Traumatic Brain Injury Children

Traumatic Brain Injury Children

Torsten Lauritsen Rigshospitalet Copenhagen

Aim

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To give an overview of severe traumatic brain injury in children focus on resuscitation first line treatment guidelines

To improve the care of children with severe traumatic brain injury

TBI

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Epidural hemorrhage Subdural hemorrhage Subarachnoid

hemorrhage Contusions Cerebral edema Ischemic injury Diffuse Axonal Injury Abusive Head Trauma –

Shaken Baby Syndrome

Head trauma - physiologyPrimary brain damage

Direct following the trauma Irreversibel– Diffuse Axonal Injury Treatment does not improve prognosis

Secundary brain injury Proper resuscitation will improve prognosis and prevent

further damage

Hypoxemia Convulsions Hypotension Hyperthermia Raised ICP Hypoglycemia

Decreased cerebral perfussionCerebral oxygen deliveryIncreased oxygen consumption

Increased ischemia

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Glucose

Temperature

pH

Electrolytes

Sedation

Cerebral perfusion

Chalkias A in J of Neurological Sciences 2012

Neuroprotective agents

ICP

ROS

Cerebral edema

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Intracellular – hypoxia Cellular metabolism Cellular retention of

sodium and water Apoptosis

Vasogenic Rupture of BBB leads

to leakage from capillaries

Paediatric trauma care

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Hypotension is bad

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131/299 = 44% had hypoxia118/299 = 39% had hypotension

Absense of BP monitoring => OR of death 4.5

Hypotension is bad

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Guidelines

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Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents

Treatment

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Resuscitation A

B C D

Treatment - Airway

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Early intubation

Modified Rapid Sequenze Induction

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Rapid Sequence Induction Premedication with spontaneous ventilation Preoxygenation Induction

Propofol/Tiopental (Ketamin/Etomidat) Rocuronium Fentanyl (Rapifen)

Mask ventilation (10-12 cm H2O) Intubation

Treatment - Breathing

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Oxygen Maintain oxygenation within normal range PEEP might increase ICP

Hypoxia is worse

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Mortality risk lowest at O2 8 – 10 kPa (60 – 75 mmHg)

Mortality risk increase with hypoxia and hyperoxia

OR 1,92

OR 1,25

Hyperventilation

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Hyperventilation => hypocapnia => vasoconstriction => lower CBF and CBV =>lower ICP

Vasoconstriction worsen cerebral ischemia

Hyperventilation only after neurosurgical consultation and if herniation is impending

Circulation

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Systolic BP > 70 + 2 x age Haemorrhage control Fluid resuscitation

Krystalloid 20 ml/kg SAGM 10-20 ml/kg FFP 10-20 ml/kg TC 5-10 ml/kg

Vasopressors?

Resuscitation - fluids

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Albumin vs saline Ringers Lactate vs Saline

osmolality 270 vs 308Sodium 130 vs 154

Physiology – cerebral perfusion

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Cerebral perfusion pressure (CPP) Mean arterial pressure (MAP) Intra cerebral Pressure (ICP)

CPP = MAP - ICP Level 3 evidence

CPP > 40 mmHg ICP < 20 mmHg

Disability - ICP monitoring

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ICP < 20 mmHg

No evidence directly in favor of ICP monitoring – but:1. Children with severe TBI have high ICP2. Poor outcome with intracranial hypertension3. Better outcome with protocols for treatment of

ICP4. Better outcome with succesful ICP lowering

therapies

Anaesthesia

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Ketamin

Propofol Tiopental

Etomidat

Increase HRIncrease BPBronchodilatation

Decrease cerebral metabolismCerebral vasoconstrictionInduce systemic hypotension => lower CPP

Anaesthesia

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Sevoflurane and Isoflurane

Nitrous oxide

Decrease cerebral metabolismVasodilatation => CBF and CBV

Increase cerebral metabolismIncrease CBF => ICPShould be avoided

Neuromuscular blocking agents

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Succinylcholine Increase ICP Provide rapid optimal conditions for intubation Cardiac arrytmias

Rocuronium Optimal drug for paediatric intubation Reversal with Sugammadex 0,6-1,0 mg/kg

Positioning

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Improve venous drainage Elevate head 15-30o

Avoid flexion or rotation

Mannitol

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Mannitol 1g/kg - reduce ICP by Reduces blood viscosity rapidly but transiently <

75 min Slow osmotic effect over 15-30 min Movement of water from the brain to the systemic

circulation. Effect up to 6 h, but requires a intact BBB

May cause hypotension (osmotic diuresis) Rebound effect

Hypertonic Saline 3 %

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5 ml/kg 513 mmol/l Na+, Osmolality 1027 mOsm/l

Osmotic action in the brain Restores intravascular volume Increased inotopy Increase MAP and CPP

Hyperosmolar therapy

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Recommendation level 2 Hypertonic saline should be considered for

treatment of TBI associated with intracranial hypertension. Effective dose for acute use range between 6,5-10ml/kg.

Recommendation level 3 Hypertonic saline for treatment of intracranial

hypertension 3% saline as a continous infusion range between 0,1-1,0 ml/kg/hour.

Mannitol is commonly used but no RCI exists

Hypothermia

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Level 2 Moderate hypothermia (32-33C) beginning early

after TBI for only 24 hrs’ duration shold be avoided

Hypothermia

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Hypothermia – adverse effects

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Hypotension Bradycardia Arrhytmias Sepsis Coagulopathy

Treatment - Conclusion

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Resuscitation

Triage – expeditious

Surgical treatment

ICP monitoring and control

Optimization of organ systems

Traumatic Brain Injury in Children32ICP raised – impending herniationHyperventilat

ion Craniotomy Tiopental Hypothermia

Hyperosmolar therapySaline 3 % Mannitol

ICP raisedCSF drainage Neuromuscular blockade

CT - scanICP monitor Surgical evacuation

Primary intervention for TBIElevate head Normothermia Sedation

ResuscitationAirway Breathing Circulation

Traumatic Brain Injury in Children