Pediatric emergency medicine trisk 3645 3645

semirigid cervical collar or inline manual stabilization If intubation is determined to be necessary, endotracheal intubation is the preferred method Evaluation by a neurosurgeon is preferred prior to intubation with neuromuscular blockade, but there should not be any delay in obtaining an advanced airway Patients should be preoxygenated, and lidocaine should be utilized as a pretreatment medication Atropine is no longer considered to be standard of care for pediatric rapid sequence intubation, and special consideration must be taken with this population as it can mask bradycardia secondary to increased ICP Lidocaine at to mg/kg of weight with a maximum of 100 mg is used to prevent potential increased ICP by blunting airway reflexes Rapid sequence intubation includes administration of medications for sedation and paralysis Sedative medications should be used to decrease airway responses and keep the patient comfortable (Refer to Chapter Airway ) Preferred medications for the child in whom a head injury is suspected include etomidate and midazolam Etomidate has minimal cardiovascular effects and is used effectively in patients with hemodynamic instability, thus providing neuroprotection The typical dose of etomidate is 0.3 mg/kg of weight Midazolam has minimal effects on systemic arterial pressure with typical dosage of 0.1 to 0.3 mg/kg of weight Neuromuscular blockade and paralysis may be achieved with rocuronium at doses of 0.6 to 1.2 mg/kg of weight or succinylcholine at doses of to mg/kg of weight There is no available outcome data regarding the use of sedatives and paralytic medications in children with ciTBI, and their use should be tailored to the individual patient Noninvasive maneuvers also should be standard management to decrease ICP The head of the bed should be elevated to 30 degrees, the head should be kept in a neutral position while maintaining cervical spine immobilization, ventilation to maintain PaCO2 at 35 to 40 mm Hg, continuous sedation infusion to prevent complications after intubation and agitation There is no evidence to support or refute the use of brain oxygenation monitoring, transcranial Doppler, cerebral microdialysis or near-infrared spectroscopy (NIRS) in conjunction with ICP monitoring Aggressive hyperventilation should not be the standard as an initial therapy; however, it may be necessary acutely for refractory intracranial hypertension and to prevent cerebral herniation