Questions - PediatricNCC

1) At what level of ICP do most physicians initiate treatment for intracranial hypertension in pediatric traumatic brain injury?

10 mmHg
15 mmHg
20 mmHg
25 mmHg

Explanation: The most recent guidelines (Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies) supports the use of less than 20 mm Hg as an initial ICP target in all age groups and also supports the need for an intervention when ICP is raised greater than 20 mm Hg for at least 5 minutes.

2) The most reliable clinical examination finding that predicts a poor outcome?

Absent pupillary light reflexes
Poor GCS
No motor movement
Inabilty to separate from mechanical ventilator

Explanation: Absence of pupillary light reflexes is the most reliable examination finding for predicting a poor outcome. Motor responses (and thus GCS) can be affected by the lingering effects of sedative and analgesic medications, so they have higher false-positive rates, especially within the first 72 hours. MV reliance is not a sensitive marker.

3) Compared to mannitol, hypertonic saline has been demonstrated to:

Decrease cerebral blood flow more than mannitol
Have a longer duration of action
Have a greater risk of nephrotoxicity
Decrease intracranial pressure (ICP) more than mannitol

Explanation: In a study by Battison et al (PubMed), median ICP reductions were greater using hypertonic saline solution versus mannitol infusion, with the mean ICP reduction of 13 mmHg for hypertonic saline versus 7.5 mmHg reduction with mannitol.

4) Central DI is characterized by:

Increased urine osmolality in the presence of hypernatremia
Decreased urine osmolality in the presence of hypernatremia
Decreased urine osmolality in the presence of hyponatremia
Increased urine osmolality in the presence of hyponatremia

Explanation: DI is a common anticipated complication following trans-cranial operation. This occurs due to injury to the pituitary stalk or hypothalamus, resulting in decreased anti-diuretic secretion and diminished ability to concentrate urine. It is characterized by increased UOP output (≥4 mL/kg/h) of dilute urine (<300 mOsm/kg).

5) Time (t1) when a Tonic-Clonic (TC) seizure is likely to be prolonged leading to continuous seizure activity and time (t2) when a TC seizure may cause long term consequences:

t1 = 5 mins, t2 = 30 mins
t1 = 10 mins, t2 = 60 mins
t1 = 5 mins, t2 = 60 mins
t1 = 10 mins, t2 = 30 mins

Explanation: Status Epilepticus (SE) is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms which lead to abnormally prolonged seizures (after time point t1). It is a condition that can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures.

For Tonic-Clonic (TC) SE, t1 is 5 mins and t2 is 30 mins.
For Focal SE with impaired consciousness, t1 is 10 mins and t2 is >60 mins.
For absence SE, t1 is 10-15 mins and t2 is unknown.

See "A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus" by Eugen Trinka published in Epilepsia 2015.