Hyperventilation In The Pediatric Blunt Head Trauma Patient

[Guest Training123]

Hi, all,

Do you think this pt should be hyperventilated?

12 year-old boy falls off his bike, suffers blunt head trauma. While assessing his breathing, you see signs of herniation.

Which of the following ventilation rates is appropriate in this situation? 10 breaths/min 20 breaths/min * 30 breaths/min 35 breaths/min

OR

Should patients no longer be hyperventilated? Should this patient should be ventilated at a rate of 10-12/min.?

Thank you

T123

Sources/references helpful

[ny10570 745]

Intubate the patient and maintain an end tidal CO2 between 30 and 35 mmHg. The issue with unmonitored hyperventilation is we tend to ventilate too aggressively and wind up depriving the brain of blood.

[FFFORD 27]

hyperventilation is still part of ER treatment for signs of ICP/herniation. you want to achieve a PCO2 of 30. it creates cerebral alkalosis and reflex vasoconstriction of arterioles leading to decreased cerebral blood volume. However in this case hyperventilation is contraindicated. Hyperventilation is not to be used within the first 24 hours of onset of herniation. you also need to be able to monitor ABGs.

Other treatment for herniation is sedation (propofol or fentanyl) especially if the patient is agitated. you can also use diuretics (mannitol) if they have normal renal function, Barbituates (decrease o2 demand of the brain) 10mg/kg load and then titrate to 1-3mg/kg/hr. At the hospital they might do surgery as another option.

Source - PA school -

Edit - it is not contrainticated, I just looked back in my notes. It says, "try to avoid in the first 24 hours"

Edited December 14, 2010 by FFFORD

[x635 4,066]

If you're lucky enough to have a vent, use that. Normal, consistent ventilation and rapid transport works best. That, if at an appropriate distance, is a good reason to use an helicopter because most carry vents. ny10570 hit the nail on the head-but as we all know, the academic community changes things all the time for us with "studies".

In Texas, some systems carry Manitol or some other experimental drug which is escaping me right now.

[Goose 188]

Agree w/ Ny10570.

[FFFORD 27]

Agree w/ Ny10570.

I do as well if there is no other means in this situation.

[NJMedic 96]

I posed that same question to our EMS Medical Director, also a paramedic and here is his response...

Ok so you want me an answer this question in 10,000 words or less? I

will try to be concise

It is really what I want the ETco2 to be. The question is what do I want this number. I would pick a number and have someone bag as fast or slow as necessary to achieve this number. Really it depends on the patient lung status, tidal

volume, degree of things like COPD to determine the degree of ventilation to get to a certain Etco2. In general I want the Etco2 nowadays in a traumatic brain injury patient of any age to be 35-40 which is not considered hyperventilation.

H

yperventilation is considered any Etco2 below 30mmhg and not really a rate. The concept of hyperventilation being "bagging fast" is really a false notion. For example a co2 retainer for any cause may need a ventilation of 30 to get the etco2 down. Sombody who is breathing shallow but then doing better will need various rates of ventilation.

So if the patient starts herniating and I dont have available hypertonic saline and mannitol which is what I would normally give first, I would hyperventilate to an Etoc2 of approximately 30mmhg.

If the patient was really herniating as determined by acutely dilated pupil I would do hypertonic and mannitol and

hyperventilation all at once. This is the only pt by the way that the literature suggests is ok to hyperventilate

If this patient could not have Etco2 and did not have a unilaterally dilated pupil I would tell people to bag at 10 breaths per minute.

[RNEMT26 40]

As far as field treatment goes, medics dont have invasive hemodynamic monitoring there is not much you can do. If the kid is herniating then it's time for surgery, however by the time s/s of herniation are detected it's already too late. Also depends on the type of herniation (central. uncal, subflacine), if it's a central then good luck with that one. I haven't seen many people come back from those, they usually end up being veggies, trached/peg'ed and off to the nursing home, sounds like fun right? Not the way I'd wanna live.

I honestly don't think that medics should carry mannitol, do you know what the ICP is that ur treating? Sounds dangerous to me. In my ICU we aren't treating with mannitol until they are 15 or so and no coming down with drugs (propofol/Fentanyl/ativan) We usually snow these kids down as far as we can get them, they are usually max at 50mcg/kg/min of propofol and whatever we can give them. We don't often use hyperventilation off the bat, but we attempt to keep the PCO2 near 30.

So how do you help this kid. 1. Pray and 2. Get him to a level 1 trauma ASAP because he needs an emergency craniotomy.

Hypercarbia (high CO2) = Vasoconstriction, less blood flow

Hypocarbia (low CO2) = Vasodilation, more blood flow

[FFFORD 27]

+1 RNEMT - only one you missed was a tonsillar herniation lol.

[RNEMT26 40]

Thank you thank you and yes you are right (should have put an etc on the end of that) but i wasnt going to name all 6, most people wont know what the hell they are....lol