Traumatic Brain Injury

Katie Clement, MDPICU Resident Lectures2011Traumatic Brain InjuryObjectivesUnderstand the mechanisms of Pediatric Traumatic Brain InjuryUnderstand the pathophysiology of TBIUnderstand the management of TBIOverviewEpidemiologyInjury is leading cause of death for children

40% of those are from TBI

Mortality between 17 33%

Most common cause of death & disability in childhood in developed countries

3000 children die each year from TBI in the USKrug EG et al. Am J Public Health. 2000.Langlois JA et al. Centers for Disease Control & Prevention. 2006.White JR et al. CCM. 2001.Krug EG et al. Langlois JA et al. GCSSeverity of TBI is defined by the GCS Score

MildGCS 13-15

ModerateGCS 9-12

SevereGCS 320Adelson PD et al. PCCM 2003.Hypertonic SalineCan be administered as a bolus or as an infusionOptimal dosing not clear3% saline commonly used as bolus of 2-6 ml/kgContinuous infusion of 0.1 1 ml/kg/hr also describedEffective at reducing ICP in small randomized trials & observational reportsDoes not cause profound osmotic diuresis, so decreased risk of hypovolemiaAdverse effects:Rebound intracranial hypertensionCentral pontine myelinolysis (theoretical, not reported)Qureshi AI. CCM 2000.Huang SJ. Surg Neurol 2006.Glucose ControlHyperglycemia associated with poor outcomesMarker for severity of injuryWorsens brain tissue lactic acidosisRecommend to keep glucose level at least less than 200Adelson PD. PCCM 2003.CorticosteroidsNo benefit in traumaLarge, prospective multicenter trial demonstrated increased mortality among patients with acute TBI who received steroids

Useful only for vasogenic edema from tumors because they stabilize the BBBBarbiturate comasecond tier therapyUsed if ICP refractory to other modalitiesPentobarbital typically usedDecreases cerebral metabolic rate and thus cerebral blood flowMay have protective effects during periods of hypoxia and/or hypoperfusionCardiac suppression, hypotensionTreat with fluids & inotropic supportNo evidence for prophylactic use

Other second tier therapiesAggressive hyperventilation (PaCO2 < 30)Recommend brain tissue oxygenation monitoring or jugular venous O2 saturation or CBF monitoringDecompressive craniectomyIdeal patient has had no episodes of ICP > 40 before surgery, have had a GCS > 3 at some point Evolving herniation syndrome within 48 hrs of injuryLumbar CSF drainageNot commonMust have a functioning EVD in place, open basal cisterns, no mass effect or shift on CT (to avoid herniation)HypothermiaCore temp 32 34 degreesMore studies needed

Management Algorithm

Adelson PD et al. PCCM 2003

Adelson PD et al. PCCM 2003

Adelson PD et al. PCCM 2003

Second Tier TherapiesAdelson PD et al. PCCM 2003 SummaryHave Neurosurgery involved EARLYFor surgical intervention & monitor placementKeep ICP 40 60 mmHg)

ReferencesVavilala MS, Waitayawinyu P, Dooney NM. Initial approach to severe traumatic brain injury in children. www.uptodate.com 2011.Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiology Clin 2009:27;213-240.Brasher WK. Elevated intracranial pressure in children. www.uptodate.com 2011.