fran lockie on paediatric tbi
TRANSCRIPT
Traumatic Brain Injury in Kids: What’s New?Bedside Critical Care
Daydream IslandSeptember 2012
Dr Francis Lockie,
Paediatric Emergency Department,
Women’s and Children’s Hospital
MedSTAR Emergency Medical Retrieval
South Australia
Scope
• Case
• Recent guideline update
• Avoid Secondary Brain Injury – Pre-hospital– ED– Definitive care
18 month old boy
HPC
•Dropped 4 times by mum
•Cried after first fall, quiet after fourth
•Baby left on couch whilst ambulance called
•Bradycardia en route
In ED• A – maintained with jaw thrust• B – chest clear, rr 20, SaO2 100% in HF O2 via
NRB• C – hr 130, BP 67/55• D - GCS 15 initially, PERL but sluggish initially,
then blown on Rt– Obvious bilat parietal haematomas
• VBG: pH 7.17, pCO2 50.6, b/c 18, BE -10, Hb 75
Alternating hypotension / hypertension
• 2 x 10ml/kg 0.9% NaCl
• 150ml O neg blood
• Modified RSI: ketamine and sux
• Episode of bradycardia / hypertension– Given 3% saline– Briefly hyperventilated
• Taken to CT
Progress
• Taken to theatre from CT
• Multiple arrests on the table
• BP difficult to manage
PICU:
• Protracted course
• Eventually extubated: guarded prognosis
Definitive Care
Pediatric Critical Care Medicine. 13:S1-S82, January 2012
Guidelines for the acute medical management of severe traumatic brain
injury in infants, children and adolescents – second edition
Pediatrics 2009;124;56
Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury
• 299 kids with mod-severe TBI
• 39% became hypotensive– Of these only 48% were treated
• 44% became hypoxic– Of these 92% were treated
Pediatrics 2009;124;56
Prevent secondary injury
• Hypoxia• Hypotension
Emerg Med J 2007;24:139–141
164 out of theatre intubations83% had 6 mths anaesthetic experience41% consultant presentPropofol in 76%96% NMBD32% DID not use capnography87% had rescue device39% suffered at least one adverse event around time of intubation
Anaesthesia 2009, 64(5):532-9
MilitaryPre-hospital care servicesEmergency / ICU settingsControversial
• Prospective, controlled trial• 30 ventilated, sedated trauma patients• ICP >18mmHg• Single ketamine bolus
Results
• 82 events total (groups 1 &2
• ICP reduced by 30% within 2 minutes of Ketamine administration
• P<0.001
“..refutes the notion that ketamine increases ICP..”
• In ventilated, anaesthetised patients, with raised ICP, ketamine decreased ICP with no untoward effects on MAP or CPP
• Combined with a BDZ, ketamine may be preferred agent for raised ICP
Conclusions
• Physician led prehospital trauma teams decrease the length of ICU stay for patients with severe head injury
• Trial compromised by highly selective patient cross-over (careflight vs ASNSW)
Steroids?
Steroids?
Pediatric Critical Care Medicine. 13:S1-S82, January 2012
C-spine collars may be bad for you
C-spine collars may be bad for you
• Tapes• Head up 30 degrees• Judicious use of PEEP
More Issues for the Intensivist
• Indications for ICP monitoring• Threshold for treatment of intracranial
hypertension• CPP thresholds• Advanced neuromonitoring• Neuroimaging• CSF drainage• DC for treatment of intracranial hypertension
Pediatric Critical Care Medicine. 13:S1-S82, January 2012
High quality neuro-intensive care from scene to definitive treatment
• Rigorous attention to ABC
• Care with RSI, ? Ketamine for all
• Crystalloid
• Sedation: have a plan!
• Deteriorates: – brief hyperventilation– Hypertonic saline over mannitol
• Systems: where is definitive care?