Hypoxic-ischaemic brain injury

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Target exams

Red flags

• A comatose child after return of spontaneous circulation has hypoxic-ischaemic brain injury, and intensive care targets the secondary injury over the hours and days that follow
• Fever extends the ischaemic lesion, so temperature must be measured continuously and treated actively throughout the admission
• Early postresuscitation hypotension is strongly associated with worse survival, so an age-appropriate mean arterial pressure must be defended with fluids and inotropes
• Up to half of comatose post-arrest children have non-convulsive seizures that are invisible to the bedside examination, so continuous EEG is mandatory
• Neuroprognostication is multimodal and deferred to at least 72 hours; no single predictor, including an early EEG or biomarker, is sufficient to define the outcome
• Hyperoxia and hyperventilation both worsen cerebral injury, so ventilation targets normoxia and normocapnia, not the highest possible oxygen
• The child with pre-existing neurodisability must be judged against their pre-arrest baseline, not an age-normative standard

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines hypoxic-ischaemic brain injury in the infant and child beyond the neonatal period as global brain injury from an ischaemic or asphyxial insult, and states that it is the dominant cause of death and disability after cardiac arrest
• States that the injury splits into a primary injury at the moment of arrest and a secondary injury over the hours and days that follow, and that intensive care targets the secondary injury
• States that targeted temperature management at 32 to 34 degrees or at 36 to 37.5 degrees with active fever prevention is the single neuroprotective intervention after return of spontaneous circulation
• Applies the THAPCA out-of-hospital and in-hospital trial findings and the Bayesian reanalysis to choose between hypothermia and normothermia for an individual child
• Explains the ischaemia-reperfusion cascade and why each element of neurocritical care, from avoiding hypotension to detecting non-convulsive seizures on continuous EEG, limits secondary injury
• Runs the cause-specific and age-specific assessment across drowning, asphyxial arrest, cardiac arrest, and the child with pre-existing neurodisability, and runs a structured neuroprognostication at 72 hours or beyond
• Classification of hypoxic-ischaemic brain injury into primary and secondary injury, and the common paediatric causes including drowning, asphyxia, cardiac disease, sepsis, and trauma
• Targeted temperature management protocol: 32 to 34 degrees Celsius for 48 hours for out-of-hospital arrest or 36 to 37.5 degrees normothermia with rewarming at no more than 0.5 degrees per hour
• Neurocritical care targets of normoxia, normocapnia, normotension, normoglycaemia, and normothermia, and the use of continuous EEG to detect non-convulsive seizures
• Runs the immediate post-return-of-spontaneous-circulation assessment and stabilisation of a comatose child and initiates targeted temperature management
• Interprets the continuous EEG and the early neuroprognostic features and counsels the family honestly about uncertainty and the timeline for prognostication
• Coordinates the neurocritical care, cause search, and early rehabilitation for a drowned or post-arrest child, including the child with pre-existing neurodisability
• Level 1: Recognition that a comatose child after cardiac arrest has hypoxic-ischaemic brain injury and that intensive care targets the secondary injury
• Level 2: Application of targeted temperature management and the neurocritical care bundle of normoxia, normocapnia, normotension, normoglycaemia, and normothermia
• Level 3: Coordination of neuroprognostication with EEG and examination, family communication, and the early rehabilitation and follow-up plan
• Primary versus secondary brain injury and the ischaemia-reperfusion cascade that underpins the neurocritical care strategy
• The THAPCA out-of-hospital and in-hospital trial results and why neither hypothermia nor normothermia is proven superior, with the Bayesian reanalysis
• Targeted temperature management targets and rewarming rate, and the high rate of non-convulsive seizures detected by continuous EEG
• Structured bedside assessment and initiation of targeted temperature management in a comatose post-arrest child
• Interpretation of the continuous EEG and the neuroprognostic examination, and recognition of the child at risk of a poor outcome
• Communication of the diagnosis, the uncertainty of early prognostication, and the rehabilitation plan to the family
• Hypoxic-ischaemic brain injury after paediatric cardiac arrest as a primary and secondary injury process managed with targeted temperature management
• The THAPCA trials and the recommendation that fever is prevented and that hypothermia and normothermia are both acceptable
• Continuous EEG for non-convulsive seizures and a multimodal neuroprognostication deferred to at least 72 hours
• Recognition of the comatose post-arrest child and initiation of targeted temperature management and the neurocritical care bundle
• Maintenance of normoxia, normocapnia, normotension, and normoglycaemia, and the avoidance of hyperoxia and hyperventilation
• The high prevalence of non-convulsive seizures and the principle that no single test defines prognosis
• Canadian and international approach to post-arrest targeted temperature management guided by the THAPCA trials
• Primary and secondary brain injury and the neurocritical care targets that limit the secondary cascade
• Multimodal neuroprognostication with EEG, examination, and neuroimaging, deferred to at least 72 hours