neuropediatric

1. Pediatric Severe Traumatic Brain Injury
And
Updates on management guidelines

2. Case presentation
 6 months old girl
 PMH : -
 PSH:-
 C.C:
 agitation
 somnolence
 spastic movement of extremities
 following 2 hours history of head trauma after a fall down from her
brother shoulders posteriorly .

3. Upon presentation to our ER
1) Vital signs:
Tº BP HR SPO2 HGT
36 130/80 122 99 258

4. Upon presentation to our ER
2) Neurological examination:
a)GCS=8
b) somnolence appearance
c) Pedaling movement and myoclonus of extremities ( on/off)
Eye opening Verbal response Motor response
Absence of spontaneous
eyes opening with
areactive dilated pupils
inappropriate crying withdrawing from pain
upon painful stimuli

5. Upon presentation to our ER
3) The rest of physical exam :
 Head: no laceration, no cut wound , no external bleeding
 Respiratory wise: GBAE, no wheezing ,no tachypnea , no respiratory effort
 Cardiac wise : regular rhythm , no murmur , no tachycardia
 Abdomen : non distended , soft
 Back : no ecchymosis , no bruises , no cut wound

6. THUS…
1.Severe traumatic brain injury with
possible intracranial bleed
2.Seizure activity
What is the
diagnosis ?

7. Rapid actions taken:
1.
• Epanutin IV loading dose for seizure given
2.
• CT brain without contrast (done as out):
• a)left pericerebral fronto-parietal hematoma
• b)no mass effect
• c)right fronto-parietal subarachnoid petechial lesion
• d)right parietal and para-occipital bone fracture
extending to the foramen magnum
3. • Neurosurgeon consultation

9. Neurosurgeon consultation:
• No indications for surgery
1.
• Conservative management
2.
• Clinical ,imaging and
laboratory follow -up
3.

10. The following actions taken …
1.PICU admission
2.Monitor attachement with monitoring of vital signs ,HGT
3.IV hydration : 500 c.c NSS (2/3 of maintenance)
4.Medications:
a. Pain killers >>> perfalgan
b. Dexamethasone (1mg/kg/day ) IV
c. PPI >>> risek
d. Antiepileptic >>>Epanutin maintenance dose IV
5. position: 45º elevation of head from bed
6. Diet : NPO

11. One hour later…
Neurological condition improve :
Stable vital signs with decrease in HGT to 133
spontaneous eye opening with reactive pupils to light from time to time
better response to painful stimulus
on/off pedaling movement persist >>> valium once given

12. Laboratory tests at Admission:
HB HCT MCV PLA
T
WBC Na K Ca Ph Mg Cr BUN INR PTT CRP
11 31.9 82.2 169 13.69 141 4.52 9.53 4.26 1.99 0.21 7 0.9 28.1 <0.6

13. Repeated CT brain
6 Hrs from the first one
stable

14. Evolution of patient’s
condition within the
following days of
hospitalization…

15. Vital
signs
Physical exam Imaging results Blood test Treatment
Day 2 BP=
100/60
HR=140
T°= 37°c
Spo2=99%
HGT=175
• No seizure
• Unconscious
• Better response to painful stimulus
• Spontaneous eye opening with
reactive pupils
• Otherwise normal
CT brain findings:
stables without
changes
Hb =8.3
MCV=82.1
plat=291
Na=142
K=3.93
Co2=16
• Epanutin IV
(5mg/kg/day)
• Dexamethasone
IV
(1mg/kg/day)
• PPI
• Pain killers
• 45° head
elevation
• NPO
• IV 500c.c NSS
(2/3 maintenance)

16. Vital signs Physical exam imaging Blood tests Treatment
Day 3 BP= 110/50
HR=145
T°=37.5°c
Spo2=99%
HGT= 140
• Episodes of seizure with
bradycardia and desat
• Unconsious
• Mild response to painful
stimulus
• Alternation between
pesence versus absence
of spontaneous eye
opening
• otherwise normal
Hb =8.1
MCV=83
Plat=384
Wbc=17.48
• Epanutin IV
(5mg/kg/day)
• Dexamethasone IV
(1mg/kg/day)
• PPI
• Pain killers
• 45° head
elevation
• Feeding started
then stoped
when seizure
reccured
• Valium IR PRN
• Gardenal POGT
( 6mg /kg/day)
• IV 500c.c NSS
(2/3 maintenance)

17. Vital signs Physical
exam
imaging Blood tests treatment
Day 4 BP=110/50
HR=140
T°=36.5°C
Spo2=99%
HGT=121
• Episodes of
seizure
decreasing in
intensity and
frequency
• Unconscious
• Mild response
to painful
stimulus
• Alternation
between
pesence versus
absence of
spontaneous
eye opening
• Positive
babinski sign
mainly right
• Positive Gag
reflex
• otherwise
normal
• CT of brain :
Stable without
cerebral
involvement
with
reappeanrance of
Median extradural
occipital
hematoma 30*10
mm
• EEG:
dysfuncion
with
multifocal
epileptiform
activity on
left
posterior
(temporal
and parietal
lobe)
derivations
Hb =7.6
MCV= 83.9
Plat=382
wbc=14.94
Na =138
K=4.44
Ph=4.04
Ca= 8.79
Mg=1.98
Cr =0.16
Phenytoin level =13.29
• Neuropediatric
consultation
• Epanutin IV
(5mg/kg/day)
• Dexamethasone IV
(1mg/kg/day)
• PPI
• Pain killers
• 45° head elevation
• NPO
• Valium IR once PRN
• Gardenal stoped
• Lepitam POGT
(30mg/kg/day) started
• IV 500c.c NSS
(2/3 maintenance)

18. Vital signs Physical exam imaging
Blood
tests treatment
Day 5 BP=100/60
HR=130
T°=37.5°c
Spo2=99%
HGT=91
• Episodes of
seizure decreasing
in intensity and
frequency
• Conscient with
spontaneous eye
opening
• Otherwise normal
• Epanutin IV
(5mg/kg/day)
• Dexamethasone IV
(1mg/kg/day)
• PPI
• Pain killers
• 45° head elevation
• NPO
• Valium IR once PRN
• Lepitam POGT
(30mg/kg/day
• IV 500c.c d5w+7c.c
Nacl +7c.c Kcl (2/3
maintenance)

19. Vital signs Physical exam Imaging Blood tests
Day 6 BP=90/50
HR=130
T°=37.3°c
Spo2=99%
HGT=122
• Absence of seizure
• Normal neurological
examination
Hb =7.8
MCV= 83.6
Plat=405
Na=134
K=4.56
Ca=9.29
Ph=4.68
Mg=2.04
• Epanutin IV
(5mg/kg/day)
• Dexamethasone IV
tapering
(0.5mg/kg/day)
• PPI
• Pain killers
• 45° head elevation
• Lepitam PO
(30mg/kg/day)
• Feeding restarted
• IV 500c.c d5w+7c.c
Nacl +7c.c Kcl (2/3
maintenance)

20. Vital signs Physical exam imaging Blood tests treatment
Day 7-8-9 BP=100/50
HR=125
T°=37°c
Spo2=99%
• Absence of seizure
• Normal neurological
examination
Na=135
K=4.98
Ph=4.9
Ca=9.44
Mg=2.16
Cr=0.15
CRP=5
• D/C all
medications
other than
lepitam PO
• IV 100c.c KVO
• Transfer to
regular floor
• D/C patient on
day 9 on lepitam,
nexium
•
• Follow up with
neuropediatrician
and ophthalmologist
• Repeat EEG after
1 month

21. Pediatric traumatic brain injury
 leading cause of death and disability in children
 result in traumatic injuries to the scalp, skull, and brain that are comparable to those in adults
but differ in both pathophysiology , management, accompanying neurological symptoms

22. EPIDEMIOLOGY
 traumatic brain injury (TBI) leads to:
-640,000 emergency department visits
-18,000 hospitalizations
-1,500 death
 in children ages 14 and younger each year
 occur more frequently in children ages 4 and younger population than in any other age
group except those 75 and older
 Boy > girl

23. Age dependant etiology
Infants and
young
children
toddler age
1-falls
2-Motor vehicle
accident
3-Abusive or
intentional injury
1-falls
2-Motor vehicle
accident
School-aged
children
Adolescents
bicycle-related
injuries
1.motor vehicle
injuries
2. sports-related
injuries
3.assaults.

24. Pathophysiology
• Skull fracture
• Intracranial hemorrhage
• contusions
Primary brain injury :
immediate consequence of
the force of the trauma
• cerebrovascular dysregulation
• Diffuse cerebral swelling
• Traumatic axonal injury
• Inflammation
Secondary brain injury:
Due to physiologic, metabolic and
cellular alterations following minutes
to weeks the primary brain injuries

25. Grades of TBI
 The clinical presentation is extremely variable depending on the severity of trauma
 The Pediatric Glasgow Coma Scale (PGCS) is commonly used to assess consciousness and to define
the severity of head injuries :
 GCS above 12: Mild/minor TBI
 GCS of 9-12: Moderate TBI
 GCS below 9: Severe TBI
 Generally, neurological deficits are found at the time of injury, and newly appeared clinical signs
may indicate further progression of pathological changes due to head injuries

26. Severe traumatic brain injury
 Associated with high mortality and morbidity rate
 Hallmark of severity is the presence of coma. (GCS 3-8)
 seizures, nausea/vomiting, headache, visual changes, amnesia, and confusion are
also manifestation of severe TBI and possible ICH or brain herniation
 Caution should be taken to prevent the development of Intracranial hypertension
and brain herniation

27. Management of severe TBI in pediatrics
 Initial intervention focuses on the detection of the primary injury and prevention or treatment of secondary brain injury
 Stabilization begins with applying the basic elements of resuscitation:
1.securing the airway
2. achieving adequate oxygenation and ventilation with maintaining eucapnia [PaCO2] of 35-39 mm Hg
And prevent hypoxia [PaO2] <60-65 mm Hg
3.avoiding or rapidly treating hypotension.
N.B:Hypercarbia and hypoxia must be avoided, because they are both potent cerebral vasodilators that result in increased
cerebral blood flow and volume and, potentially, increased ICP and ICH
 Neurosurgeon will evaluate the potential need for surgical intervention by the evaluation of injuries on CT of Brain done
afte immediate stabilization of patient and clinical evaluation

28. Updates on management guidelines to
continue treatment
 Pediatric critical care medicine, 3rd edition, update its guidelines and include new
recommendations designed to improve patient care and increase survival and recovery in
children who experience a severe TBI
 All recommendations are grouped into three categories :
1. Monitoring
2. thresholds
3. Treatments
 And graded according to the quality of evidence:
1. Level I recommendations : high-quality body of evidence.
2. Level II recommendations :moderate-quality evidence.
3. Level III recommendations :low-quality evidence.

29. Monitoring Recommendations
monitoring does not directly affect patient outcomes but help direct treatment decisions
which may, in turn, lead to better outcomes than those based on clinical assessments alone:

30. ICP monitoring
 Level III To improve overall outcomes :
III.1. Use of ICP monitoring is suggested.

31. brain tissue oxygenation (Pbro2)
monitoring
 Advanced Neuromonitoring (level III):
There was insufficient evidence to support a recommendation for the use of a monitor
of Pbro2 to improve outcomes.
 maintaining a level greater than 10 mm Hg is suggested
 should only be for patients with no contraindications to invasive neuromonitoring
such as coagulopathy and for patients who do not have a diagnosis of brain death

32. Neuroimaging recommendation:
 Level III recommendation
 Excluding the possibility of elevated ICP on the basis of a normal initial (0-6 h after
injury) CT examination of the brain is not suggested in comatose pediatric patients
 Routinely obtaining a repeat CT scan greater than 24 hours after the admission and
initial follow-up is not suggested for decisions about neurosurgical intervention,
unless there is either evidence of neurologic deterioration or increasing ICP

33. Neuroimaging recommendation:
 Initial CT is mandatory in severe TBI
 Use of CT to Rule Out Intracranial Hypertension: low-quality evidence to support the recommendation do
not exclude the possibility of intracranial hypertension based on a normal initial head CT

34. Thresholds recommandations
 Thresholds for Treatment of Intracranial Hypertension Recommendations (level III):
Treatment of ICP targeting a threshold of less than 20 mm Hg is suggested.
 Thresholds for CPP (cerebral perfusion pressure: ) Recommendations: (level III)
1. Treatment to maintain a CPP at a minimum of 40 mm Hg is suggested. (Because decrease in CPP
may induce cerebral ischemia)
2. studies suggest that in the pediatric age range, there may be an age-related threshold between
40 and 50 mm Hg, with infants at the lower end and adolescents at the upper end of this range.

35. Treatment recommandations
1.Hyperosmolar therapy
 Level II For ICP control II.1. Bolus hypertonic saline (3%) is recommended in patients with intracranial
hypertension. Recommended effective doses for acute use range between 2 and 5 mL/kg over 10-20 min.
 Level III For ICP control
a) III.1. Continuous infusion hypertonic saline is suggested in patients with intracranial hypertension. Suggested effective
doses as a continuous infusion of 3% saline range from between 0.1 and 1.0 mL/kg of body weight per hour,
administered on a sliding scale. The minimum dose needed to maintain intracranial pressure ICP < 20 mm Hg is
suggested.
b) III.2. Bolus of 23.4% hypertonic saline is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a
maximum of 30 mL.
Safety recommendation (applies to all recommendations for this topic):
avoiding sustained (>72 h) serum sodium >170 mEq/L is suggested to avoid complications of thrombocytopenia and anemia
avoiding a sustained serum sodium >160 mEq/L is suggested to avoid the complication of deep vein thrombosis.
Note. Although mannitol is commonly used in the management of raised ICP in pediatric traumatic brain injury, no studies
meeting inclusion criteria were identified for use as evidence for this topic

36. 2. Analgesics, sedatives, and
neuromuscular blockade
 Level III For ICP control
III.1. With use of multiple ICP-related therapies, as well as appropriate use of
analgesia and sedation in routine ICU care, avoiding bolus administration of
midazolam and/or fentanyl during ICP crises is suggested due to risks of cerebral
hypoperfusion.
Note 1. In the absence of outcome data, the specific indications, choice, and dosing of
analgesics, sedatives, and neuromuscular blocking agents should be left to the treating
physician
Note 2. Based on guidance from the US Food and Drug Administration, prolonged
continuous infusion of propofol for either sedation or the management of refractory
intracranial hypertension is not recommended.

37. 3. Cerebrospinal fluid drainage
Level III For ICP control :
III.1. Cerebrospinal fluid drainage through an external ventricular drain is suggested to
manage increased ICP.

38. 4. Seizure prophylaxis
Level III For seizure prevention (clinical and subclinical)
III.1. Prophylactic treatment is suggested to reduce the incidence of early
(within 7 d) PTS.
Note. At the present time there is insufficient evidence to recommend levetiracetam
over phenytoin based on either efficacy in preventing early PTS or toxicity.

39. 5. Ventilation therapies
Level III To improve overall outcomes
III.1. Prophylactic severe hyperventilation to a PaCO2 < 30 mm Hg in the initial 48 h
after injury is not suggested.
III.2. If hyperventilation is used in the management of refractory intracranial
hypertension, advanced neuromonitoring for evaluation of cerebral ischemia is
suggested.

40. 6. Temperature control/ hypothermia
Level II To improve overall outcomes
II.1. Prophylactic moderate (32°C to 33°C) hypothermia is not recommended over
normothermia to improve overall outcomes.
Level III For ICP control
III.1. Moderate (32°C to 33°C) hypothermia is suggested for ICP control.
Safety recommendation 1.
If hypothermia is used and rewarming is initiated, it should be carried out at a rate of 0.5°C
to 1.0°C every 12-24 h or slower to avoid complications.
Safety recommendation 2.
If phenytoin is used during hypothermia, monitoring and dosing adjusted to minimize
toxicity, especially during the rewarming period, is suggested.

41. 7. Barbiturates
Level III For ICP control
III.1. High-dose barbiturate therapy is suggested in hemodynamically stable patients
with refractory intracranial hypertension despite maximal medical and surgical
management.
Safety recommendation:
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 because
cardiorespiratory instability is common among patients treated with barbiturate coma.

42. 8. Decompressive craniectomy
Level III For ICP control:
III.1. Decompressive craniectomy is suggested to treat neurologic deterioration,
herniation, or intracranial hypertension refractory to medical management.

43. 9. Nutrition
Level II To improve overall outcomes:
II.1. Use of an immune-modulating diet is not recommended.
Level III To improve overall outcomes
III.1. Initiation of early enteral nutritional support (within 72 h from injury) is
suggested to decrease mortality and improve outcomes.

44. 10. Corticosteroids
Level III To improve overall outcomes:
III.1. The use of corticosteroids is not suggested to improve outcome or reduce
ICP.
Note. Recommendation III.1 is not intended to circumvent use of replacement
corticosteroids for patients needing chronic steroid replacement therapy, those with
adrenal suppression, and those with injury to the hypothalamic-pituitary steroid axis.

45. Baseline care in treatment:
1.Analgesia and Sedation
Maintenance of an Appropriate Level of Analgesia and Sedation:
benzodiazepine and opiate combination with the most commonly used
agents being midazolam. and morphine/fentanyl

46. 2-Controlled Mechanical Ventilation
 titrating Fio2 to achieve a threshold (Spo2) greater than 92% - 99%.
 target Pao2 of 90–100 mm Hg
 Pa co2 35-40 mmHg

47. 3.Temperature control
Maintaining Normothermic Core Temperature and Preventing and Treating Fever:
maintaining temperature at values greater than 35°C and less than 38°C

48. 4. Intravascular Volume Status control
 CVP between 4 and 10 mm Hg
 urine output >1ml/kg/hr
 IV fluid: 75% of maintenance values for normovolemia with NSS or D5W in the first 48 hrs
 baseline target for plasma concentration of sodium ([Na+]) :ranges with a lower limit greater
than 135 mEq/L and an upper limit less than 150 mEq/L
 baseline glucose level :normoglycemia or a concentration up to 180 mg/dL
 nutrition should be started as early as possibly, generally by 72 hours

49. 5.Hemoglobin level
Maintaining Minimum Blood [Hemoglobin]: minimum target greater than 7.0 g/dL

50. 6. Treatment of Coagulopathy
 Treatment of abnormal coagulation variables is recommended prior to insertion of ICP or
Pbro2 monitors
 coagulopathy was defined as :
1. platelet count less than 100,000 per mm3
2. INR greater than 1.2
3. activated partial thromboplastin time of greater than 36 seconds
 Overresuscitation may worsen caagulapathy

51. 7.Head position
Neutral Head Positioning With Head-of-Bed Elevation: using any angle from 0° up to
45° head-up positioning

52. 8. Seizure control
 Antiepileptic Drug Therapy : levetiracetam is considered easier to administer in
comparison with phenytoin
 Children, particularly infants, have lower seizure thresholds and are at high risk for
early seizures. Immediate prophylactic administration of anticonvulsant is
recommended in children with severe TB
 If no further seizures occur more than 2 years after the last seizure, imaging
studies, electroencephalogram (EEG), and CBF studies are recommended to decide
potential reduction in dosage by half

53. 9-continuous EEG monitoring
continuous electroencephalography (cEEG) considering its use throughout the
management course particularly when neuromuscular blockade is used

54. • ICP Pathway:
 the guidelines committee supports the use of less than 20 mm Hg as an initial ICP target in all age
groups
 also supports the need for an intervention when ICP is raised greater than 20 mm Hg for at least 5
minutes:
1.CSF drainage when using an EVD
2. a bolus and/or infusion of hypertonic saline
3. A bolus dose of mannitol may be considered as an alternative to hypertonic saline
(0.5–1 g/kg) over 10 minutes
4. Serum osmolality should be maintained at less than 360 mOsm/L
5. If hyperosmolar therapy proves ineffective, additional analgesia and/or sedation should be considered,
along with potential initiation of neuromuscular blockade

55. CPP Pathway:
 thresholds between 40 and 50 mm Hg, with infants at the lower end and adolescents at the
upper end of this range:
1. adequate CVP, generally between 4 and 10 mm Hg achieved by a fluid volume bolus
2. SBP greater 95 mmhg -140 mmhg achieved by ensuring normovolemia before using
vasopressors such as dopamine or norepinephrine

56. • Pbro2 Pathway
 A minimum target level of 10 mm Hg
 Interventions that can specifically increase Pbro2 include
1. raising Fio2
2. raising MAP with vasopressors
3. increasing Paco2 to increase cerebral blood flow (CBF)
4. optimizing blood [hemoglobin].

57. For intracranial hypertension, or inadequate CPP or
Pbro2, refractory to first tier interventions:
 repeat CT scan should be performed, if it can be done safely, in order to identify any lesions that could
be corrected surgically
 surgical decompression may be indicated in the setting of diffuse swelling when ICP is refractory, or
when hypertonic saline treatment has failed, or when barbiturates have failed
 The other second tier therapies , other than neurosurgery :
1. higher levels of hyperosmolar therapy
2. late moderate hypothermia,(32–33°C for refractory intracranial hypertension)
3. induced hyperventilation(significant hypocapnia (between 15 and 30 mm Hg), is well described in the
older protocols to treat late (> 24 hr) and refractory intracranial hypertension,)
4. Barbiturate Infusion: The most frequently described medication is pentobarbital. Its use is considered
when osmotherapy and hyperventilation have failed to maintain ICP less than 25 mm Hg

58. Management of Severe Pediatric TBI
Without ICP Monitoring:
 A detailed protocol for the management of severe TBI without ICP monitoring in
adults (and adolescents 13 yr old and older) has been published and included the
use of serial imaging (CT at 48 hr and 5–7 d after injury) and clinical examination
(pupillary response and GCS score) to guide therapy

59. Conclusion
The optimal care of an infant or child with TBI requires a multidisciplinary approach
Long-term follow-up is often required to evaluate both physical and intellectual disability
outcomes by Neuroimaging in pediatrics due to the devastating impact of injury on the
fragile brain in development
Management of pediatric TBI provides challenges due to differences in the basic mechanisms
of injury

60. The 2019 Third Edition of the Guidelines for the Management of Pediatric Severe Traumatic
Brain Injury (TBI) presents evidence-based recommendations to inform treatment .
The available evidence, however, remains limited, and there are many major gaps in our
knowledge, thereby limiting translation of the guidelines to bedside management and the
continue of use of clinical assessment to guide therapy

61. Thank you for your attendance!!