:58
    and that's true for status epileptic,
  283. 00:12:59
    as it is for other conditions as well,
  284. 00:13:02
    is that in pediatric, the doses are
  285. 00:13:05
    weight-based, right? So first thing
  286. 00:13:07
    you want to make sure you know is what
  287. 00:13:09
    is the child's weight? Lorazepam,
  288. 00:13:13
    which is the first agent used in
  289. 00:13:16
    treatment of status epileptic is, or
  290. 00:13:21
    there are also other benzodiazepines,
  291. 00:13:22
    which are those differently, but
  292. 00:13:24
    specifically for for lorazepam, the
  293. 00:13:27
    dosing is 01 milligram per kilogram.
  294. 00:13:29
    with a maximum of four milligrams dose
  295. 00:13:34
    per dose. So that's something to keep
  296. 00:13:37
    in mind. Now, in terms of Capra, the
  297. 00:13:40
    dose is used similar to that in adults.
  298. 00:13:43
    So it's still 16 milligrams per kilogram.
  299. 00:13:48
    And the other medications are dose
  300. 00:13:52
    similarly. So for sanitone, for
  301. 00:13:54
    example, is a 29 per kilogram as well
  302. 00:13:59
    Phenobarbital is 20 milligrams per
  303. 00:14:01
    kilogram as well. And I think we
  304. 00:14:05
    monitor for similar systemic
  305. 00:14:08
    complications that may be related to the
  306. 00:14:10
    treatment of status epilepticus. So you
  307. 00:14:13
    wanna make sure that you're reassessing
  308. 00:14:15
    the patients on ongoing basis, from the
  309. 00:14:18
    cardiovascular, as well as respiratory
  310. 00:14:22
    perspective. You wanna make sure that
  311. 00:14:25
    you're continuing reassessing at the
  312. 00:14:28
    Baltic state. and as well as monitoring
  313. 00:14:33
    effects on the endocrine system as well,
  314. 00:14:37
    looking for stress response, et cetera.
  315. 00:14:43
    Of course, similarly to adults,
  316. 00:14:45
    prolonged seizure activity, convulsive
  317. 00:14:47
    seizure activity can lead to
  318. 00:14:51
    like sustained muscle contraction, so
  319. 00:14:53
    that can lead to rapid myelitis, which
  320. 00:14:55
    can then result in renal damage
  321. 00:15:01
    So this is something quite similar to
  322. 00:15:02
    what may happen in adults, and all
  323. 00:15:05
    patients need to be monitored for it as
  324. 00:15:07
    well.
  325. 00:15:09
    Awesome, thank you so much. It's
  326. 00:15:12
    really interesting. I think I am
  327. 00:15:14
    learning that we have more in common
  328. 00:15:17
    than not. I am surprised about all the
  329. 00:15:22
    overlaps. It looks like all the
  330. 00:15:25
    principles are the same it looks like.
  331. 00:15:28
    Everything really works. focusing on,
  332. 00:15:30
    you know, in adults, obviously, I
  333. 00:15:32
    think in pediatrics, you had a great
  334. 00:15:33
    point that, you know, in adults, I
  335. 00:15:35
    think it's easy to kind of have an
  336. 00:15:37
    average body weight or kind of estimate,
  337. 00:15:39
    but in pediatrics, it's hard because
  338. 00:15:41
    I'm sure every age category has a
  339. 00:15:44
    different body weight, and you can
  340. 00:15:46
    easily overdose or underdose these
  341. 00:15:48
    patients. I think that's a great
  342. 00:15:50
    clinical pearl that that could be really
  343. 00:15:53
    make it or break it if you're not doing
  344. 00:15:55
    a good job with assessing a body weight
  345. 00:15:58
    or having a very accurate body weight.
  346. 00:16:01
    You could harm or not provide effective
  347. 00:16:05
    treatment. That's great. Thank you so
  348. 00:16:08
    much. I think we talked about the most
  349. 00:16:11
    important things that we want to talk
  350. 00:16:12
    about. Is there anything else that we
  351. 00:16:15
    missed and you would like to talk about
  352. 00:16:18
    before we say goodbye?
  353. 00:16:21
    I think it's always interesting to,
  354. 00:16:22
    like, in addition to the neurology of
  355. 00:16:25
    the status central because to also think
  356. 00:16:27
    about like the. Some exchanges occur a
  357. 00:16:30
    physiologically during the status. I'm
  358. 00:16:33
    so. Ah, as I mentioned, I'm a. In
  359. 00:16:37
    terms of their respiratory system. I
  360. 00:16:39
    think a. It's a interesting to remember
  361. 00:16:43
    that A initially during a are very often
  362. 00:16:46
    will see increasing ventilation due to
  363. 00:16:49
    the stimulation of the central nervous
  364. 00:16:51
    system and then as the seizure continues,
  365. 00:16:54
    I'm Ah. The ability to maintain
  366. 00:16:57
    adequate ventilation may be compromised,
  367. 00:16:59
    leading to the hyper ventilation hypoxia
  368. 00:17:02
    and eventually respiratory failure, So
  369. 00:17:04
    this is why it's so important to
  370. 00:17:06
    continue to a reassessed. The
  371. 00:17:08
    respiratory started now for
  372. 00:17:10
    cardiovascular changes are initially
  373. 00:17:13
    again. There's an increasing your blood
  374. 00:17:14
    pressure and heartrate. I'm there can
  375. 00:17:17
    be able to arrest me as a related to
  376. 00:17:20
    their release off. I'm a cut colonies
  377. 00:17:23
    or so and again. One thing that needs
  378. 00:17:28
    to be continuously reassess them are
  379. 00:17:31
    also important to know that prolonged
  380. 00:17:32
    future activity can lead to hypertension
  381. 00:17:35
    later, a myocardial infarction, and in
  382. 00:17:39
    severe cases, even heart failure, you
  383. 00:17:41
    are again, are providing more reasons
  384. 00:17:44
    to make sure that were treating status
  385. 00:17:46
    epilepticus early, and then in terms of
  386. 00:17:50
    I'm a metabolic states, right, so so
  387. 00:17:54
    er, status epilepticus can trigger.
  388. 00:17:57
    I'm increased oxygen consumption and
  389. 00:18:00
    glucose utilization rate, so we can
  390. 00:18:03
    often see hyperglycemia initially due to
  391. 00:18:05
    trust response, Ah, but then we can
  392. 00:18:10
    subsequently we see hypoglycemia due to
  393. 00:18:13
    the continuous high metabolic demand.
  394. 00:18:16
    I'm the the high preventable estate can
  395. 00:18:20
    also lead to hyperthermia or you may see
  396. 00:18:24
    some other electrolyte shifts. M and
  397. 00:18:30
    again, this is why it's so important to
  398. 00:18:33
    continue monitoring or electrolyte
  399. 00:18:36
    balance. I'm as the. As the season
  400. 00:18:39
    continues, particularly, it's a very
  401. 00:18:41
    prolonged seizure
  402. 00:18:44
    or a great. Thank you so much and thank
  403. 00:18:47
    you to our audience for joining us.
  404. 00:18:49
    This was something that was a hot topic
  405. 00:18:53
    and we had a lot of requests for, so
  406. 00:18:55
    we're really excited to do this and
  407. 00:18:57
    provide this for audience. Thank you so
  408. 00:18:58
    much, Dr. Killian and we'll see
  409. 00:19:01
    everyone next time. Thank you. Bye
  410. 00:19:05
    time his brain when it comes to seizures,
  411. 00:19:08
    cerebral point of care. Eg empowers the
  412. 00:19:10
    bedside team to detect or rule out
  413. 00:19:13
    seizure activity in minutes to learn
  414. 00:19:15
    more visit Sarah, Belle, Dot Com,
  415. 00:19:21
    All right, too Hi, everyone I am so
  416. 00:19:23
    delighted. Usually it is just an myself
  417. 00:19:26
    and failure. Today, since neither of
  418. 00:19:28
    us are pediatric specialist, and this
  419. 00:19:31
    will be a continuation of the status
  420. 00:19:33
    epilepticus sort of discussion in
  421. 00:19:35
    pediatrics, and I am so delighted that
  422. 00:19:38
    I am being joined by Dr. Miller
  423. 00:19:40
    Ferguson, who is faculty at the
  424. 00:19:42
    Children's Hospital Of Richmond, At Vc
  425. 00:19:44
    You, and is currently an associate
  426. 00:19:46
    professor. She received her Md from the
  427. 00:19:49
    Medical University Of Ohio, and her
  428. 00:19:51
    pediatric, and, and completed her
  429. 00:19:53
    pediatric residency at the University Of
  430. 00:19:56
    Virginia, She then went on to complete
  431. 00:19:58
    a pediatric critical care fellowship at
  432. 00:20:00
    Children's Hospital Of Pittsburgh At U.
  433. 00:20:03
    P. M C Aunt. She's currently the
  434. 00:20:06
    pediatric medical director for critical
  435. 00:20:08
    care transport, and the co -director of
  436. 00:20:10
    the. I am gonna have to ask you, is it
  437. 00:20:13
    C H O R. The chore, Yeah, so
  438. 00:20:15
    Children's Hospital of Richmond, that's
  439. 00:20:17
    the shortened version of it Perfect
  440. 00:20:20
    brain injury program. So really there's
  441. 00:20:23
    no one better to discuss what we're
  442. 00:20:24
    going to talk about in the next fifteen
  443. 00:20:26
    minutes. Which is the approach to
  444. 00:20:28
    pediatric trauma and she is an active
  445. 00:20:30
    member of the pediatric nurse critical
  446. 00:20:32
    care research group, and her interest
  447. 00:20:34
    is focused on pediatric trauma and brain
  448. 00:20:36
    injury and abusive head trauma. She has
  449. 00:20:38
    recently been part of the Adapt trial,
  450. 00:20:40
    which is the largest International
  451. 00:20:42
    multicenter pediatric Tb, I trial to
  452. 00:20:44
    date, So really there's actually no one
  453. 00:20:46
    better that we can be talking to you
  454. 00:20:47
    about this, and I can say as an
  455. 00:20:50
    intensive as an as an adult,
  456. 00:20:51
    intensivists that you know, I can
  457. 00:20:54
    certainly appreciate that children are
  458. 00:20:56
    not just tiny adults, and this is a a
  459. 00:20:58
    really unique pathophysiology, and that
  460. 00:21:02
    is unfortunately common, and I think we
  461. 00:21:04
    were hoping that she could kind of walk.
  462. 00:21:06
    You know the listeners through sort of
  463. 00:21:09
    some pearls, advise you know, when
  464. 00:21:11
    first encountering a child or a teenager
  465. 00:21:14
    with traumatic brain injury. What are
  466. 00:21:16
    some of the most important stabilization
  467. 00:21:19
    considerations?
  468. 00:21:22
    Well, thank you so much an honor to be
  469. 00:21:23
    here and excited to talk about my. My
  470. 00:21:26
    loves and Tv, I, I think when
  471. 00:21:31
    considering pediatrics and the biggest
  472. 00:21:34
    thing is that one size does not fit all,
  473. 00:21:37
    and in, so we take care of a spectrum
  474. 00:21:40
    from very young to up to most adult age,
  475. 00:21:45
    and so I enter, the initial
  476. 00:21:48
    consideration is really thinking about
  477. 00:21:50
    what age of child do you have in front
  478. 00:21:51
    of you and you know there's a big
  479. 00:21:55
    difference between an infant and a
  480. 00:21:57
    thirteen year old and thinking about the
  481. 00:22:01
    equipment that you need to making sure
  482. 00:22:03
    that you have proper equipment to take
  483. 00:22:05
    care of that size of child, so things
  484. 00:22:08
    like you know appropriate if you need to
  485. 00:22:11
    integrate appropriate size and tubes and
  486. 00:22:15
    mass, If you just need oxygen and
  487. 00:22:18
    thinking about Central lines, Arterial
  488. 00:22:20
    lines, all of those things, and you
  489. 00:22:23
    need to make sure that you have
  490. 00:22:24
    appropriate sides equipment. take care
  491. 00:22:26
    of the patient that's in front of you.
  492. 00:22:29
    Along with that, vital signs. So
  493. 00:22:31
    normal vital signs are very different
  494. 00:22:34
    for a six-month-old versus a
  495. 00:22:36
    six-year-old versus a 16-year-old. And
  496. 00:22:39
    so that really plays into things when
  497. 00:22:40
    you're thinking about intracranial
  498. 00:22:43
    pressure and cerebral perfusion pressure,
  499. 00:22:46
    you know, what is a normal vital sign
  500. 00:22:48
    for that age of child and along with
  501. 00:22:52
    that, yeah, and can I ask you, like,
  502. 00:22:54
    do you, how do you normalize that? Do
  503. 00:22:56
    you post it like on the child's chart,
  504. 00:22:59
    like, this is what our goal should be
  505. 00:23:01
    so that we can optimize their CPP for
  506. 00:23:04
    this age group. So I imagine that's
  507. 00:23:06
    like kind of challenging if you're not
  508. 00:23:08
    doing this day in and day out to kind of
  509. 00:23:10
    know what are we targeting for their CPP
  510. 00:23:13
    and how should we normalize that to what
  511. 00:23:15
    their blood pressure and their
  512. 00:23:17
    intracranial pressure should be.
  513. 00:23:20
    So I will say for me specifically when
  514. 00:23:23
    I'm taking care of a patient, you know,
  515. 00:23:25
    it's a On rounds we do have a T V I
  516. 00:23:29
    guide mine, so a printed out thing of
  517. 00:23:32
    where we want, and all of our vital
  518. 00:23:35
    signs and Aicp, and Cbp. What range we
  519. 00:23:38
    want them and but you know, I think
  520. 00:23:40
    it's it's really helpful to write those
  521. 00:23:43
    things down for, and if you're taking
  522. 00:23:47
    care of a kid like this, Certainly, if
  523. 00:23:49
    you're not in a pic, you, I think
  524. 00:23:50
    those of us that do this day in and day
  525. 00:23:52
    out. Just it's automatic. It's It's
  526. 00:23:55
    memorize. We know what a normal vital
  527. 00:23:57
    sign is, but for those that don't do
  528. 00:23:59
    this all the time, and you know using
  529. 00:24:02
    even just and you know normalized and
  530. 00:24:07
    vital signs that you can find from the
  531. 00:24:09
    Atp, but having it written down, I
  532. 00:24:13
    think for everybody is always really
  533. 00:24:15
    helpful, and I have to ask like I are
  534. 00:24:19
    this the icy peoples the same in
  535. 00:24:21
    pediatric as they are an adult, or is
  536. 00:24:23
    that does that change as the child ages
  537. 00:24:25
    as well?
  538. 00:24:27
    So we don't really know. You know,
  539. 00:24:29
    there is some thought that perhaps a
  540. 00:24:32
    younger child should have a little bit
  541. 00:24:35
    lower ICP, but we generally use 20 just
  542. 00:24:40
    like you do in adults. So the ICP goals,
  543. 00:24:44
    we generally use 20.
  544. 00:24:46
    There hasn't been any really solid
  545. 00:24:49
    literature to support using anything
  546. 00:24:51
    different For CPP goals, for your
  547. 00:24:55
    cerebral perfusion pressure, that
  548. 00:24:58
    really is because CPP is your mean
  549. 00:25:01
    arterial pressure minus your ICP. So
  550. 00:25:04
    that really is somewhat age-based
  551. 00:25:07
    because your mean arterial pressure is
  552. 00:25:08
    gonna be different for different ages.
  553. 00:25:11
    Again, the literature out there is not
  554. 00:25:15
    super solid on what that should be. We
  555. 00:25:18
    know that a CPP less than 40 in anyone
  556. 00:25:22
    is an issue issue. So certainly
  557. 00:25:23
    targeting at least above 40
  558. 00:25:27
    There is some okay data out there for
  559. 00:25:31
    supporting a CPP above 50 to 55 for that
  560. 00:25:35
    infant toddler age and then CPP above 60
  561. 00:25:40
    or so for your school age up to the
  562. 00:25:43
    teenagers. So for our TBI guidelines
  563. 00:25:47
    that we use at my hospital, anyone zero
  564. 00:25:51
    to two years of age, we try to keep the
  565. 00:25:53
    CPP at least above 50 Most of us try to
  566. 00:25:56
    target a little bit above 55 and then
  567. 00:26:00
    school age kids above 60. So
  568. 00:26:03
    unfortunately there's not great data but
  569. 00:26:07
    definitely we try to target at least
  570. 00:26:10
    above 50 for kids. That's super helpful
  571. 00:26:12
    'cause I think that those ranges are so
  572. 00:26:16
    codified in adults and it's great to
  573. 00:26:18
    hear that there's like, hey, there is
  574. 00:26:20
    some evidence, maybe it's not great but
  575. 00:26:22
    at least some guidance The other
  576. 00:26:24
    question I had sort of about the initial
  577. 00:26:26
    approach to these people.
  578. 00:26:30
    in adult populations, we so rely on CT
  579. 00:26:34
    scans. And I imagine that in the
  580. 00:26:36
    pediatric population, you may still be
  581. 00:26:39
    using that sort of radiation, but
  582. 00:26:42
    probably to a less extent. And sort of
  583. 00:26:45
    what, how do you walk through or like
  584. 00:26:48
    think about the approach to neuroimaging
  585. 00:26:50
    in these patients?
  586. 00:26:53
    So yeah, we definitely use CT a lot as
  587. 00:26:55
    well A lot of pediatric radiologists.
  588. 00:26:58
    So within children's hospitals, we have
  589. 00:27:01
    certain protocols to use dose reduction
  590. 00:27:05
    in terms of radiation. And so we try to
  591. 00:27:08
    be mindful about that and work closely
  592. 00:27:11
    with our pediatric radiologists to
  593. 00:27:13
    ensure that we're using imaging to the
  594. 00:27:18
    fullest and that we're getting the right
  595. 00:27:20
    study and also using what lower
  596. 00:27:23
    radiation that we can to get accurate
  597. 00:27:26
    studies. We have started to move a
  598. 00:27:29
    little bit more to MRI as well, and so
  599. 00:27:33
    getting earlier MRIs, then I think we
  600. 00:27:36
    did 10 years ago.
  601. 00:27:39
    Certainly having, you know, if you
  602. 00:27:40
    have a codman or an EVD in this MRI
  603. 00:27:42
    compatible, it's important.
  604. 00:27:46
    But definitely in our, especially in
  605. 00:27:48
    our abusive head trauma population,
  606. 00:27:51
    getting an MRI can be really beneficial,
  607. 00:27:53
    not only for clinical purposes, but
  608. 00:27:56
    also for kind of medical legal issues
  609. 00:28:00
    down the road. Right, and I imagine
  610. 00:28:02
    some of those medical legal issues
  611. 00:28:05
    really take precedence and sort of are a
  612. 00:28:07
    backbone of this sort of situation. I
  613. 00:28:10
    think we could probably spend a whole
  614. 00:28:12
    podcast just talking about medical legal
  615. 00:28:14
    aspects in this, but let's just say a
  616. 00:28:16
    trainee is in, you know, the first
  617. 00:28:19
    responder position. Are there any sort
  618. 00:28:22
    of tips, you know, If this is
  619. 00:28:24
    suspected to be an abusive case, are
  620. 00:28:26
    there things that you would say? It's
  621. 00:28:28
    really important that that frontline
  622. 00:28:30
    trainee documents X, Y, or Z or how do
  623. 00:28:33
    they approach this? This is a really,
  624. 00:28:35
    I would say tricky and also probably
  625. 00:28:37
    quite scary experience if this is a
  626. 00:28:41
    first time a trainee is encountering one
  627. 00:28:43
    of these type of cases. Yeah.
  628. 00:28:45
    Absolutely. And unfortunately, it's
  629. 00:28:48
    very, very common in pediatrics. I
  630. 00:28:51
    would say at least 50 if not more of the
  631. 00:28:55
    two years and under TBIs that we see are
  632. 00:28:58
    due to abuse of head trauma. So I think
  633. 00:29:01
    the first thing is it's really important
  634. 00:29:04
    for anyone taking care of pediatric
  635. 00:29:06
    patients to always have in the back of
  636. 00:29:08
    their mind that this could be potential
  637. 00:29:11
    abuse. And so just having that in the
  638. 00:29:17
    back of your mind, and so really the
  639. 00:29:19
    biggest thing is the history So taking a
  640. 00:29:22
    very accurate history,
  641. 00:29:25
    you know, what has been going on with
  642. 00:29:27
    the child, has If you know, if a child
  643. 00:29:29
    shows up sometimes with just vomiting,
  644. 00:29:32
    or they show up with altered mental
  645. 00:29:34
    status and or sometimes we also see kids
  646. 00:29:38
    that show up in arrest, who are
  647. 00:29:41
    actually all abusive head trauma herself,
  648. 00:29:44
    even outside of somebody presenting with
  649. 00:29:46
    a story of brain injury, thinking about
  650. 00:29:50
    that, but really asking does probing a
  651. 00:29:55
    lot of questions of what happened who
  652. 00:29:57
    was with the child. It's not our job to
  653. 00:29:59
    figure out. You know if this is abuse
  654. 00:30:03
    and trauma and who did it, but the
  655. 00:30:06
    initial history is really really
  656. 00:30:09
    important. Because if it changes over
  657. 00:30:11
    time, oris that the patient has you
  658. 00:30:16
    know a brain injury on imaging, but
  659. 00:30:18
    there is no history of trauma, and that
  660. 00:30:22
    is also really important, so I really
  661. 00:30:23
    think, and you know taking a really
  662. 00:30:26
    thorough history. documenting that
  663. 00:30:28
    history, and also your physical exam.
  664. 00:30:31
    So being very focused on, are there any
  665. 00:30:36
    bruises anywhere on the child? Is there
  666. 00:30:40
    any injury to, unfortunately, their
  667. 00:30:44
    perineal area, their rectal area,
  668. 00:30:47
    looking in their mouth? All those sorts
  669. 00:30:49
    of things are really important to
  670. 00:30:51
    document, to look for and to document
  671. 00:30:53
    on your exam. I think that's really
  672. 00:30:55
    helpful advice and pearls for
  673. 00:30:59
    rotators who may not spend a lot of time
  674. 00:31:00
    doing this kind of work. So what I
  675. 00:31:03
    heard you say, initially, when you're
  676. 00:31:05
    thinking about stabilization, you wanna
  677. 00:31:07
    make sure airway circulation and
  678. 00:31:08
    breathing are all the priority and that
  679. 00:31:10
    you have the right equipment, which I
  680. 00:31:11
    think
  681. 00:31:13
    is a challenge if this is not sort of a
  682. 00:31:16
    day in and day out sort of occurrence
  683. 00:31:18
    with pediatric patients. I love the
  684. 00:31:21
    advice of sort of aiming for a CPP
  685. 00:31:23
    greater than 50, at least sometimes
  686. 00:31:25
    greater than 55, in those younger -
  687. 00:31:27
    Relations, and in greater than sixty,
  688. 00:31:29
    when you're getting into that sort of
  689. 00:31:31
    teenage population that Moore has an
  690. 00:31:33
    adult physiology. Yep, I specifically
  691. 00:31:36
    was going to ask you. You know
  692. 00:31:37
    pharmacologically like dosing for
  693. 00:31:40
    pediatric patients is like quite
  694. 00:31:42
    challenging, and and again, I think we
  695. 00:31:44
    could spend a lot of time talking about
  696. 00:31:45
    that, but specifically when think about
  697. 00:31:48
    highbrows molar therapy? How do you
  698. 00:31:50
    kind of dose adjust for a small small
  699. 00:31:54
    human?
  700. 00:31:56
    Why also what we sow and ph. I think,
  701. 00:31:59
    unlike adults, and a lot of cases is
  702. 00:32:01
    all weight -based dosing, and some of
  703. 00:32:04
    them were talking about her brows
  704. 00:32:05
    Mueller Therapy, Is you know the two
  705. 00:32:08
    that generally or user hypertonic man at
  706. 00:32:11
    all, and it? It depends on what
  707. 00:32:18
    hypertonic solution you're using, so I
  708. 00:32:21
    think a lot of people use three per cent,
  709. 00:32:24
    but it's dependent on the level of. In
  710. 00:32:27
    the city of your fluid, but speaking
  711. 00:32:29
    about three percent, because I think
  712. 00:32:31
    that's what a lot of people use for a
  713. 00:32:35
    Bolus dosing, which is what we would
  714. 00:32:37
    initially use and you know if you're
  715. 00:32:39
    having a a spike in your ice and keep
  716. 00:32:42
    need Bolus dose, three to five ml per
  717. 00:32:47
    kilo, so anywhere three to five
  718. 00:32:51
    milliliters per kilo is a that lead the
  719. 00:32:54
    gas, and you can certainly just push,
  720. 00:32:57
    and that it doesn't have to be run over
  721. 00:33:00
    a certain time. The other thing that I
  722. 00:33:02
    am constantly reminding our staff is
  723. 00:33:05
    that you can give bolus doses of three
  724. 00:33:08
    per cent through a peripheral Id. You
  725. 00:33:10
    do not needs, and a central line to do
  726. 00:33:13
    that. You certainly don't want to give
  727. 00:33:15
    multiple bullets in is a runaway fusion,
  728. 00:33:17
    but you know if it's early in the case,
  729. 00:33:21
    and you're having a nice the crisis.
  730. 00:33:23
    It's certainly fine.
  731. 00:33:26
    talking about, you know, if you've
  732. 00:33:27
    given a couple of bolostoses and you're
  733. 00:33:30
    trying to maintain your sodium at a
  734. 00:33:32
    certain level, we use infusions of 3.
  735. 00:33:36
    And generally, we start those infusions
  736. 00:33:38
    at 05 to 1 ml per kilo per hour and then
  737. 00:33:46
    kind of titrate from there based on what
  738. 00:33:48
    our sodium levels are after that. We
  739. 00:33:52
    generally target sodiums if you're
  740. 00:33:54
    having ICP issues in the high 140s to
  741. 00:33:58
    150s. Certainly, once you get into the
  742. 00:34:02
    higher 160s, it does cause some issues
  743. 00:34:04
    with kidney function, pulmonary issues.
  744. 00:34:08
    So we generally stick to like 165 or
  745. 00:34:10
    less.
  746. 00:34:12
    Talking about manatol,
  747. 00:34:15
    so bolostosing manatol, we use 05 to 1
  748. 00:34:18
    gram per kilo per
  749. 00:34:25
    kilo per kilo per kilo per kilo per kilo
  750. 00:34:25
    per kilo per kilo per kilo per kilo per
  751. 00:34:25
    kilo per um what your osmas are um so
  752. 00:34:28
    checking your your osmas in your blood
  753. 00:34:31
    to make sure that your osmas aren't
  754. 00:34:33
    higher than three to money. Absolutely
  755. 00:34:37
    so similar guidance principles it just
  756. 00:34:39
    seems like you're using a much more
  757. 00:34:41
    weight-based approach which makes sense
  758. 00:34:43
    for yeah a range of you know tiny tiny
  759. 00:34:46
    children to you know a full-size
  760. 00:34:49
    adolescent um in terms of like more
  761. 00:34:54
    extensive management you know and adults
  762. 00:34:55
    we think about paralyzing sedating
  763. 00:34:57
    cooling are those things that you're
  764. 00:34:59
    doing in the pediatric population as
  765. 00:35:00
    well. Yeah absolutely so I would say
  766. 00:35:03
    especially for kids sedation is a huge
  767. 00:35:07
    thing and so we tend to start with an
  768. 00:35:11
    opioid and we actually use a lot of
  769. 00:35:15
    dexmetatomidine for kids. So typically
  770. 00:35:18
    we start with fentanyl and
  771. 00:35:19
    dexmetatomidine benzos I think
  772. 00:35:26
    A lot of pediatric intensive S try to
  773. 00:35:30
    stay away from a little bit just because
  774. 00:35:32
    it can cause pretty significant
  775. 00:35:34
    hypertension especially in the younger
  776. 00:35:36
    kids and so trying to avoid that, but
  777. 00:35:40
    yeah, we certainly sedation is a
  778. 00:35:43
    frontline Aicp therapy for us, and we
  779. 00:35:47
    will quickly move to using neuromuscular
  780. 00:35:49
    blockade as well for having Sep issues
  781. 00:35:53
    and kind of from there, and you know
  782. 00:35:59
    there have been several different
  783. 00:36:01
    hypothermia trials and pediatrics, all
  784. 00:36:04
    of which have been negative, and so we
  785. 00:36:06
    don't generally use cooling, and except
  786. 00:36:10
    for a kind of as like a third tier
  787. 00:36:12
    therapy. If we have refractory into
  788. 00:36:13
    perennial hypertension then we'll
  789. 00:36:16
    consider cooling, but the bigger thing
  790. 00:36:18
    that we focus on is making sure that
  791. 00:36:20
    they don't become subbarao which happens
  792. 00:36:23
    very frequently and our kiddos with T V
  793. 00:36:25
    I. Absolutely, and then I guess the
  794. 00:36:28
    final sort of thing to kind of ask you
  795. 00:36:31
    about. We know in adults, you know,
  796. 00:36:34
    there have been mixed results for
  797. 00:36:36
    decompressive hemichraniaectomies or did
  798. 00:36:38
    by frontal craniectomies. You know,
  799. 00:36:40
    maybe better literature supporting their
  800. 00:36:42
    use. If we look at two years out data,
  801. 00:36:46
    you know, that maybe this is something
  802. 00:36:48
    that we see a benefit really long-term
  803. 00:36:50
    from. What about the pediatric
  804. 00:36:53
    population? Like, is there evidence to
  805. 00:36:55
    support, you know, decompression and
  806. 00:36:59
    does biferental have a role or are those
  807. 00:37:01
    not really used?
  808. 00:37:04
    So I would say it depends on which
  809. 00:37:06
    pediatric neurosurgeon you're talking to.
  810. 00:37:11
    There isn't great literature in Pete's.
  811. 00:37:14
    There's an older study and by older, I
  812. 00:37:17
    mean like 23 years ago, looking at
  813. 00:37:23
    craniotomy in abusive head trauma and
  814. 00:37:25
    there was
  815. 00:37:27
    Good support for that and but I would
  816. 00:37:32
    say you know, certainly it is a third
  817. 00:37:35
    tiered therapy. You know, certainly,
  818. 00:37:37
    if right off the bat of the cake comes
  819. 00:37:39
    in, and already has pretty significant
  820. 00:37:41
    swelling, and or a large epidural or
  821. 00:37:44
    something along those lines, and I
  822. 00:37:47
    would say that we would go to Grenada to
  823. 00:37:49
    me right away. I think great now we sit.
  824. 00:37:54
    Sort of. You know. Either do it early
  825. 00:37:57
    because late doesn't seem to have
  826. 00:38:00
    anecdotally as much benefit,
  827. 00:38:03
    but I think it's really neurosurgeon
  828. 00:38:06
    dependent and pediatrics that I didn't.
  829. 00:38:09
    That's true of adults as well, and I
  830. 00:38:11
    think that this speaks to peanut a
  831. 00:38:12
    center where there is familiarity with
  832. 00:38:14
    ease with this type of pathophysiology
  833. 00:38:17
    and comfort in making is kind of complex
  834. 00:38:19
    decisions that don't have hard and fast
  835. 00:38:21
    evidence, but certainly have a role in
  836. 00:38:24
    some patients some of the time, yeah.
  837. 00:38:27
    Absolutely, it's always a conversation
  838. 00:38:30
    with our neurosurgeons and you know it
  839. 00:38:33
    back and forth and trying to figure out
  840. 00:38:34
    what the best route is for that
  841. 00:38:36
    particular child, absolutely, and I
  842. 00:38:39
    think that sort of brings us through,
  843. 00:38:41
    like I think some of the most important
  844. 00:38:43
    things in terms of how to take care of
  845. 00:38:45
    this really complicated pathophysiology
  846. 00:38:47
    and a, you know a small human, or
  847. 00:38:51
    maybe an adult sized human eye that has
  848. 00:38:53
    like a totally different physiology over
  849. 00:38:55
    the course of that that I age range.
  850. 00:39:00
    Are there any pearls that you would
  851. 00:39:01
    listen to you or like things that you
  852. 00:39:03
    think of when you see you know new
  853. 00:39:04
    providers trying to kind of work through
  854. 00:39:06
    this that you're like. Oh, this is one
  855. 00:39:08
    of the things that always want to impart
  856. 00:39:09
    with people
  857. 00:39:11
    and I think I would say you know it's I
  858. 00:39:16
    always said time he was brain, and so I
  859. 00:39:18
    think you know acting on these kids as
  860. 00:39:21
    soon as possible, you know when they
  861. 00:39:23
    come in through the trial away and
  862. 00:39:25
    getting them. to CT to see what's going
  863. 00:39:28
    on and whether they need to go to the OR
  864. 00:39:29
    right away or straight up to the PICU,
  865. 00:39:31
    I think.
  866. 00:39:33
    Acting quickly and trying not to be
  867. 00:39:35
    reactive. If you see your ICP starting
  868. 00:39:39
    to creep up, trying to get ahead of it
  869. 00:39:42
    as best as possible. The other thing I
  870. 00:39:45
    would say for pediatrics and TBI is be
  871. 00:39:49
    mindful of seizures. It is very, very
  872. 00:39:53
    common that we see traumatic seizures in
  873. 00:39:58
    kids, especially in our abusive head
  874. 00:40:00
    trauma population. So being mindful of
  875. 00:40:03
    that, and certainly if you're heavily
  876. 00:40:05
    sedating or neuromuscularly blocking,
  877. 00:40:07
    making sure that that child has an EEG
  878. 00:40:09
    in place. That's great advice. Dr.
  879. 00:40:13
    Miller Ferguson, thank you so much for
  880. 00:40:15
    joining us. This has been just like,
  881. 00:40:17
    I've actually learned quite a bit. This
  882. 00:40:19
    is hopefully something
  883. 00:40:23
    that brings our listeners a little bit
  884. 00:40:24
    more familiarity with the process that I
  885. 00:40:26
    imagine can be. intimidating if this is
  886. 00:40:28
    not something that you're doing day in
  887. 00:40:29
    and day out. So thank you again so much
  888. 00:40:32
    for joining us. Oh, thank you. It was
  889. 00:40:34
    a pleasure. All right, until next time
  890. 00:40:36
    guys. Bye Bye.