1. Traumatic Brain injury
in Paediatric
Dr. Bahari A.Yusuf
KIU-TH, Pediatric Department
DEC-2022
Moderator; Proff. Henry
2. Objectives
• Classification of Traumatic Brain injury
• Indication for imaging
• Aproach of severe TBI management.
• Focus on increased intracranial pressure.
4. Definitions
• Traumatic Brain injury;is a form of acquired brain
injury, occurs when a sudden trauma causes
damage to the brain.
• Primary injury; is direct trauma to the brain.
• Secondary injury; is cascade of biochemical, and
metabolic responses to direct injury which worsens
when the patient develop hypoxia,hypotention or
both.
5. Epidemiology
• TBI is the leading cause of pediatrics death and
disability and affects up to 280 out of 100 000
children worldwide
• Falls and motor vehicle collusions are common
unintentional causes,
• Abuse in infants and young children and
assaults in adolescents are unfortunate
inflicted causes of TBI.
6. • Study btw July 2008 and June 2009(Tu M Tran,
Anthony T Fuller) in MNRH,Kampala; 120 patients
identified and reviewed retrospectively The
cumulative incidence of admissions was 89 per
100,000.
• Thirty one patients of those 120 died. Yeading 25.8%
mortality rate.
• Motor cycle road traffic accident was the leading
mechanism of injury followed by falls.
• Study in 2015(Jihad Abdelgader & David kitya); in
between 2012 and 2015 a total of 381 Pediatric were
admitted to MRRH.
• The mean age was 8.6 with a male
predominnce(62%). The most common mechanism of
injury overall was RTI, which was responsible for
71% of all TBI cases.
7. The unique anatomy of children
can make them more prone to TBI
• Large head to body ratio.
• Less myelinated neuronal tissue
• Thinner cranial bone
8. Causes head trauma
• Falls
• Motor vehicles
• Sports related
• Injuries involving the use of bicycles
• Non-accidental trauma.
9. Head Trauma causes according to age
• Newborns;
-Delivery head injury
-Intracranial hemorrhage
-Cephalohematoma
-Subgaleae hematoma
• Infants;
-Accidental head injury
-Abusive head trauma
Toddlers and school children;
-Accidental head injury
Adolescents;
-Bicycle and motorcycle injuries
- Sports related head injuries
10. Classification of severity
• Severity of traumatic brain injury (TBI) is typically
defined by the initial Glasgow Coma Scale (GCS)
score.
• The GCS score is a widely used assessment of
neurological function that has been validated in
many studies. It has been modified for use in
children.
11.
12. Mild (GCS score 13 to 15)
Moderate (GCS score 9 to 12)
Severe (GCS score <9)
14. Diffuse brain injury
Diffuse brain injury (DBI) is the most common
type resulting in death in children and is
usually produced by impact, acceleration and
deceleration forces.
Diffuse traumatic axonal injury (DAI);is a
severe form of DBI. DAI develops as the result
of tissue shearing at the interface of grey and
white matter; focal injuries may also be
present in patients with DAI.
12/26/2022 14
15. Focal brain injury
Several types of focal brain injury may occur:
Brain contusion –typically arise from blunt
trauma between the brain and the skull after
acceleration and deceleration of the head.
- Contusions may be in the location of impact
(coup), or on the opposite side of the brain
(contrecoup), or both.
Intraparenchymal brain hemorrhage –develops
from tears in the brain tissue and/or vasculature
and may complicate blunt or penetrating trauma.
12/26/2022 15
16. Cont…
Subdural hematoma – Forms when there is
hemorrhage into the potential space between the dura
and the arachnoid membranes.
There are two major sources of bleeding in patients
with SDH: bridging blood vessels that cross the
subdural space and cerebral cortical hemorrhage
caused by direct brain trauma.
SDH commonly complicates severe brain injury,
including abusive head trauma in children.
12/26/2022 16
17.
18. Cont…
Epidural hematoma is a hemorrhage into the
space between the dura and the overlying
calvarium.
After blunt trauma, an EDH may result from
disruption of the middle meningeal artery, the
middle meningeal vein, diploic veins, or venous
sinuses.
A child may be alert on presentation but may
deteriorate after a period of hours.
Subarachnoid hemorrhage –develops from
tearing of small vessels in the pia mater. It may
complicate other brain injuries in children with
severe head trauma or be found in isolation.
12/26/2022 18
19. Clinical manifestations of TBI
• Headache
• Amnesia
• Altared level of
conciousness
• Vomiting
• Blurred vision
• Seizure
Ominous signs of intra-
cranial injury
• Prlonged or impaired loss
of conciusness
• disorientation or
confusion; amnesia.
• worsening headache
• repeated or persistent
vomiting
20. Intra-cranial pressure(ICP)
• Monro-kellie doctrine
-Intracranial vault is comprised of three
elements; Brain(80%),cerebrospinal
fluid-CSF(10%),and cerebral blood
volume-CBV(10%).
-An increase in one should cause
a reciprocal decrease of either one or both
of the remaining two.
The end goal is to prevent further injury or cerebral
herniation.
21. Intracranial pressure should be maintained at < 20 mm Hg
Age-dependent cerebral perfusion pressure targets are
approximately 50 mm Hg for children 2-6 yrs old; 55 mm
Hg for those 7-10 yrs old; and 65 mm Hg for those 11-16
yr old.
24. Increased ICP clinical manifestation
The level of consciousness can range from irritability to
obtundation or coma.
Clinical presentation depends on age of the patient and the
nature of lesion.
Main clinical features are hypertention,bradycardia, and irrigular
breathing(cushing triad)
Infants, there may be bulging fontanelle or seperated sutures.
In children, there may be vomiting,headche,altered mental
status,papile edema,strabismus(3rd and 6th CN pulses) and
sunset sign
In older children, when cranial sutures are closed headache and
occasional vomiting are common initial findings.
The most common cause of death in raised ICP is herniation of
brain tissue from one compartment of the skull to another.
28. Approach to critically injured
child
primary survey ( rapid primary evaluation and
resuscitation of vital functions ( ABCD )
Secondary survey (fully exposed head-to-toe
examination )
definitive care (pediatric trauma center)
29. Primary survey
• Involves assessment of life threatening conditions
• A – Airway patency and c-spine protection
• B – Breathing
• C – Circulation
• D- Disability
• E – Exposure and envirnment
30. Airway patency
• Determine patency ,
• Access for presence of FB in mouth or pharynx –
removed under visual
• Use Sniffing position ( jaw thrust) – maintains
neutral spine
• Suction for secretion
• In case airway still inadequate: then
• Oropharyngeal / nasopharyngeal airway adjuncts for
bagging prior to ETI ( prevents hypoxemia and
hypercarbia)
31. C- spine protection (
immobilization)
• Jaw thrust ( sniffing position)
• Use appropriate sized cervical collar
• Towel roll or IV bags placed on both sides of the head for
small children and infants
• Spine board use - with towels under buttocks and shoulders
• Head positioning – The head should be maintained in a
neutral position to avoid jugular venous obstruction.
Elevating the head to 30 degrees appears to optimize
cerebral perfusion pressure and decrease ICP
36. Indications for endotracheal tubation
(ETT)
Severe head injury (GCS less than 8)
Hemorrhagic shock
Impending or potential airway compromise
(airway trauma, inhalation trauma)
Flail chest with inadequate chest wall movement
e.g. multiple rib.
37. • Nasotracheal intubation should not be performed in
patients with midface trauma or signs of a basilar skull
fracture (raccoon's eyes, mastoid hematoma, or CSF
drainage from the nose or ear canals).
• Children with these injuries may have fractures of the
cribriform plate.
• Use cuffed tracheal tubes for all major pediatric trauma
to protect the airway from aspiration.
38.
39.
40.
41.
42.
43. B-Breathing
Check the work of breathing, pulse oximeter. Provide high flow
oxygen.
Hyperventilation (PaCO2 <35 mmHg) may cause cerebral ischemia
as the result of decreased cerebral blood flow. Consequently, PaCO2
should be maintained between 35 and 38 mmHg unless there are signs
of pending herniation.
Because herniation and its devastating consequences can sometimes
be reversed if promptly addressed, it should be treated as a medical
emergency , with use of hyperventilation, with a fraction of inspired
oxygen of 1.0, and intubating doses of either thiopental or
pentobarbital and either mannitol (0.25-1.0 g/kg IV) or hypertonic
saline (3% solution, 5-10 mL/kg IV).
44. C-Circulatory failure
Pass 2 large bore lines
Iv fluids 20ml/kg in 10-15 minutes. (isotonic saline/ R/L )
Volume should be restored. Isotonic solutions should be used for
fluid resuscitation. Blood products should be administered as
indicated.
Vasopressors may be needed as guided by monitoring of central
venous pressure, with avoidance of both fluid overload and
exacerbation of brain edema.
45. Management of increased
Intracranial pressure ICP
• Therapy includes elevation of the head of the bed, ensuring
midline positioning of the head, controlled mechanical ventilation,
and analgesia and sedation
• hypertonic saline (often given as a continuous infusion of 3%
saline at 0.1-1.0 mL/kg/hr) and mannitol (0.25-1.0 g/kg IV over
20 min), given in response to ICP spikes >20 mm Hg or with a
fixed (every 4-6 hr) dosing interval.
• Use of hypertonic saline is more common and has stronger
literature support than mannitol, although both are used; these 2
agents can be used concurrently. It is recommended to avoid
serum osmolality >320 mOsm/L. A Foley urinary catheter
should be placed to monitor urine output.
46. Continue……
• In some centers, surgical decompressive craniotomy is
used for refractory traumatic intracranial hypertension.
• Others use a Pentobarbital infusion , with a loading dose
of 5-10 mg/kg over 30 min followed by 5 mg/kg every
hour for 3 doses and then maintenance with an infusion of
1 mg/kg/hr.
47. D-Disability
• Disability refers to child’s neurologic function in
terms of level of conscious and cortical function.
• GCS
• AVPU
• Pupillary responsiveness
E-Exposure
• Full exposure of the baby
• Eases identification.
48. Others…
• Check glucose.
-Maintain normal glycemia
-Hypoglycemia can lead further injury
-Hyperglycemia is associated worse outcome in critical
patients.
• Treat seizures
-Pos-traumatic epilepsy(10-20%)
-More common in children compared to adult.
-Some guidelines recommend early prophylaxis
with phenytoin has shown early and late seizure onset.
• Avoid hypothermia – use radiant warmer, warm fluids& warm blanket.
However there is studies suggesting in refractory elevated ICP that
hypothermia decreases ICP in initially but after 5 days has little or
no effect.
49. Secondary survey
Systemic head to toe physical examination
Post resuscitation monitoring of vital functions
Its done after stabilization of the patient
Can be delayed in case of urgent procedures and
investigations
50. • TBI are common but vast majority are minor injuries.
• All TBI needs CT scan of head. X-ray has limited role
• Important to recognise severe TBI early to prevent
further secondary injury.
• Monitor signs of increased ICP and herniation and
promptly treat.
• Early communication with a tertiary care centre.
Conclusion
51. 1. NELSON PEDIATRICS 21ST EDITION
2. BASIS OF PEDIATRICS 10th EDITION.
3. MEDSCAPE
4. UPTODATE
5. INTERNET.
References
