Cerebral oedema

Cytotoxic vs vasogenic (resistant to steroids) vs interstitial (obstruction eg meningitis – not steroids, ?osmotic) vs osmotic (CSF, ECF low osmo) vs hypertensive.

In DKA, there is a 25% mortality from cerebral oedema, 34% long term neurodisability. 

Presents with headache, irritability, agitation (which can be difficult when child is unwell with something else).  Then altered consciousness, posturing, focal neurology (check eye movements, pupils).  Classically Cushing’s triad: hypertension, bradycardia, irregular breathing pattern.

Clinical diagnosis really.  CT can show (better than MRI!).

Hypertonic saline (2.7 or 3%, 2.5-5ml/kg over 10-15 mins) or mannitol (20%, 0.5-1g/kg over 15 mins), some people prefer hypertonic saline but whatever is closest to hand!  Frusemide adjunctive.   

Consider Aciclovir if diagnosis unclear (in case herpes encephalitis – CT not great, LP can be non specific).

Brain protection = 30deg head up, midline position. Avoid hypotension. Avoid hypocapnia (intubate and ventilate if in doubt).

Hyponatraemia common – typically due to SIADH but treat any underlying cause, esp hypovolaemia.