TRAUMATIC BRAIN TRAUMATIC BRAIN INJURY IN CHILDRENINJURY IN CHILDREN

Marc D. Berg, M.D.Marc D. Berg, M.D.Professor of PediatricsProfessor of PediatricsChief, Pediatric Critical Care MedicineChief, Pediatric Critical Care MedicineMedical Director, University of Arizona PhysiciansMedical Director, University of Arizona Physicians

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OBJECTIVES

Review Of…

Physiology, Assessment, and Management of TBI

Outcome in Children With TBICorrect Common Myths

Childhood Head Injuries: Statistics

• 85% are “mild”, but…• 80% of children with multiple trauma

die because of severe head injury (50% in adults)

– > Head/body ratio– Softer skull– Open fontanelles

MYTH #1• Myth…All Brain Injuries Are the Same

• Fact… Each Brain Injury Is Different

DEFINING SEVERITY

• Mild Brain Injury– GCS = 13-15– Limited impaired consciousness (<30 min)– Normal CT scan– Shows signs of a concussion

• Vomiting• Lethargy• Dizziness• Lacks recall about injury (<1 hr PTA)

DEFINING SEVERITY• Moderate Brain Injury

– GCS = 9 - 12– Impaired Consciousness (<24)– CT scan Evidence– PTA 1-24 hr

• Severe Brain Injury– GCS = 3 - 8– Impaired Consciousness (> 24 hours)– PTA > 24hr

CAUTION!!

• GCS of 13 may not be so “mild”• SC Stein, J Trauma. 2001;50:759-760

– Reviewed 14 studies (1047 adult patients with GCS of 13) – 33.8% had intracranial lesions– 10.8% required surgery

MYTH #2

• Myth… Younger children recover better than older children.

• Fact… The developing brain may be at more risk. It will take longer to see the effects of the brain injury.

INTRACRANIAL FLUID COMPARTMENTS

(INTRACELLULAR AND(INTRACELLULAR ANDEXTRACELLULAR)EXTRACELLULAR)

MODIFIED MONROE-KELLIE DOCTRINE

A

B

C

VOLUME

ICP

For pressure to remain constant, an increase in For pressure to remain constant, an increase in volume in one compartment must be accompanied volume in one compartment must be accompanied by an equal decrease in the volume in othersby an equal decrease in the volume in others

CEREBRAL BLOOD FLOW/AUTO REGULATION

• May be lost after trauma

• Principles are used in treatment strategies but are the source of much debate

From Shapiro HM: Anesthesiology 43:445-471, 1975

CEREBRAL PERFUSION PRESSURE

• CPP = MAP - ICP

• Useful Concept, But Has Limitations

• Good CPP, Better Outcome In Adult Literature (>70 mmHg in adults, >40-65 mmHg ? in children)

• The CPP (>70) versus the ICP(<20) As The Primary Therapeutic End-point (Debatable Concept)

BRAIN INJURYPATHOPHYSIOLOGY

• Primary Brain Injury (occurs at time of impact)– Intracranial hemorrhage– Diffuse axonal injury– Hyperemia/edema– Ischemia, release of toxic mediators

SUBDURAL VS. EPIDURAL

LifeArt: Williams & WilkinsLifeArt: Williams & Wilkinshttp://www.lifeart.comhttp://www.lifeart.com

SUBDURAL HEMATOMA

WebPath: University of UtahWebPath: University of Utahhttp://www-medlib.med.utah.eduhttp://www-medlib.med.utah.edu

WebPath: University of UtahWebPath: University of Utahhttp://www-medlib.med.utah.eduhttp://www-medlib.med.utah.edu

EPIDURAL HEMATOMA

SUBDURAL vs EPIDURAL HEMATOMA

• EPIDURAL– Requires linear

force– Associated with

skull fracture and torn artery. Brain often uninjured

– “Lucid” interval common

– Common in accidental trauma

• SUBDURAL– Requires significant

rotational forces– Associated with brain

injury and torn bridging veins

– Neurologic symptoms from the start

– Common in infants with abusive head trauma

PEDIATRIC FALLS FROM HEIGHTS

• Falls From 1 - 3 Stories Often Not Fatal• Falls Less Than 4 Feet Often Reported in Fatal Injuries

– Unwitnessed– Subdurals– Retinal Hemorrhages

• Falling off a Bed or Couch Should Not Kill!

COUP - CONTRA COUP INJURY

BRAIN INJURY PATHOPHYSIOLOGY

• Secondary Brain Injury : – Occurs over hours to days (hypoxia, hypercarbia,

hypotension/ischemia, intracranial hypertension, acidosis, seizures, hyperthermia, hypothermia, infections

– Potentially Avoidable Or Treatable With Close Monitoring / Treatment of ABC’s

UNCONTROLLED INTRACRANIAL PRESSURE AND/OR CEREBRAL

PERFUSION

DISPLACEMENT OF DISPLACEMENT OF NERVOUS TISSUESNERVOUS TISSUES

DECREASED GLOBALDECREASED GLOBALAND REGIONALAND REGIONALOXYGEN DELIVERYOXYGEN DELIVERY

HERNIATIONHERNIATION

WORSE FUNCTIONAL OUTCOMEDEATH

KEY POINTS

• THE BRAIN NEEDS OXYGEN• OXYGEN IS CARRIED IN BLOOD

NO BLOOD, NO OXYGEN, ……BRAIN CELLS DIE

Assessment

MINOR CLOSED HEAD INJURY

• Evaluation and Management of Children Younger Than Two years old With Apparently Minor Head Trauma: Proposed Guidelines– Schutzman SA et al., Pediatrics 2001; 107:983-993

• The Management of Minor Closed Head Injury in Children– AAP/AAFP, Pediatrics 1999; 104:1407-1415

IMPORTANT ISSUES FOR THE < 2 YEAR OLDS

• Clinical Assessment Difficult!• Occult ICI More Common• Increased Risk of NAT• Increased Risk of Skull Fracture• Increase Sedation Risk

MYTH #3

• Myth… A mild brain injury has no consequences.

• Fact… A mild brain injury can affect a child’s ability to concentrate, learn and function at home and in school.

CASE PRESENTATION

• 6 year old male• Struck by car while riding his bike• Brought in by EMS with c-spine protected• Spontaneously breathing• GCS = 8

• HR = 145, RR = 25, B/P = 80/45, O2 sats = 99%

• Multiple abrasions, no other obvious injuries• Next Steps?

INITIAL ASSESSMENT

• A IRWAY

• B REATHING

• C T SCAN CIRCULATION

MANAGEMENT OF TBIINITIAL MANAGEMENT

• Level II and III (adult and pediatric): – AVOID HYPOTENSION AND HYPOXIA– Know Age Based Normals (For children keep BP > 5th %tile)– In adults, MBP > 90.– Intubate if GCS < 9 (peds) and Airway or Oxygenation is

Unstable (adults)

EARLY RESUSCITATION OF CHILDREN WITH MODERATE-TO-SEVERE TRAUMATIC BRAIN INJURY PEDIATRICS 2009;124;56-64 MICHELLE ZEBRACK, CHRISTOPHER DANDOY, KRISTINE HANSEN, ERIC SCAIFE, N. CLAY MANN AND SUSAN L. BRATTON

• CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved out-comes.

EMERGENCY MANAGEMENT AIRWAY

• Handle Neck With Caution: Assume C-spine Injury• Use Jaw Thrust• Avoid Obstruction of Venous Drainage• Intubate If GCS < 8• May Need to Protect Airway Due to Seizures or Trauma• Intubation Should Be Oral

3 y/o boy after MVA. Spontaneously breathing but

nasal flaring present. Atlantoaxial distraction with

severed spinal cord

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EMERGENCY MANAGEMENTBREATHING

• Even a Small Rise in PaCO2 Causes a Significant Rise in ICP

• “Adequate” Breathing May Not Be Enough- Aim for PaCO2 of 35-40 Torr

• Hyperventilation Is the Quickest Way to Lower ICP If There Are Signs of Herniation

EMERGENCY MANAGEMENT CIRCULATION

• Blood Pressure Must Be Optimized to Help Maintain Adequate CPP

• Only Use Isotonic Fluids for Volume Expansion• May Need Inotropic or Pressor Support• Control Bleeding

EMERGENCY MANAGEMENT DISABILITY

• Glasgow Coma Score– Modified for Children

• Cranial Nerve Exam– Including Pupillary Response to Light, Eye Position and

Movement, Corneal Sensation, Gag

• Motor, Sensory, Reflex Exam• Cranial Exam

– Evaluate for Fractures, CSF Leak, Battle’s Sign Etc.

GLASGOW COMA SCALE

• EYE OPENING (1-4)1-none2-response to pain3-response to voice4-spontaneous

• BEST VERBAL RESPONSE (1-5)1-none2-incomprehensible3-inappropriate4-confused5-oriented

• BEST MOTOR RESPONSE (1-6)

1-none2-abnormal extension3-abnormal flexion4-withdrawal from pain5-localization of pain6-obeys commands

GLASGOW COMA SCALE (MODIFIED FOR YOUNG CHILDREN)

• BEST VERBAL RESPONSE (1-5)• 1-none• 2-restless, agitated• 3-persistently irritable• 4-consolable crying• 5-appropriate words, smiles, fixes/follows

MANAGEMENT OF TBI

• Guidelines For The Management of Severe (Adult) Head Injury

– A joint venture of• The Brain Trauma Foundation• The American Association of Neurological Surgeons• The Joint Section on Neurotrauma and Critical Care

– Journal of Neurotrauma, 1996; 13:626-734– Journal of Neurotrauma, 2000; 17:451-553– Journal of Neurotrauma, 2007; 24:s1-s106

GUIDELINES FOR THE ACUTE MEDICAL MANAGEMENT OF SEVERE TRAUMATIC BRAIN INJURY IN INFANTS, CHILDREN AND ADOLESCENTS

• Crit Care Med 2003 Vol. 31, No. 6 (Suppl.)• Endorsed or supported by:

– American Association for the surgery of Trauma– Child Neurology Society– International Society for Pediatric Neurosurgery– International Trauma and Critical Care Society– Society of Critical Care Medicine– World Federation of Pediatric Intensive and Critical Care Society– National Center for Medical Rehabilitation Research– National Institute of Child Health and Human Development– Syntheses USA– The International Brain Injury Association

DEVELOPMENT OF GUIDELINES

• CLASSIFICATION OF EVIDENCE– CLASS I (PRCT)– CLASS II (“clearly

reliable data”)– CLASS III (retrospective,

case reviews, clinical series)

– TECHNOLOGY ASSESSMENT

• DEGREES OF CERTAINTY– STANDARDS (high

degree)– GUIDELINES (moderate

degree)– OPTIONS (unclear)

CASE CONTINUES…

• Pt intubated, on vent• 20/Kg Saline given

• B/P 115/75, HR 120, O2 sat 100%

• GCS = 7 (Paralyses from RSI resolved)• Head CT = small scattered contusions, small non-surgical sub-

dural.• Abd CT = neg• C-spine CT = neg

What next?

MANAGEMENT OF TBIINDICATIONS FOR ICP MONITOR

• OPTION (Pediatric): – Severe head injury (GCS ≤ 8)

CASE CONTINUES…

• Pt has ventriculostomy placed• Clear CSF flows freely• ICP = 26mmHg

• MAP = 70, HR = 100, RR = 15 (on vent), O2sat=99%, GCS = 7, PEERL

• Questions? Plans?

MANAGEMENT OF TBIHYPERVENTILATION (PEDIATRIC)

• OPTIONS (no standards or guidelines): – Mild or prophylactic hyperventilation (pCO2 < 35 mmHg) should

be avoided. – Mild hyperventilation (30 - 35 mmHg) may be considered for

longer periods if ICP refractory to all other tx.– Aggressive hyperventilation (< 30mm Hg) considered second tier

for refractory hypertension.

CASE CONTINUES…

• ABG shows pCO2 of 45

• Vent rate increased to 18/min, 20/kg NS IV bolus

• Repeat pCO2 = 35

• ICP still 25, MAP = 75, CPP = 50• Head of the bed elevated to 30o

• Pt is sedated and paralyzed• No change in ICP or CPP

What next?

MANAGEMENT OF TBIOSMOTHERAPY - PEDIATRIC

• STANDARDS: none

• GUIDELINES: none

• OPTIONS: HT Saline is effective for control of raised ICP (.1-1 ml/kg/hr). Mannitol is effective therapy (0.25-1/kg) for control of raised ICP– Keep osmolarity <320 (maybe higher for HT saline)

– EUVOLEMIA MUST BE MAINTAINED!

CASE CONTINUES…

• Pt started on Hypertonic saline• Repeat CT shows diffuse swelling and evolution of

contusions.• ICP now 34, MAP = 70, CPP = 46, PER slugish• HR = 82• GCS = 5 when not paralyzed

What now? Time to quit? Is there a chance for good outcome?

OUTCOME IN PEDIATRIC HEAD INJURY

LIMITATIONS OF THE GLASGOW COMA SCALE IN PREDICTING OUTCOME IN CHILDREN WITH TRAUMATIC BRAIN INJURY LIEH-LAI MW, THEODOROU AA, ET AL. J PEDIATR 1992;120:195-9

• 64% with GCS≤5 survived• Nonsurvivors had greater incidence of shock/CPR• 45 survivors with GCS3-11 had neuropsychologic testing

– 37% memory deficits– 30% speech/language deficits– 34% motor function deficits– 18%attention deficits with or without hyperactivity

CASE CONTINUES…

• ICP now 34, MAP = 70, CPP = 46, PER sluggish• HR = 82• GCS = 5 when not paralyzed

• Dopamine started, pCO2 now 30, HR = 72, pupils becoming asymmetric…

MANAGEMENT OF TBIBARBITURATES

• “Option”(Level II for adults): may be considered if ICP control is refractory to other treatment and patient is hemodynamically stable– Reduction in cerebral O2 requirement, ICP– Pentobarbital 2-4 mg/kg/dose, 1-2mg/kg/hour, burst-suppression

on EEG– Questionable effect on outcome– Disadvantages: myocardial function - use inotropes. Difficult

neuro exam

MANAGEMENTCRANIAL DECOMPRESSION

• Ventriculostomy (“option”)• Tumor Debulking• Hematoma Evacuation• Lobectomy• Decompressive Craniectomy (“2nd tier”)

MANAGEMENT OF TBI STEROIDS

• STANDARDS: NOT recommended for improving outcome or reducing ICP in TBI

• Useful for edema around brain tumors– Dexamethasone 0.4mg/kg/q 6 hours

MANAGEMENT OF TBISUPPORTIVE MANAGEMENT

• Temperature control - Maintain low normal temp. ~35˚c (hypothermia under study)

• Head position - 15-30 elevated, avoid jugular compression

• Pain control- pain is bad on ICP!!!• Seizure control (prophylaxis is “option”)• Antibiotics• Adequate nutrition (VERY IMPORTANT!!)

CRITICAL PATHWAY FOR INCREASED ICP TREATMENT

Critical Pathway for Increased ICP Treatment

Critical Pathway for Increased ICP Treatment

CASE PROGRESSION…

• ICP normalizes after 2 weeks• GCS 8-9• Pt has trach and G-tube• Transferred to inpatient rehab after 1 mos• Returns to PICU to say “Hi” one year later…

MYTH #4

• Myth… A Severe Brain Injury Means that the Child Will Be Permanently and Totally Disabled.

• Fact… Patterns of Recovery Vary.– ~80% will have some type difficulty.– The long term consequences are different for each child.

OUTCOME IN PEDIATRIC HEAD INJURY

• Better Then You Think, (For Severe Injury) So Be Aggressive!

• Do NOT Rely on Initial GCS For Prognosis• Mild Brain Injury May Have More Consequences Than

Expected• Injury Severity and Level of Family Support May Best

Predict Outcome!

MYTH # 5

• Myth… The brain injury can’t be that serious if the child came right home from the hospital.

• Fact… More children with disabilities go home upon discharge from the hospital than to in-patient rehab.

Thank you

marcb@peds.arizona.edu

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