Pediatric emergency medicine trisk 2679 2679

Brain tumors can cause increased ICP by blocking CSF drainage. The symptoms
of increased ICP vary based on patient age. Infants with an open fontanelle can
sometimes present with bulging of the fontanelle as well as seizure, vomiting,
irritability, or loss of acquired skills. Older children often have headache and early
morning vomiting. Sixth nerve palsies are common. Sometimes increased ICP is
detected only on imaging of the brain that reveals enlargement of the ventricles or
effacement of the gyri.
Seizures developing in the setting of a child with cancer, whether due to a CNS
tumor or another malignancy, should be managed as described in Chapter 72
Seizures . Brain tumors should be considered in the differential diagnosis of newonset seizures.
Patients with brain tumors are at risk for several metabolic complications. The
presence of an intracranial tumor may cause for cerebral salt wasting or SIADH. DI
can result from tumor involvement of the pituitary gland. Patients should be
screened for these abnormalities with serum chemistries. However, these
complications are not managed uniquely because of the brain tumors. Chapter 89
Endocrine Emergencies provides guidelines on evaluation and management.
Clinical Assessment
After ensuring that the airway, breathing, and circulation are stable, the evaluation in
the ED should focus on a thorough history and physical examination, assessing for
any neurologic symptoms and screening for complications described above. A
complete physical examination should include a thorough ophthalmologic and
neurologic assessment and an evaluation of the patient’s external genitalia for
precocious puberty or virilization, since some pediatric brain tumors may be
hormone secreting. A rectal examination to evaluate the anal “wink” is also useful
as a screen for spinal cord compression. If the history or physical examination raises
concern for increased ICP or spinal cord compression, therapy should be initiated as
described below. A CT scan is useful to rule out hemorrhage and assess for
increased ICP, and can sometimes visualize a brain tumor. However, a CT scan may
miss infratentorial masses so in most cases, magnetic resonance imaging (MRI) with
gadolinium will ultimately be needed. Laboratory evaluation should include serum
electrolytes to evaluate for SIADH, salt wasting, or DI. A CBC is also useful to

ensure the patient’s hematocrit and platelet count are adequate for any upcoming
procedures.
Management
The emergency management of increased ICP is critical as patients often present
with signs and symptoms of this condition at the time of diagnosis. If increased ICP
is known or suspected, a lumbar puncture should be avoided, as this theoretically