HEAD INJURYO Major cause of mortality and morbidity in children.O Leading cause of death in children > 1year is trauma.O Head injury is responsible for most trauma deaths approximately 80%. (50% in adults)
PATHOPHYSIOLOGYO Children are more vulnerable to injury from head trauma O Relatively large (10% of body weight) means increased momentum and tend to land on head with falls. O Elastic, underdeveloped cervical ligaments and muscles are less protective. O Soft calvarium. O Large subarachnoid space (veins at increased risk of tearing)
ETIOLOGYO Road traffic accidentsSevere head injuriesO FallsUsually in children <4years and usually mildO Recreational activitiesBicycle accidentsO Assaults/NAIMost head injuries in kids <1yrare from falls and NAI
ANATOMYO BRAIN Inelastic and non compressible Has no internal supportO CRANIUM Rigid and unyielding Bony buttresses at anterior and temporal polesO MEMBRANOUS “SLINGS”
Rhoads & Pflanzer (1996) Human Physiology p. 211
Layers of the Cranial Vault Anatomy of the Brain www.neurosurgery.org/pubpgages/patres/anatofbrain.
BRAIN INJURY Primary Secondary Ischaemia hypoxia,Intracranial Delayed cell Mass Lesion hypotension HTN death and hypercarbia
PRIMARY BRAIN INJURY Coup Focal ContraPrimary coup Diffuse DAI
TRAUMATIC HEAD INJURYALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) LippincottWilliams & Wilkins.www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
TYPES OF PRIMARY INJURYO Focal injuries Skull fracture Parenchymal contusion Parenchymal laceration Vascular injury resulting in epidural, subdural or parenchymal haematoma.O Diffuse injuries Diffuse axonal injury Diffuse vascular injury
Scalp haematomas/lacerationsO Very vascular, but generally can‟t lose enough blood to cause shock or hypovolemiaO Cephalohematoma – beneath periosteum (does not cross suture lines)O Subgaleal bleed - beneath galea (crosses suture lines, often boggy) O Critical in neonate (e.g. from birth trauma) O Can lead to shock/hypovolemiaO Clean and examine scalp wounds well to r/o underlying skull fracture; often staple
SKULL FRACTURESO ANY skull fracture can cause underlying ICH, but 50% of bleeds have no fracture QuickTime™ and aO Skull films are of little decompressor are neede d to see this picture. use - if suspect skull fracture or bleed, get non contrast CT
SKULL FRACTURESO Linear(3/4)- outpatient observation OK, but get neurosurgical evaluation and f/u if under age 2 O Can develop leptomeningeal cyst if dural tearO Depressed - require neurosurgical evaluation possible repair if depression>skull thickness O More often develop seizures O Often get prophylactic AEDsO Basilar (Battle‟s sign, haemotympanum, raccoon eyes) - head CT with inpatient observation, neurosurgical evaluation.
Case 1O A 2 year-old comes in after falling approximately 3 feet from her parent‟s bed. The CT scan shows the following:
What is your diagnosis?1. Epidural hematoma2. Subdural hematoma3. Diffuse axonal injury4. Contusion
Subdural HematomaO More common than epidural in childrenO Tears in parasagittal bridging veinsO Concave shapeO Often associated with more diffuse shear injuryO Immediate surgical tx if pt is unconscious and has subdural bleedO Suspect NAI
Case 2O A 5 year old girl falls from a second story window. You find the following on CT scan:
What is your diagnosis?1. Epidural hematoma2. Subdural hematoma3. Diffuse axonal injury4. Contusion
Epidural HematomaO Caused by tears of meningeal vesselsO Convex shapeO Often associated bone fracture (up to 75%)O Typically few hours of lucidity followed by rapid deteriorationO Need close observation and often surgical evacuationO Good prognosis if recognized and treated
SUBDURAL VS. EPIDURALLifeArt: Williams & Wilkinshttp://www.lifeart.com
SUBDURAL HEMATOMA WebPath: University of Utah http://www-medlib.med.utah.edu
SUBDURAL vs EPIDURAL HEMATOMAO EPIDURAL O SUBDURAL O Requires linear force O Requires significant O Associated with skull rotational forces fracture and torn O Associated with brain artery. Brain often uninjured injury and torn O “Lucid” interval bridging veins common O Neurologic O Common in symptoms from the accidental trauma start O Common in infants with NAI.
Cerebral ContusionO Occur at the site of blunt traumaO Usually have loss of consciousnessO Can be very small/mild or large, resulting in significant symptoms (cerebral edema, increased ICP)O Often associated with intracranial hematomas or skull fractures
Intracerebral HaemorrhageO Rare in Paediatric population.O Usually frontal or temporal lobeO Can be bilateral(countracoup injury)O Can act as mass lesions and cause intracranial hypertensionO CT-Hyperdense/mixedO MRI-Small petechia+DAIO Rx: Small-non operative Large-Sx drainage
Penetrating Head InjuryO Infants and children: fall on sharp objects, NAI, GSWO CT- Localizes bullet and bone fragments.O MRI-Not advised till magnetic properties of bullet knownO Treatment: Debridement of entry and exit wounds Remove accessible bullet and bony fragments Control haemorrhage Repair dural lacerations+closure of wounds No attempt to REMOVE BULLET OR BONE beyond entry and exit wounds.
Diffuse Axonal InjuryO Often from acceleration/deceleration injuries (RTA, falls, shaking)O Widespread shearing of white matterO Suspect if patient has subarachnoid bleeding and cerebral edemaO Edema develops over 24-48 hours
Diffuse Axonal Injury• Shearing injury of axons • Deep cerebral cortex, thalamus, basal ganglia • Punctate hemorrhage and diffuse cerebral edemaImage from: Neuroscience for Kidswww.faculty.washington.edu/chudler/cells/html
Secondary InjuryO Subsequent factors that secondarily cause brain tissue damageO Intracranial O Hemorrhage/Ischemia O Edema O Increased ICPO Systemic O Hypoxia/hypercapnia O Hypotension O Hyperglycemia
Defining SeverityO Mild Brain Injury O GCS = 13-15 O Limited impaired consciousness (<30 min) O Normal CT scan O Shows signs of a concussion O Vomiting O Lethargy O Dizziness O Lacks recall about injury
Defining SeverityO Moderate Brain Injury O GCS = 9 - 12 O Impaired Consciousness (<24) O CT scan EvidenceO Severe Brain Injury O GCS = 3 - 8 O Impaired Consciousness (> 24 hours)
CAUTION!!O GCS of 13 may not be so “mild”O SC Stein, J Trauma. 2001;50:759-760 O Reviewed 14 studies (1047 adult patients with GCS of 13) O 33.8% had intracranial lesions O 10.8% required surgery
Defining SeverityO GCS, hypoxemia and radiologic evidence of SAH, cerebral edema and DAI are predictive of morbidity.O GCS alone does not predict morbidity. Ong et al. (1996) Pediatric Neurosurgery, 24(6)O Hypotension is predictive of morbidity.O GCS and Pediatric Trauma Score are not predictive of outcome. Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
CT or no CTO A 3months old baby presented with minor head injury. Fell of the table about 2 feet high. NO LOC GCS 15 O/E well, pupils b/l equal and reacting 6 cm laceration occipital area
CT or no CTO 15 year old boy football injury. Brief LOC Vomited once at scene O/E Well, alert, GCS 15 No focal neurology
Admission or no Admission O 15 year old boy hit by car. O GCS 14/15 E 4 M6 V4 O Rest all ok! CT or no CT? Admission? Neuro obs:
Head injury triage, assessment, investigation and early management of head injury in infants, children and adults (update) Implementing NICE guidance December 2007NICE clinical guideline 56
Updated guidanceO This guideline replaces „Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults‟ (NICE clinical guideline 4, 2003)O There was sufficient new evidence to prompt an update to be carried out which means changes in clinical practiceO There are new and amended recommendations
Key recommendationsO Initial assessment in the emergency departmentO Urgency of imagingO Admission • Criteria for admission • When to involve the neurosurgeonO Organisation of transfer of patients between referring hospital and neuroscience unitO Advice about long-term problems and support services
Initial assessment in the emergency department (ED)O All patients presenting to an ED with a head injury should be assessed by a trained member of staff within 15 minutes of arrival at hospitalO This assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury
Urgency of imaging: head CTOCT of the head should be performed and analysedwithin 1 hour of imaging request in patients whohave any of these risk factors: O Glasgow Coma Scale (GCS) < 13 on initial assessment in A&E or < 15 at 2 hours after injury O Suspected open or depressed skull fracture or any sign of basal skull fracture O Two or more episodes of vomiting in adults; three or more in children O Post-traumatic seizure O Coagulopathy, providing that some loss of consciousness or amnesia has been experienced O Focal neurological deficit
Urgency of imaging: head CTO Patients who have any of the risk factors below, and none of the risk factors on the previous slide should have CT imaging of the head performed within 8 hours of the injury: O Amnesia for > 30 minutes of events before impact (assessment unlikely to be possible in any child aged under 5 years) O Age 65 years, providing that some loss of consciousness or amnesia has been experienced O Dangerous mechanism of injury (e.g. a fall from a height of > 1 metre or 5 stairs), providing that some loss of consciousness or amnesia has been experienced.
Admission: CriteriaO Clinically significant abnormalities on imagingO Patient has not returned to GCS 15 after imaging, regardless of the imaging resultsO Criteria for CT scanning fulfilled, but scan not done within appropriate period, either because CT not available or because patient not sufficiently cooperative to allow scanningO Continuing worrying signs (e.g. persistent vomiting)O Other sources of concern (e.g. drug intoxication, other injuries, non accidental injury)
Secondary Brain InjuryPotentially Avoidable Or Treatable With CloseMonitoring / Treatment of ABC‟sO HypoxiaO HypercarbiaO Hypotension/ischemiaO Intracranial hypertensionO AcidosisO SeizuresO HyperthermiaO HypothermiaO Infections
Evidence based management of severe traumatic brain injury in childrenO Guidelines for the Acute Medical Management of severe traumatic Brain Injury in infants, Children, and Adolescents. Journal of Pediatric Critical Care Medicine. January 2012-Second editionO Text book of Paediatric critical care Bradley P.Fuhrman, Jerry J.Zimmerman Third edition2006O NICE Guidelines- Updated December 2007
Level of EvidenceO Level I Good quality RCTO Level II Moderate or poor quality RCT Good quality cohort Good quality case controlO Level III Moderate or poor quality RCT or cohort Moderate or poor quality case control Case series, databases, registeries
INITIAL MANAGEMENTO AIRWAY with C-Spine controlO BREATHINGO C T SCAN CIRCULATIONODOEOF&G
EARLY RESUSCITATION OF CHILDREN WITH MODERATE-TO-SEVERE TRAUMATIC BRAIN INJURYPEDIATRICS 2009;124;56-64 MICHELLE ZEBRACK, CHRISTOPHER DANDOY,KRISTINE HANSEN, ERIC SCAIFE, N. CLAY MANN AND SUSAN L. BRATTONO 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.
Circulatory Support:Maintain Cerebral Perfusion CPP = MAP -Pressure ICP 6 5 Number of 4 Good Hypotensiv Moderate e Episodes 3 Severe in the first 24 hours 2 Vegetative after TBI Dead 1 0 Patient Outcome Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
Airway and ventilationCriteria for the intubation of Head injured child O GCS<10 O Decrease in GCS of >3, independent of the initial GCS. O Anisocoria>1mm O Cervical spine injury compromising ventilation. O Apnoea O Hypercarbia(PaCo2>45mmg/6.0Kpa) O Loss of pharyngeal reflex O Spontaneous hyperventilation causing PaCo2<25mmHg/3.3Kpa
Airway and ventilationO Hypoxia to be avoided. Aim Pao2 of >13kpa Aim PaCo2 of 4.5-5.0kpaO Avoidance of prophylactic severe hyperventilation to a PaCO2 of <30mmHg(4.0kpa).O If hyperventilation is used in the management of refractory intracranial hypertension, advanced neuromonitoring like jugular venous oxygen saturations, brain tissue oxygen tension measurements for evaluation of cerebral ischemia may be considered. (LEVEL III)
Head elevation of 30 degreesO This improves venous drainage with minimal effect on arterial pressure.O Head in midline to ensure no pressure or kinking of neck veins.O If head raised more then 30 degrees possible adverse effect on cerebral arterial pressure.Carter BG, Butt W, Taylor A: ICP and CPP: Excellent predictors of long termoutcome in severely brain injured children. Childs Nerv Syst 2008; 24:245–251
Keep neck mid-line and elevate head of bed …. To what degree? Feldman et al. (1992) Journal of Neurosurgery, 76 March et al. (1990) Journal of Neuroscience Nursing, 22(6) Parsons & Wilson (1984) Nursing Research, 33(2)
Normal Cerebral MetabolismO Brain tissue relies on aerobic metabolism.O Normal cerebral metabolism requires a blood flow of approximately 50 mL/100g/min.O Serious neurological deficits begin to occur at 20 mL/100g/min.O Prolonged Cerebral Blood Flow < 12 mL/100g/min. results in cerebral infarction.
CBF AutoregulationO CBF maintained within CPP range of 50 – 150 mmHg.O CPP =MAP – ICPO <50 CPP= Maximal dilation CBF fallsO >150 CPP=Maximal constric CBF raisesAutoregulation1)Completely lost-linear relation CBF & CPP2)Incompletely lost-Plateau after CPP of 80 mmHg
Copied from: Rogers (1996) Textbook of Pediatric Intensive Care p. 646
ICP Monitoring-Level IIIO A frequently reported high incidence of intracranial hypertension in children with severe TBI.O A widely reported association of intracranial hypertension and poor neurologic outcomeO The concordance of protocol-based intracranial hypertension therapy and best-reported clinical outcomesO Improved outcomes associated with successful ICP-lowering therapies
Monitoring of Intracranial pressureO Indications: GCS <8 Abnormal head CT Rapid neurological deterioration Normal CT head in adults O Age>40 O Unilateral or bilateral motor posturing O Systolic BP <90
Treatment of raised ICPO Treatment of intracranial pressure (ICP) may be considered at a threshold of 20 mm Hg (LEVELIII).Grinkeviciute DE, Kevalas R, Matukevicius A, et al.: Significance ofintracranial pressure and cerebral perfusion pressure in severepediatric traumatic brain injury. Medicina (Kaunas, Lithuania) 2008;44:119–125
Cerebral perfusion pressureO A minimum CPP OF 40mmHg (Level III) may be considered in children with TBI.O A CPP threshold of 40-50mmHg may be considered; infants at lower end and adolescents at the upper end of this range. (Level III).
ICP Measurement-InvasiveO Intraventricular catheter coupled to ICP transducer is Gold standard. Adv: CSF can be drained Dis adv: Infection, Ventricular compressionleads to inaccuracyO Fiberoptic cath: Adv: Improved Longevity, can be placedintraparenchymal/intraventricular/subdural Dis adv: Not able to drain CSFO Subdural/subarachnoid Bolts: Occulusion of ports can lead to inaccuracy
Advanced NeuromonitoringO If brain oxygenation monitoring is used, maintenance of partial pressure of brain tissue oxygen (PbtO2) >10 mm Hg may be considered.(LEVEL III)O Figaji AA, Zwane E, Thompson C, et al.: Brain tissue oxygen tension monitoring in pediatric severe traumatic brain injury. Part 1: Relationship with outcome. Childs Nerv Syst 2009; 25:1325–1333O Narotam PK, Burjonrappa SC, Raynor SC, et al.: Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome. J Pediatr Surg 2006; 41:505–513
NeuroimagingO In the absence of neurologic deterioration or increasing intracranial pressure (ICP), obtaining a routine repeat computed tomography (CT) scan >24hrs after the admission and initial follow-up study may not be indicated for decisions about neurosurgical intervention. (LEVEL III)
Hyperosmolar therapyO Hypertonic saline should be considered for the treatment of severe paediatric traumatic brain injury associated with intracranial hypertension. Effective doses for acute use range between 6.5 and 10 mL/kg (of 3%) (LEVEL II).
Temperature controlO Moderate hypothermia (32–33°C) beginning early after severe traumatic brain injury (TBI) for only 24hr‟s duration should be avoidedO Moderate hypothermia (32–33°C) beginning within 8 hrs after severe TBI for up to 48 hrs‟ duration should be considered to reduce intracranial hypertension.O If hypothermia is induced for any indication, rewarming at a rate of >0.5°C/hr should be avoided (LEVEL II).O Moderate hypothermia (32–33°C) beginning early after severe TBI for 48 hrs, duration may be considered (LEVEL III).
Cerebrospinal fluid drainageO Cerebrospinal fluid (CSF) drainage through an external ventricular drain may be considered in the management of increased intracranial pressure (ICP) in children with severe traumatic brain injury (TBI).O The addition of a lumbar drain may be considered in the case of refractory intracranial hypertension with a functioning external ventricular drain, open basal cisterns, and no evidence of a mass lesion or shift on imaging studies (LEVEL III).
BarbituratesO High-dose barbiturate therapy may be considered in haemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management.O When high-dose barbiturate therapy is used to treat refractory intracranial hypertension, continuous arterial blood pressure monitoring and cardiovascular support to maintain adequate cerebral perfusion pressure are required (LEVEL III).
Decompressive craniectomy O Decompressive craniectomy (DC) with duraplasty, leaving the bone flap out, may be considered for paediatric patients with TBI who are showing early signs of neurologic deterioration or herniation or are developing intracranial hypertension refractory to medical management during the early stages of their treatment. (LEVEL III).
CorticosteroidsO The use of corticosteroids is not recommended to improve outcome or reduce intracranial pressure (ICP) for children with severe traumatic brain injury.(LEVEL III)
Analgesics, sedatives, andneuromuscular blockadeO Thiopental may be considered to control intracranial hypertension.O Propofol Not recommended.(LEVEL III)O Etomidate can be used as a one off bolus but look for adrenal suppression.
Nursing Activities and ICP 20 18 16 14ICP 12 Turning 10 8 Suctioning 6 Bathing 4 2 0 Before During After Rising (1993) Journal of Neuroscience Nursing, 25(5)
Glucose and nutritionO The evidence does not support the use of an immune-modulating diet for the treatment of severe traumatic brain injury (TBI) to improve outcome (LEVEL II).O In the absence of outcome data, the specific approach to glycemic control in the management of infants and children with severe TBI should be left to the treating physician (LEVEL III)
Antiseizure prophylaxisO Prophylactic treatment with phenytoin may be considered to reduce the incidence of early posttraumatic seizures (PTS) in paediatric patients with severe TBI (LEVEL III).O The incidence of early PTS in paediatric patients with TBI is approximately 10% given the limitations of the available data. Based on a single class III study, prophylactic anticonvulsant therapy with phenytoin may be considered to reduce the incidence of early posttraumatic seizures.
SummaryO Serial neurologic assessments and physical examinationO Continuous cardio-respiratory, ICP, and CPP monitoring, +/- cerebral metabolism monitoring adjunctsO Maximize Oxygenation and Ventilation Maximize oxygenation Normo-ventilate Support circulation / maximize cerebral perfusion pressure Maintain mean arterial blood pressure and maintain CPP.
SummaryO Decrease intracranial pressure O Evacuate mass occupying hemorrhages/lesions. O Consider draining CSF when possible O Hyperosmolar therapy, cautious use to avoid hypovolemia and decreased BP O Mid-line neck, elevated head to 30 degree. O Treat pain and agitation - consider pre- medication for nursing activities, +/- neuromuscular blockade. O Careful monitoring of ICP during nursing care, cluster nursing activities and limit handling when possible
SummaryO Decrease Cerebral Metabolic Rate O Prevent seizures O Reserve thiopentone for refractory conditions O Avoid hyperthermia, +/- hypothermia O Avoid hyperglycemia (early)