Thalasemic child with non accidental extr dural Hematoma

1. CLINICOPATHOLOGICAL
CONFERENCE
BY:
Dr.Inayat Ullah
PGY-III Paediatrics
Shifa International Hospital Islamabad.

2. Case:
A Thalassemic child with Extra Dural
Hematoma

3.  Name: A.B.C
 Age: 11yrs 5 months
 Gender: Female
 D.O.A: 01/01/2017
 T.OA: 1800 Hrs PST
 Address: Attock City
 M.O.A.: Via ER

4. Presenting Complaints:
 Known case of thalassemia major on
monthly regular transfusion and oral
chelation therapy presented with
 Drowsiness………….1 day
 Irritability…………..3 hours
 Vomiting……………..2 episodes

5. History Of Presenting Illness:
 11 year old Thalassemic girl on regular Monthly
transfusion and oral chelation therapy
presented via ER with history of drowsiness for
1 day, Irritability for 3 hours followed by 2
episodes of vomiting before arrival to Hospital.
 She was having associated irritability, stool and
urinary incontinence.
 She had an uneventful PRBC’s transfusion 1 day
before admission

6. Systemic inquiry:
 No fever
 No fits
 No rash
 No bruises or petechiae
 No flu or cough
 No history of trauma or fall
 No history of drug ingestion

7. Vitals in ER:
 Age: 11 yr 5 months
 Weight:29 kg
 Height:ND
 Vitals:
 HR:108 bpm
 RR:22bpm
 B.P:120/55 mmHg
 BSR:151 mg/dL

8. On Examiantion:
Drowsy, irritable with Equally reactive pupil
Chest: Equal A/E no added sounds
CVS: S1+S2+0
GIT: Liver palpable, No distension or
tenderness BS+
CNS: GCS: 09/15 Rt upper & lower limb
power 2/5
PERLA.
DTR normal

9. Differential diagnosis
 Meningoencephalitis
 Sepsis
 Stoke (thromboembolic phenomenon)
 Plan: CBC Diff, CRP CHEM 7, ALT, BLOOD
C/S CT Brain with contrast in plan.

10. PICU Arrival
 GCS: 9/15
 General conditions were same
 Plan:
 Pass 2 iv lines, intake/output monitoring
 Repeat N/S bolus, then 2/3rd maintenance fluid
 ABG’s PT/APTT, NH3, Lactic acid
 IV Ceftriaxone, IV Acyclovir, FFP’S transfusion,
Norepinephrine if B.P low, CT Brain with
contrast, pass foley’s send UA & C/S.

11. LABS ON 01/01/2017
Hb 13.4 Na 135 ALT 70
WBC 7700 K 4,3 CRP 43
Platelets 194000 HCO3 26
PT/INR 41.1/3.6 CL 101
APTT 4100 BUN/UREA 17/37
NH3 60 CREATININ 0.32
Lactate 16 BSR 176

12. URINE TOXICOLOGY
Cannabinoids Negative
benzodiazepines Positive
opiates Negative
barbiturates Negative
Cocaine Negative
Methadone Negative
Methamphetamine Negative
Phencyclidine Negative

13. CT Brain with contrast
Large epidural hemorrhage in left parietal region with mass effect on adjacent
brain parenchyma and midline shift towards left. Thickened calvarium. Scalp soft
tissue swelling and subgaleal hematoma in the left parietal region.

14. Neurosurgical opinion1/1/17
2345 Hrs
 Reviewed CT Brain and advised:
 Need for urgent craniotomy and hematoma
evacuation
 Normalise INR to 1.0
 Will need 5 units FFP’s in hand for surgery
 Low dose Mannitol
 OR Booking & high risk consent
 Keep head end up 40 degree.

15. Elective intubation 1/1/17 2300Hrs
 She was electively intubated as well for
impending surgery
 ETT 5 Fr @ 15cm
 AC/VC
 VR: 20bpm
 TV: 300 ml
 PEEP: 5 cm H2O FiO2: 100

16. 02/01/2017
 She was transfused 3 units of FFP’s
 Had an episode of self extubation after
which she was re-intubated.
 Had bloody aspirates via ET.
 Given vit-k and repeated FFP’s transfusion
 CXR done
 Acyclovir discontinued
 IV Omeprazole added, 2/3rd maintenance
IV Fluid and urgent NS intervention.

17. LABS 02/01/2017
Hb 9.4 Na 142
WBC 5600 K 3.8 CRP 41
Platelets 144000 HCO3 26
PT/INR 11.3/1.3 CL 101
APTT 36 BUN/UREA 17/37
NH3 60 CREATININ 0.32
Lactate 16 BSR 167

18. 02/01/2017 1300 Hrs
 Shifted to OR for surgery
 Received @ 1630 Hrs from OR post
craniotomy and hematoma evacuation
 On vent AC/VC Rate;28 Tv;290 ml
 Fio2 100 PEEP 4
 Sedation midazolam @ 3mic/kg/min
 Relax with atracurium @ 0.3 mic/kg/min
 2 PRBC’s 2 Platelets and 2 FFP’s transfused in
OR

19. Post-op plan 2/1/17 1430 Hrs
 IV Vancomycin @ 15mg/kg/dose Q6H
 IV Ceftriaxone 100mg/kg/day÷ BID
continued
 IV Fluid @ 2/3rd Maintenance
 IV Paracetamol @ 15mg/kg/dose Q6H
 IV Tranexamic acid 250 mg TDS.

20. Post-op reassesed @ 1730 2/1/17
 Keep ventilated, sedated and paralysed
 PRBC’s transfusion as planned
 Vitamin-k 5 mg IV stat
 FFP’s transfusion accordingly

21. 03/01/2017 0900 Hrs AM Round
 Wean off atracurium
 Wean off midazolam
 Switch to SIMV Mode
 Trial of extubation in evening
 2/3rd maintenance fluid
 Neurosurgical review

22. 03/01/2017 Neurosurgeon Review
 Advised repeat post-op CT
 After reviewing CT Brain they told patient
hematoma had been successfully
evacuated and you can proceed
extubation if she is stable clinically

23. Post-op CT Brain 03/02/2017

24. Post-op CT Brain report 03/01/2017
 Comparison is made with patient's previous CT performed on 01/01/2016.
 Patient is status post left parietal craniotomy with a drain in the left
extra-axial hemorrhage, mild scalp edema and overlying scalp staples.
There is significant interval reduction of the left extra-axial hematoma
with maximum thickness of about 15 mm near vertex. There is an interval
reduction in mass effect and midline shift, only residual mild mass effect
with effacement of cortical sulci in left frontoparietal lobes is noted.
 No midline shift is seen, in the current scan. There is persistent mild
subdural hemorrhage along the midline falx appears to be slightly
increased in interval. Bilateral ventricles are decompressed in the
interval.
 There is moderate opacification of paranasal sinuses more in sphenoid
sinus in interval. Rest of the findings are unchanged.

25. 03/01/2017 1930 Hrs
 Extubation in plan
 Patient off sedation and paralytics on SIMV
mode of ventilator
 Had an episode of desaturation, bradycardia,
and cyanosis on ventilator
 Immediately umbu bagging done and copious
secretion were removed on suction
 Extubation was postponed to next day
morning and patient kept sedated and
paralysed

26. 04/01/2017 0900 Hrs
 Early morning extubated after discontinuing
sedation and paralysis
 Serial labs followed which were in normal
range
 Nebulized with N/S and epinephrine
 Kept NPO for 6 hours
 2/3rd maintenance IV fluid continued
 PRBC’s Platelets and FFP transfusion were
planned
 Physiotherapy to be started

27. 04/01/2017 post extubation
 On nasal canula O2 @2 lit/min
 GCS 14/15
 02 saturation 95% HR 117bpm RR 32 bpm
 BP 130/80 mmHg
 CNS: Tone: Normal, Reflexes: Normal
 Power: Right Upper and Lower limb 3/5
Left Upper and Lower Limb 5/5

28. 05/01/2017 0830 Hrs
 Remained stable overnight
 Conciousness improved, husky voice
 GCS: 15/15 Sats: 98% with 2lit/min O2 BP
120/70mmHg, Power in Rt sided upper and lower
limbs4/5(improved) left sided 5/5
 Plan: Discontinue NGT, Start PO blenderized diet,
D/C Foley’s, Neuroobservation and physiotherapy.
 Plan to send Factor V,VII,X assay to AFIP.

29. 05/01/2017 1700 Hrs
 Reviewed
 Awake, concious, and slightly wobbly
 Vitals normal
 Plan: was to
 Wean off oxygen
 Encourage oral intake

30. 06/01/2017 0500 Hrs
 Had complain of headache
 O/E B.P158/92 mmHg rest of vitals normal
 IV Hydralazine and IV Paracetamol given
and repeat neurosurgery consult sought
after discussing with primary
 CT Brain repeated on recommendation of
neurosurgry collegues
 Repeat CT came out to be normal

31. 06/01/2017 0830 Hrs
 Had an episode of headache overnight and
complained of dizziness
 O/E Vital Normal except BP 141/91 mmhg
 GCS: 15/15 Power right side upper and
lower limb 4/5 and was able to stand.
 Plan was to continue antibiotics,
analgesia, and physiotherapy and do USG
Abdomen

32. 06/01/2017 2000Hrs
 On off headache
 BP in high range 160/75 mmHg
 USG Abd: Mild Hepatosplenomegaly and
minimal abdominpelvic ascites
 Plan: Add regular IV Hydralazine @ 0.2
mg/kg/dose Q4H Labetalol IV PRN
 Continue rest of Tx Antibiotics, analgesics,
& physiotherapy

33. 07/01/2017 0830 Hrs
 Had headache and raised BP
 Otherwise remained well
 Vital on room air Spo2:100 % BP 110-150
Systolic and 70-90 mmHg diastolic
 CNS: well coordinated gait, intact CN’s
and power in all limbs 5/5
 Plan: continue ABX, antihypertensives,
physio, repeat PT/APTT and discontinue IV
Fluid

34. 08/01/2017 0955 Hrs
 Remained uneventful, hemiparesis
resolved and was doing self care
 O/E: GCS: 15/15 Power in all limbs 5/5
Gait normal and CN intact.
 Plan: transfer to room, continue
ceftriaxone and vancomycin, Discontinue
IV Mannitol, Omeprazole and Tranexamic
acid IV Paracetamol
 Space out IV Hydralazine Q8H if BP in
noraml range

35. 09/01/2017 0900 Hrs
 Remained stable in past 24 hours
 Systemic exam unremarkable
 Plan: stop IV Labetalol, switch to oral
hydralazine, stop antibiotics ceftriaxone
and vancomycin
 Neuro Observation, GCS, Vitals Q4H
 Encourage orally

36. 10/01/2017
 Remained clinically stable
 No active complaint over 24 hours
 Plan: Discharge Home on
 Oral desferrosirox (Asunra) 400 mg
 Follow-up 5/7 days

37. EXTRADURAL HEMATOMA

40. EPIDURAL HAEMATOMA
•It is a collection of blood between the potential
space that exists between the inner table of skull
and the dura (periosteal layer).
•Extension of hematoma usually is limited by the
suture lines owing to the light attachment of the
dura at these locations (continuation of
periosteal layer of the dura with the pericranium
at the sutures)

42. HEAD INJURY
•DEFINITION –a history of a blow to the head or the presence of
a scalp wound or those with evidence of altered consciousness
after a relevant injury’.
• The level of consciousness as assessed by the Glasgow Coma
Scale

44. SYMPTOMS
 Neonates: Asympyomatic: open
fontanelles in these patients permit
expansion of the skull volume with
accumulation of the EDH. Thus, initial
findings are nonspecific
 Can occur infant< 3 mo age with relatively
minor mechanism of injury
 Scalp hematoma provides clue to
underlying EDH.

45. Symptoms in neonates
 ●Irritability
 ●Anemia
 ●Cephalohematoma
 ●Vomiting
 ●A bulging anterior fontanelle
 ●Lethargy
 ●Coma
 ●Seizures
 Seizures and hypotonia are frequent presenting signs
in neonates
 Hemorrhagic shock

46. Symptoms in older children
 An EDH should be suspected if there is a
witnessed deterioration in neurologic status
at any time after a head injury
 Children may present with varying degree of
concious level and GCS

47. Older children S/S
 ●Mild to moderate signs and symptoms -Often
neurologically intact.Common symptoms include headache,
vomiting, or irritability.
 ●Severe signs and symptoms –Large hematomas often are
comatose (GCS ≤8 or rapidly changing level of
consciousness). These patients warrant urgent surgical
evacuation.
 Lateralizing neurologic signs (eg, anisocoria, hemiparesis,
hemiplegia) arising from compression of the third cranial
nerve and brainstem may also be present. These findings
are indicators of impending uncal herniation. The side of
the dilated pupil matches the side of the hematoma in
roughly 90 percent of cases.

48. Uncal Herniation
 The constellation of
 Systemic hypertension,
 Bradycardia, and
 Respiratory disturbance (Cushing triad) is
another late sign associated with cerebral
herniation.

49. Lucid interval
•An epidural hemorrhage is often characterized by the
following sequence of events:
Blunt trauma/ a blow to the head, followed by:
1) Initial confusion, decreased consciousness, or loss of
consciousness
2) A “lucid interval” (37-60%):
a brief period of full conciousness/restored mental status. The
patient seems back to his/her “normal self.”
3) Change in mental status +/- unstable vital signs (blood pressure,
heart rate):
the patient becomes confused, somnolent (sleepy), may have
neurologic signs such as hemiparesis, one dilated pupil, may become
comatose.

50. Posterior fossa EDH 3-27 %
 Assoc occiptal fracture 78-90 %
 Initial LOC, Headache and vomiting
 May have dizziness, stiff neck, dysmetria,
cerebellar signs or pyramidal signs
 They can deteriorate rapidly with lethal
outcomes due to compression of the
brainstem or by hydrocephalus secondary
to 4th ventricular obstruction

51. Imaging
 Imaging of the head is essential to rapidly
make the diagnosis of epidural hematoma
(EDH).
 In most centers, computed tomography is
the study of choice, but rapid magnetic
resonance imaging (MRI) will also
accurately detect the blood clot, although
is less likely to demonstrate a fracture.

52. Labs
 To assess for anemia or coagulopathy and to prepare for
potential surgery,
 ●Complete blood count with platelets
 ●Prothrombin time (PT)
 ●Partial thromboplastin time (PTT)
 ●International normalized ratio (INR)
 ●Type and cross
 Other studies (eg, AST, ALT, and urinalysis) are also
typically obtained in patients with multiple trauma,
depending upon specific findings
 Lumbar puncture is contraindicated in cases where a space
occupying lesion such as EDH is suspected, due to the risk
of herniation

54. Initial management
 A rapid overview provides the clinical features,
diagnostic evaluation, and emergent management
for epidural hematomas in children
 ●A - Airway maintenance with cervical spine
protection
 ●B - Breathing and ventilation
 ●C - Circulation with hemorrhage control
 ●D - Disability (evaluation of neurologic status)
 ●E - Exposure (complete visualization)/
environmental control (prevention of hypothermia)

55. Neurosurgical consultation
 Any child with an EDH and any pediatric
trauma patient with a GCS ≤12 warrant
prompt consultation by a neurosurgeon.
 When EDH is associated with neurologic
decompensation, then rapid evacuation of
the hematoma is the primary therapy

56. Indication for craniotomy and
hematoma evacuation
 ●Altered mental status, especially rapidly
worsening GCS or a GCS ≤8
 ●Signs of increased ICP (eg, vomiting, severe
headache, irritability, bradycardia, or
hypertension)
 ●Pupillary abnormalities or focal neurologic
findings
 ●Cerebellar signs (patients with occipital
injury)
 One or more sign prepare patient for
craniotomy

57. Radiographic criteria for surgical
intervention
 On head CT suggest the possible need for
surgical evacuation
 ●Temporal location (arterial bleeding can
lead to rapid decompensation due to uncal
herniation and brainstem compression when
the hemorrhage is in the temporal fossa)
 ●Large size (EDH thickness >10 mm)
 ●Midline shift

58. Conservative management
 Children managed nonoperatively should only
be observed if experienced pediatric trained
personnel can monitor for neurologic changes.
 Patients with GCS ≤8 should have continuous
intracranial monitoring of ICP during
observation .
 In addition, 24 hour emergency access to head
CT and a properly equipped OR are essential,
because deterioration can occur at any time.

59. Repaet CT
 After 24 hrs to look for size of hematoma
 Earlier if patient deteriorates neurologically.
 Asymptomatic patients with small,
nonprogressive EDH on head CT can be safely
discharged from the hospital in 24 to 48 hours
after injury
 Teach alarming signs for return: vomiting,
headache and altered mental status
 Resorption of hematoma: 1 month

60. Favorable outcome signs
 Good GCS at presentation
 Less time between neurologic
deterioration and surgical evacuation
 Pure EDH without assoc lesions
 No pupillary change associated at
presentation and after suregry.