Cerebral edema without increased ICP?

  1. This question pertains strictly to near drowning. My son suffered an anoxic brain injury 2 yrs ago from a near drowing and nothing was done to relieve the edema or the increased ICP. No drugs...nothing. They didn't even measure is ICP. Told me there was no use since there was nothing they could do and he would probably die by morning anyway. Some trauma docs have such lovely bedside manner. This was a level 1 pediatric trauma doc. Think he could have had a little more compassion?? He made the decision on his own that my son wouldn't recieve treatment for his brain injury. I have the doctor's notes. It makes me sick that he was just going to provide supportive measures but no treatment and allow my child to die.
    I do know now that there were things they could have done, but at the time I was not a nursing student....just a mom. He only got the code drugs....epi, atropine, lidocaine, bicarb. No diuretics....no Mannitol...nothing. He did get fentanyl and versed though when the decerebrate posturing started.
    Another mom of a near drown told me the docs told her that swelling is not the only problem....only if ICP is involved. If increased ICP is involved then there are things they can do like surgery. Since anoxia causes global injury and edema, not localized like a TBI would, how could any surgery or, in this mom's words "techniques" be done that would help?
    Is it possible to have cerebral edema without increased ICP? Seems to me the edema from lack of oxygen would cause the increased ICP in a near drowing incident. Or is there something else, other than edema from anoxia, that could cause the increased ICP in near drowning? Sorry to ramble, but her statements just didn't make sense to me. I haven't, and won't question this mom on this, but I'd like to make sense of it. I suppose if there was minimal edema that ICP may not be an issue, but most of these kids suffered massive edema. I hope I'm making sense trying to explain this!
    Thanks a lot for any info,
    Kim
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  2. 11 Comments

  3. by   BadBird
    Kim,
    I am so sorry for the loss of your son. I do not know exactly what type of surgery your friend was talking about but perhaps the Dr. mentioned burr holes to relieve pressure on the brain and prevent or correct herniation.
  4. by   OHmom2boys
    I'm sorry, I just realized I never said Thank You for answering this question.
    I don't know what this mom was talking about either. I never thought they would use burr holes for global edema, but who knows? I don't!
    I also didn't mean to imply that my son died. I just re-read what I posted and your reply and realized that's exactly what it looks like. Jacob is doing very well considering his injury. He was anoxic for at least 30 minutes. Full arrest when paramedics arrived. Pupils fixed and dilated at 6mm. But his core temp on the scene was 78 degrees. That saved him. He was not expected to live through the night, which is why I think the doctors didn't get real aggressive with the treatments. But he showed them! He's doing well phsyically. His problems are mostly cognitive. I miss the son I left that day when I went to work, but I thank God every day for the son I have now.....however different he may be from before.
    Thanks again for your reply Badbird, and I'm sorry I didn't thank you sooner.
    Kim
  5. by   mbrian46
    Some measures used for global edema would be a decompressive craniotomy, in which they would temporarily remove a bone flap to allow swelling to protrude through the opening. Mannitol is not always given for cerebral swelling alone, one disadvantage is dehydration, electrolyte imbalances
  6. by   OHmom2boys
    Thanks mbrian,
    Maybe Jacob wasn't given mannitol because of his electrolyte imbalances? They were all out of whack. Bad. His RBC's were hemolyzed also. Maybe because of fld overload? He swallowed a lot of water. I know during the first 48 hrs he had double the output than intake. So he put of a lot of fld on his own. They said in their notes that was due to SIADH. They also had me sign a consent for a bld transfusion. Thankfully, he didn't ever need the transfusion.

    I also read somewhere that mannitol is contraindicated in pulmonary edema, which of course, Jacob did have.
    Still can't figure out why they didn't measure his ICP or give Lasix or Decadron or even the bone flap removal. Oh well, I think it's time to give up on these searches. For whatever reason, they didn't think it was either necessary or would help. This one doctor was the only one I have any problem with, and to be honest I probably have no reason for these feelings. And I'm probably not informed enough to even make that judgement. I have no idea why he made these decisons, but I'm starting to accept that maybe he wasn't giving up, maybe the decisions he made were for a reason. Maybe some of the procedures/drugs would have done more harm than good. I don't know. I've been searching for answers for two years. It's a really hard thing to accept when you think a doctor like that had given up on your child. Always looking for answers. And his lack of compassion while talking to me of my son's injuries didn't help my feelings towards him. Maybe that's what all this is based on. I try to separate my mommy feelings from the facts, but it's impossible.
    Even though I get mad when I think of what he DIDN'T do, I'm so thankful Children's Hospital and their doctors are there. I don't think Jacob wouldn't have made it had he been taken to one of our little community hospitals. Children's Hospital in Columbus Ohio and the nurses, docs and therapists are the greatest! Two nurses in particular will always be remembered.....Larissa from PICU and Jenn from Rehab. Like I told them when we were finally leaving, "I don't ever want to see this place again, but I thank God it's here."
    Thanks again,
    Kim
  7. by   passing thru
    Doesn't a near drowning diagnosis mean the patient is nearly dead? That is what it means in the ER at my hospital. They explained it to me as nearly dead, but they call it near drowning because it sounds more politically correct to say to the family. Your son was more dead than alive. I cannot imagine a neuro surgeon cutting his brain open to insert ICP manometers when the patient for all practical purposes is dead and it will take a miracle to keep the heart and lungs, kidneys, etc. going. The neurosurgeon who did that would be setting himself up for a lawsuit wouldn't he?
  8. by   TraumaNurse
    I am very sorry to hear about your son. Every child I have cared for over the years I have thought...what if that were my child. It always boils me to hear how many surgeons speak with families. You would think that they could teach some sort of bedside mannerisms is MD school! After 10 or 12 years of school, they are still idiots.
    You are correct in saying you would have increase ICP with cerebral edema, but anoxic brain injury does not always cause cerebral edema and therefor ICP monitoring and interventions for decreasing ICP would not be affective. Also, severe anoxic injury is irreversible.
  9. by   OHmom2boys
    Near drowning is defined as survival for at least 24 hours following asphyxia secondary to submersion in water no matter how bad the injury.....nearly dead or not. My older son was also involved. He was revived at the scene with no lasting neuro problems, but he too had the diagnosis of near drowning.

    Yes, he was nearly dead. And I really don't care about the neurosurgeon's liability for a lawsuit. I just want to feel that he did everything possible to save my son.
    I have to say I am puzzled by your comment that you cannot imagine a neuro cutting open a head to insert an ICP monitor. I thought that's what they do on brain injured patients. Lots of brain injured pts are 'nearly dead', and most get ICP monitoring.

    Thank you Traumanurse for your explaination and compassionate response. Unfortunately, I have learned all too well that this is irreversible. I have also learned some of the reasoning behind this doc's treatments and understand things much better. Now if only he could "grow" some bedside manners.
  10. by   JACook1
    If we all followed standards, anyone who made it past the ER and to a unit with a GCS of >8 would have an ICP monitor regardless of cerebral edema. That decision lies on the physician to place one or not. However, I don't care what the doc says about "not making it to morning", if your son had decerebrate posturing he had a fighting chance at that time. Posturing means that the brain stem is still intact and with your son being as young as he was he would have a good chance of recovery. ICP with EVD capabilities, bone flap and even partial "ectomy's" have proven to prevent herniation and brain death. I don't think anyone should have given up on your son until your son gave up. I'm glad to hear he is alive and well. Modern medicine doesn't always have the answer.
  11. by   kc ccurn
    Dear OHmom2boys,

    I am saddened and angered by the trauma docs response to you. If he had a GCS<8, in our hospital that is a lead indicator for ICP placement and treatment of the ICP. With regards to the treatment of the increased ICP, I was not aware of any contraindications of mannitor and Pulmonary Edema-I'll have to look that one up. Mannitol is an osmotic diuretic so you'ld have to be more concerned with the serum osmolality and sodium levels. A touch of lasix might not have hurt (depending on the K+) but most literature nowdays shows that decadron is not as affective as we once thought. The newest stuff to come down the pike is to use hypertonic saline (3%) as a continuous drip to change the serum osmo and promote diuresus and decrease edema.

    I am thankful that your son survived. Every moment (even the hectic stressful one's) are a gift from God!!!

    i think it might be therapeutic for you, as a mom, to write this trauma doc a letter and let loose all the anger, frustration, questions and vent to him, letting him know how you felt about what he said, how he treated you, your family and son. I'd make it a minimum of 5 pages. Then put it in the fireplace and burn it if you want. Just putting your feelings on paper, you don't have to send it unless you really really want to, is cathartic enough.
  12. by   Keysnurse2008
    ohmom2boys,
    I am so sorry to hear about your son.the trauma docs bedside manner was lousy.A drowning patient is not dead until he/she is warm and dead.As your sons body core temp was 78 degrees...then ALL shoulde have been done to treat him symptomatically.If he was symptomatic exhibiting decerberate posturing then YES he shouldve had his ICP monitored.......but....he had alot of other issues it sounds like too.did the nurses tell them md when he began exhibiting this posturing? And ...perhaps.....at that moment....the trauma doc....was focusing on his ABC's.Was this incident at a teaching hospital?If so.......perhaps there is an attending MD you can discuss this with.Someone who can review the whole chart....all issues....and then explain it to you.This is your child......and unless you get some resolution in your heart.....you can not get past this.It sounds like resolution will only come from honest answers.If the MD will not answer your questions then file a formal comp[laint with the state health related boards citing negligence.THEN the state will have to investigate.....and if he is reprimanded then you will have your answer.It is a horrible way to find out if all was truly done that could/should have been done.....but......your family needs for you to be able to move past this.....and it sounds like answers will be the only way you can move past this.My heart goes out to you and your child.I know you feel "let down"....but the art of medicine and nursing is an imperfect art.take care.....
  13. by   stevierae
    Confusing that they didn't try Decadron or Solu-Medrol to reduce the cerebral edema--I know that now they are falling out of favor, but 2 years ago Decadron, especially, was still very much in use for that purpose. One wonders why they didn't follow the standards in effect at that time.

    I don't think a subarachnoid screw would have been that invasive either--it's not like a full-blown craniotomy or a trip to the O.R. was needed for that----easy enough to put in at the ICU bedside with a single burr hole created with a cordless drill by a neurosurgeon--why not monitor ICP utilizing this very simple technique? Could it have hurt? As an O.R. nurse, I have accompanied many a neurosurgeon to the ICU to insert a subarachnoid screw for cerebral edema whatever the underlying cause--

    Obviously none of us can be Monday morning quarterbacks here with the limited info available to us--one would have to review the chart in detail to determine what mitigating circumstances there were that influenced the MDs decision.

    That said, I think you, as the parent, should have had some say in how aggressive you wanted your son's care to be--even involving the hospiatal administration and ethics committee, if necessary. There was no possible way you could have known about this at the time, though, unless someone advocated for you and suggested it--I was a nurse for a long time before I even knew that a hospital ethics committee existed.

    I am so sorry for what you experienced, ohmom2boys, but very glad you have your son and are enjoying every day you have with him.

    To passing thru: I thought your response was a bit cold and callous--if you did not mean to come across this way and I misinterpreted you, I apologize--but imagine that this was your child and think how you could have worded your response a bit more empathetically--obviously ohmom2boys is hurting--
    Last edit by stevierae on Feb 1, '04

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