Status Asthmaticus Brain EdemaCompression Daxa Clarke MD Phoenix

Status Asthmaticus Brain Edema/Compression Daxa Clarke, MD Phoenix Children’s Hospital Pediatric Resource Group

Asthma Facts 5. 5 million (7. 5%) children in the US have asthma CDC. gov More than 50% of these children have at least one exacerbation in the prior 12 months

Status Asthmaticus

Baseline Severity of Asthma Severity Symptoms Mild Intermittent Daytime sxs <= 2 days/week Night awakening <=2 times/month Normal FEV 1 Exacerbation <=1/year Mild Persistent Daytime sxs >2 and <7 days/week Night awakening 3 -4 times/month Minor interference with activity Normal FEV 1 Exacerbation >= 2/year Mod Persistent Daily sxs Night awakening >1/week Daily use of short-acting beta agonist (SABA) Some activity restriction FEV 1 60 -80% predicted Exacerbation >=2/year Severe Symptoms all day Nightly awakening Use of SABA mult times per day Extreme limitation in activity FEV 1 <60% predicted Exacerbation >=2 /year National Asthma Education and Prevention Program: Expert Panel Report 3 (NAEPP-EPR 3; 2007)

Exacerbation vs. Status Asthmaticus Exacerbation Status Worsening of symptoms followed by improvement with treatment Worsening of symptoms with minimal improvement with treatment Requires continuation of treatment Requires continued escalation of treatment

Consider the diagnosis “Status Asthmaticus” when Symptoms/ History PE Findings Respiratory Distress Tachypnea Failed treatment with albuterol at home Retractions Hx asthma or reactive airway disease Head bobbing Nasal Flaring Hx prematurity/BPD Wheezing FHx asthma Recent illness Hx Allergies/Eczema Tri-podding Associated Diagnoses Plan Reactive Airway Disease Continuous Albuterol Wheezing Associated Respiratory Illness (WARI) IV Corticosteroid IV Magnesium Sulfate Asthma: Mild Int, Mild Perst, Mod, Severe PICU Admission Acute Exacerbation Terbutaline Hypoxia AMS Respiratory Failure Positive Pressure Ventilation

Brain Edema/Brain Compression

Etiology Edema Compression Vasogenic Vascular • Related to breakdown of BBB • Hemorrhage Cytotoxic • Metabolic Osmotic • Water Hydrostatic • Water and electrolytes Infectious • Abscess Neoplastic Trauma Other • Hydrocephalus

Consider the diagnosis “Brain Edema” when Symptoms CT/MRI Findings* Confused Brain swelling Disoriented Effacement Headache Herniation Poor coordination Lethargic Vomiting Swollen gyri Poor differentiation of gray and white matter *Radiographic imaging not required. Associated Diagnoses Head Trauma Plan Mannitol High Altitude Malignant Hypertension Anoxia Brain Tumor with localized edema Brain Infarct/injury with localized edema Decadron Controlled hyperventilation Controlled hypothermia DKA Meningitis Hyponatremia/ Hypernatremia Status Epilepticus Decompressive craniotomy 3% Sodium Solution

Consider the diagnosis “Brain Compression” when Symptoms CT/MRI Findings* Diagnosis Confused Mass effect Hydrocephalus Disoriented Headache Poor coordination Lethargic Vomiting Plan Elevated Head of Bed Shunt Placement Mid-line shift VP shunt malfunction Increase ventricle size Effacement Shunt Revision Decompression Brain tumor/neoplasm EVD placement Tumor Resection Herniation *Radiographic imaging not required. Intracranial hemorrhage (ICH) Evacuation of ICH

Contrasting BE and BC Edema Compression Symptoms: HA, vomiting, confusion, lethargy Something causing brain to swell: trauma, meningitis, electrolyte shifts, water shifts Something causing pressure in areas of the brain: tumor, bleeding, large ventricles, abscess Radiology: swollen gyri, effacement Radiology: midline shift, mass effect Medical management Medical and surgical management

Contact Daxa Clarke, MD @daxaclarke dclarke@phoenixchildrens. com Pediatric. RG. com Pediatric Resource Group