Topic overview

Dr. Pramod Puligandla, Traumatic Pediatric Surgeon and Intensivist at Montreal Children’s Hospital, joins the Stay Current Team to review the Cliff Notes on traumatic brain injury (TBI).

Background:

Traumatic brain injury is the cause of over 837,000 ER visits, hospitalizations and deaths in children in 2014 and is challenging to manage

Clinical case: A 15 year old male presents to your ED after being hit in the head by a line drive ball during the 3rd inning of his baseball game. On the scene, he was confused but semi-coherent. On the ambulance ride over, his GCS declines to 8 (E=2, V=2, M=4). BP is 120/80 and HR 75. In the ER, he is intubated, and head CT demonstrates a small epidural. He has no other injuries.

Initial management of this patient and first considerations?

Consult neurosurgery for further management of epidural

Discuss role of intracranial pressure (ICP) monitoring

Consider intracranial hypertension:

Need invasive BP monitoring and ICP monitoring
Presentation:

Dilated pupil (ipsilateral)
Progressive bradycardia with hypertension

Management:

Remember: MAP – ICP = CPP

Target CPP > 45; in children > 55

Raise head of bed (improve venous drainage)
Start Oxygen
Consider bag-valve masking
[If intubated] hyperventilate patient to pCO2 ~35 (vasoconstrict cranial vasculature)
[If ICP drain present] Open ICP drain

Hypertonic saline versus mannitol?

Hypertonic saline (3% NS)

5ml/kg dose--Increases serum 3-5mEq/Liter
Easy to give
Keeps Na higher
Higher osmolality limit (360 mmol) compared to mannitol (320 mmol) so you can give more

No evidence of clinical difference between hypertonic saline and mannitol according to Pediatric Critical Care Medicine
Mannitol

Hard to control diuresis which can lead to hypotension
Mechanism of action

First 15-20 Minutes—actually changes blood vessel reology allowing RBCs to pass through to brain more freely, increasing oxygen
Later—diuresis

Dosing: 0.5-1 gram/kg—easy to accidentally underdose

Blood pressure goals?

Hypotension = poor prognosticator of outcomes in closed head injury

Lower neurological outcomes
Increased morbidity overall
Avoid at all costs
Can consider inotropic agents to increase BP to maintain CPP

Target:

Older children and teenagers, keep SBP > 90-95
In younger children, use norms for their age

Any role for steroids?

No role at this time, even with suspected spinal cord injury

What about options are available after conservative management has failed?

Evacuation (if there is something to evacuate)
Decompressive craniectomy becoming option in some challenging cases

Current guidelines endorsing no difference for these patients, but is being considered more and more often across North America

When would you consider repeat CT versus MRI?

CT: for any acute presentation of increasing ICP
MRI: after stabilization to determine extent of injury and guide discussion

Clinical case continued:

Throughout his next few days, he intermittently is found posturing, hypertensive, tachycardic, tachypneic and hyperthermic.

How should we first approach the management of sympathetic storming?

Caused by: imbalance of sympathetic and parasympathetic from head injury
Presentation: autonomic dysfunction and loss of cortical control
Lack of treatment:

Can potentiate ongoing injury and cause secondary injury

Hyperventilation (vasoconstriction can cause hypoxia and further injury)
Hypertension (brain hemorrhage)
Dysrhythmias or hemodynamic instability (hypoperfusion in general, worsening head injury)

Can cause neurogenic pulmonary edema

Treatment: Sedation and pain control

Narcotics or benzodiazepines (e.g. oxycodone)
Bromocriptine (hypothalamus)—reduces hypothermia, diaphoresis, and blood pressure
Propranolol/clonidine (dysrhythmias or hypertension)

Clinical pearls:

CT scan for initial presentation and acute change, and MRI when patient is more stable
Frequent neurologic exams are important

If intubated, you have to rely on other markers of elevated ICP

Be well versed in the management of ICP

Maintain BP, elevate the HOB, oxygenating, sedating, and using 3% NS or mannitol

Image and consult neurosurgery ASAP to determine the next steps of surgical care pathway

References:

Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque. Artist URL: ccmixter.org/files/grapes/16626.

Traumatic Brain Injury

Topic overview

Background:

Clinical case continued:

Clinical pearls:

References:

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