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Pediatric �Traumatic Brain Injuries and ICP management

Alexandra Wilson MD

Assistant Professor

Dell Medical School

Austin, TX

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Topics

  • Epidemiology
  • Pathophysiology
  • Initial evaluation
  • Definitive treatment

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Why is this important?

  • The leading cause of death in children > 1yr is Trauma
  • Majority of trauma related deaths due to TBI & submersion
  • 5.3 millions Americans are living with disability due to TBI

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webappa.cdc.gov/sasweb/ncipc/leadcause.html

The Epidemiology and Impact of Traumatic Brain Injury. Langlois,, JE et al. Head Trauma Rehabil Vol. 21, No. 5, pp. 375–378

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your first case of the day

7 week old female, ex-34 week preemie found apneic and unresponsive by parents.

Brought by POV to OSH where she was intubated 30 min later (no RSI meds)

Given NS and NaHC03 along with Amp/Gent with working diagnosis of sepsis.

Fundoscopic exam revealed retinal hemorrhages. Patient then transported to your ED

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Initial Stabilization

  • ABC : airway, breathing, and circulation
  • Avoid hypotension/hypoxemia

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    • Each occurs in up to 1/3 of severe head injury patients
    • Powerful predictors of outcome

single episode of hypotension doubles mortality rate

    • Adequate fluid resuscitation to restore normal BP does NOT worsen neurologic outcome
    • Avoid hypotonic fluids

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Initial Stabilization

  • Emergent airway control for
    • GCS 8 or less
    • Rapid neurologic deterioration
    • If needed for other injuries

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RSI Medications

      • Lidocaine 1% 1mg/kg no conclusive evidence

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      • Sedation

Etomidate 0.3 mg/kg

Ketamine 1- 1.5 mg/kg

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      • NMB

Rocuronium 1-1.2 mg/kg

Succinylcholine 1-2 mg/kg

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Patanwala, A.et al.. (2016), Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy, 36: 57–63.

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Caveats :Intubation

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  • Ventilate, aiming for pCO2 35-40
  • Oxygenate, using PEEP if necessary
  • Cardiovascular assessment and stabilization
    • use VOLUME
    • Inotropes

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Head injury evaluation

  • Neurological evaluation
  • Secondary survey-look for other injuries

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Glasgow Coma Score

  • Three components. Score derived by adding the score for each component.

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Eye opening (4 points)

Verbal response (5points)

Best motor response (6 points)

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Glasgow Coma Scale

≥13 mild

9-12 moderate

≤8 severe

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Neuroimaging

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  • CT scan is initial imaging modality of choice for moderate and severe head injury
  • Look for: blood, ventricle size, basilar cisterns
  • Initial CT may be normal in severe head injury Repeat CT in 12 to 24 hours

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off to the scanner

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Epidural

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Subdural

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Cerebral edema

quadrigeminal cistern

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Cerebral contussion

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Diffuse axonal Injury

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Types of Cerebral Edema

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  • Cytotoxic Edema
    • Intracellular swelling caused by direct cell injury
    • Usually irreversible injury
    • Common in TBI, diffuse axonal injury, HIE
  • Vasogenic Edema
    • Increased permeability of capillary endothelial cells
    • Not direct primary injury to neurons
    • Treat to prevent secondary injury to neurons
    • Can respond to steroids
    • Common with tumors, intracranial hematomas, CNS infections
  • Interstitial Edema
    • Increased fluid in the periventricular white matter for increased CSF hydrostatic pressure
    • Occurs with hydrocephalus

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Case 1

You accompany a 6yo to the CT scanner s/p fall from 2nd story window. The patient become somnolent and apneic what drugs do you want to intubate?

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a. versed and succinylcholine

b. Ativan, morphine and vecuronium

c. etomidate, fentanyl and vecuronium

d. lidocaine, morphine and vecuronium

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To the OR….

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ICP monitoring- Indications

  • Glasgow coma scale <8
  • Clinical or radiographic evidence of increased ICP
  • Post-surgical removal of intracranial hematoma
  • Less severe brain injury in the setting which requires deep sedation or anesthesia

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ICP monitoring��

How ?

    • Ventriculostomy-added benefit fluid drainage
    • Intraparenchymal fiberoptic catheter

Goals

      • Intracranial pressure <20 mmHg
      • Cerebral perfusion pressure > 40-60 mm Hg

CPP = MAP - ICP

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To the PICU

and the plan now?

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Simple moves make a difference

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Treatment to ↑ CPP: ↑ MAP

CPP = MAP - ICP

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Maintain adequate intravascular volume

      • Goal is NORMOVOLEMIA/Na >145
      • Total fluid intake should be @ 100% maintenance
      • Use Normal saline

Pharmacological

      • Inotropes/pressors: epinephrine, norepinephrine

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Treatment to ↑CPP: ↓ ICP

CPP = MAP – ICP

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Decrease intracranial volume using these methods

  • Keep HOB up 30 degrees (improves venous drainage)
  • Keep head midline/avoid venous constriction: make sure C- collar/trach ties not too tight
  • Use Osmolar therapy options

Mannitol: 0.25 to 1 gr/kg

3% saline: 5-10cc/kg

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  • Drain CSF - via ventriculostomy

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Importance of pCO2 and pO2

  • Hypoxia increases CBF by vasodilation
  • Hypoventilation →Hypercapnia and increases CBF
  • Hyperventilation→ hypocapnia and decrease CBF

Use Hyperventilation is useful to impending herniation only

Below 50 mmHg get acute rise CBF

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Case 2

Now that you know the determinants of cerebral blood flow, please tell the RT what to do with the following ABG on your 1-year-old patient with CHI and GCS of 5

7.32/55/50 on vent TV = 8cc/kg rate 20 Fio2 30%

  1. increase the tidal volume, increase the Fio2
  2. decrease the rate , increase the Fio2
  3. increase the rate, increase the Fio2
  4. increase the rate , leave the Fio2 alone

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Treatment to ↑CPP: ↓ ICP� CPP = MAP - ICP�

Decrease metabolic demands

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    • sedation, analgesia,
    • NMB
    • avoid seizures
    • maintain normothermia

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Anti-seizure Prophylaxis & TBI

Pediatric Guidelines (2019)

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  • Prophylactic use recommended (w/in 7 days)
  • High risk patients <2 yrs, severe TBI, NAT

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Avoid Hyperthermia

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cooling device to maintain normothermia

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Case 3

You have admitted a 3yo s/p MVA to the IMC. The initial CT showed a tiny SDH. The patient becomes increasingly unresponsive. You (appropriately ) order a CT scan and notify neurosurgery. What would be the best choice to lower the patient’s ICP on the way to the scanner?

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  1. Mannitol
  2. 3% saline
  3. Hyperventilate
  4. Lasix

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When nothing works

  • Decompressive craniotomy
  • Barbiturate “coma”
  • Moderate Hypothermia ?

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Decompressive craniotomy

RESCUEicp Trial: Multicenter RCT in 408 pts age 10- 65 yrs. old with refractory ICP to DC versus continued medical management

  • GOS-E at 6 mo patients with DC had in lower mortality (26.9% versus 48.9%)
  • At 6 months more survivors in the surgical group than in the medical group were dependent on others.

Decompressive Craniectomy for Traumatic Intracranial Hypertension (2016) N Engl J Med Vol375(12):1119-1130

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Barbiturate use for ICH

Mechanism of action:

Evidence:

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Re

Recommendation:

“High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy.”

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Roberts I, Sydenham E. Barbiturates for acute traumatic brain injury. Cochrane Database of Systematic Reviews 2012, Issue 12.

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Case 4

The RN tells you that the patient’s ICP is 25

What questions do you have now?

    • the patient’s most recent Na,C02
    • the patient’s most recent PH, CL and C02
    • the patient’s most recent Na, CL and Pa02

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Special Topics: Hematology and CHI

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    • Coagulopathy common with head injuries
      • Brain derived thromboplastin activator substances released
    • Follow PT/PTT/Fibrinogen
    • Blood component replacement if evidence of active bleeding or if surgical intervention anticipated
    • Maintain hgb 8-9 to optimize oxygen delivery

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��1. Avoid hypoxemia/hypotension��2. Remember easy ways to control ICP � Head positioning� Hyperosmolar therapy � Sedation/ NMB� Normothermia��3. Barbiturate therapy /DC craniotomy� individualized to the patient

In Summary

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Caveats in Brain Injury prognostication

  • Neurologic examination - the most important information you have
  • Histories may be unreliable/ unavailable
  • Difficult to prognosticate and treat based on imaging alone
  • Patients with TBI do better overall than those with hypoxic ischemic cerebral injuries

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Useful Reference

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Guidelines for the acute Medical management of severe traumatic brain injury in Infants, Children and Adolescents-second edition

Brain Trauma Foundation :www.braintrauma.org

DCMC Evidence based website

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Pediatric submersion injuries: emergency care

Pediatr Emerg Med Pract. 2014 Jun;11(6):1-21

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