TYK257

A 10 year-old boy presents to the emergency department following a 20 foot fall from the balcony of a house. The boy was unresponsive at the scene and arrives with a GCS of 5. Initial vital signs include a BP of 140/65, HR of 60, RR 16, and SpO2 of 97% in 100% oxygen via facemask. The decision to immediately intubate in the trauma room is made. Which of the following best describes the most appropriate management for this patient?

a) The patient’s hypertension should be treated with a direct acting vasodilator

b) Succinylcholine may be administered to ensure the airway is intubated quickly and efficiently

c) Following intubation, the patient may be ventilated at a rate to achieve normocapnia

d) Fluid resuscitation should be limited due to concern for worsening cerebral edema and increasing intracranial hypertension with fluid overload

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Answer

Answer b. The patient presents with clinical findings suggesting acute intracranial hypertension that require immediate surgical intervention to prevent neurologic catastrophe. The mechanism of injury necessitates cervical spinal immobilization with a rigid collar, which may make intubation more challenging by inexperienced providers, especially if there is accompanying facial trauma obscuring the airway. Succinylcholine is an appropriate paralyzing agent to use to facilitate intubation, and immediate hyperventilation to a goal end-tidal CO2 of 30 mmHg is indicated. Fluid resuscitation is often also required due to volume depletion that may be due to underlying trauma. Anti-hypertensive drugs are not indicated, as CPP will be compromised by lowering the MAP.

Notes

This question originally printed in the Pediatric Anesthesiology Review Topics kindle book series, and appears courtesy of Naerthwyn Press, LLC.

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