Evidenced-Based
Care of the Child
with Traumatic Head
Injury
A. Student
The Children’s Hospital of Philadelphia
Dr. Abdul-Monim Batiha
Objectives
• Describe the pathophysiology of traumatic brain
injury
• Discuss the scientific rationale for the therapeutic
interventions used in the care of brain injured
children
• Provide research based recommendations for the care
of children with traumatic brain injury
Rhoads & Pflanzer (1996) Human Physiology p. 211
Traumatic Head Injury
ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro
(1998) Lippincott Williams & Wilkins.
www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
Layers of the Cranial Vault
Anatomy of the Brain
www.neurosurgery.org/pubpgages/patres/anatofbrain.html#micro
Epidural and Subdural Hematoma
ALL-NET Pediatric Critical Care Textbook - Source: LifeART EM Pro (1998)
Lippincott Williams & Wilkins.
www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
Subarachnoid
Hemorrhage
Rogers (1996)
Textbook of
Pediatric Intensive
Care pp. 829
Cerebral Spinal Fluid
• Produced by the choroid plexus
• Average volume 90 - 150 ml
– (0.35 ml / minute or 500 ml / day)
• Reabsorbed through the arachnoid villi
• Drainage may be blocked by inflammation of the
arachnoid villi, diffuse cerebral edema, mass effect of
hemorrhage or intraventricular hemorrhage
Brain Cells
Concussion
Contusion
Intracerebral
hemorrhage
Rhoads & Pflanzer (1996) Human Physiology p. 213
Neurons
Neuroscience for Kids www.faculty.washington.edu/chudler/cells/html
Diffuse Axonal Injury
• Shearing injury of axons
Deep cerebral cortex, thalamus, basal ganglia
• Punctate hemorrhage and paranchymal edema
Cerebral Blood Flow
Regulation of Cerebral Vascular Resistance
CBF
Normal
50 - 100
ml / min
MAP
PaCo2
(mmHg)
(mmHg)
Normal 60 - 150 mmHg
Normal 30 - 50 mmHg
Rogers (1996) Textbook of Pediatric Intensive Care pp. 648 - 651
Cerebral Edema
• Cellular response to injury
– Primary injury
• Secondary injury
– Hypoxic-ischemic injury
• Injured neurons have increased metabolic needs
• Concurrent hypotension and hypoxemia
• Inflammatory response
Neuronal Response to Injury
Primary mechanical injury & secondary hypoxic-ischemic injury
Ca+
Lactate
ATP
Glucose
Acidosis
NMDA
O2 -
Edema
Glutamate
Cyclooxygenase
Lipoxygenase
Arachidonic Acid
Leukotriene
Thromboxane
Prostaglandin
Fluid
Inflammation:
Vasoreactivity
Thrombosis
Neutrophils
Monitoring Brain Metabolism
Jugular Venous Catheter
Jugular Venous Oxygen Saturation (SJVO2)
Arteriojugular Venous Oxygen Difference (AJVO2)
Cerebral Metabolic Rate For Oxygen (CMRO2)
Possible better outcome in adults
Cruz (1998) Critical Care Medicine, 26(2)
Brain Sensors
Brain tissue pH, PaO2, PcO2, lactate
Kiening (1997) Neurology Research, 19(3)
Cerebral Edema after Head Trauma
ALL-NET Pediatric Critical Care Textbook Source: Research by Samuel Neff
MD. www.med.ub.es/All-Net/english/neuropage/trauma/head-10htm
Monroe- Kellie Principle
Rogers (1996) Textbook of Pediatric Intensive Care p. 646
Management of
Traumatic Head Injury
• Maximize oxygenation and ventilation
• Support circulation / maximize cerebral perfusion
pressure
• Decrease intracranial pressure
• Decrease cerebral metabolic rate
Monitoring
• Serial neurologic
examinations
• Circulation / Respiration
• Intracranial Pressure
• Radiologic Studies
• Laboratory Studies
Scherer & Spangenberg (1998)
Critical Care Medicine, 26(1)
Fibrinogen and platelets are
significantly decreased in TBI
patients
Ong et al. (1996) Pediatric
Neurosurgery, 24(6)
GCS, hypoxemia and radiologic
evidence of SAH, edema and
DAI predict morbidity
GCS alone does not predict
morbidity
Kokoska et al. (1998), Journal
of Pediatric Surgery, 33(2)
Hypotension is predictive of
morbidity
GCS and PTS are not predictive
of outcome
Respiratory Support: Maximize Oxygenation
• Hypoxemia is predictive of morbidity
– Ong et al. (1996) Pediatric Neurosurgery, 24(6)
• Neurogenic pulmonary edema / concurrent lung injury
– Positive End Expiratory Pressure
• May impair cerebral venous return
– Cooper et al. (1985) Journal of Neurosurgery, 63
– Feldman et al. (1997) Journal of Neurosurgical
Anesthesiology, 9(2)
• PEEP > 10 cm H2O increases ICP
Respiratory Support: Normoventilation
Hyperventilation : Historical management more harm than good?
Originally
adapted from
Skippen et al.
(1997)
Critical Care
Medicine, 25
ALL-NET Pediatric Critical Care Textbook
www.med.ub.es/All-Net/english/neuropage/\protect/vent-5htm
Evidence Supporting Normoventilation
• Forbes et al. (1998) Journal of Neurosurgery, 88(3)
• Marion et al. (1995) New Horizons, 3(3)
• McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5)
• Muizelaar et al. (1991) Journal of Neurosurgery, 75(5)
• Newell et al. (1996) Neurosurgery, 39(1)
• Skippen et al. (1997) Critical Care Medicine, 25(8)
• Yundt & Diringer (1997) Critical Care Clinics, 13(1)
Use of Hyperventilation ...
• Management of very acute elevation of intracranial pressure
• Preemptive for activities known to increase intracranial
pressure
• No lower than 32-35 cmH20
--- Moderate and transient
Suctioning
• Hyper-oxygenation
• Mild / moderate hyperventilation
Brown & Peeples (1992) Heart &
Lung, 21
Parsons & Shogan (1982) Heart &
Lung, 13
• Intratracheal / intravenous
lidocaine
Donegan & Bedford (1980)
Anesthesiology, 52
Wainright & Gould (1996)
Intensive & Critical Care Nursing,
12
• As needed basis and individualize
according to patient response
53%
Percent
increase in
ICP with
suctioning
0%
Hypervent
IV lido
IT lido
Wainright & Gould (1996)
Circulatory Support:
Maintain Cerebral Perfusion Pressure
6
5
Number of
Hypotensive
Episodes
Good
Moderate
Severe
Vegetative
Dead
4
3
2
1
0
Outcome
Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
Circulatory Support:
Maintain Cerebral Perfusion Pressure
• Adelson et al. (1997) Pediatric Neurosurgery, 26(4)
– Children (particularly < 24 months old) are at increased
risk of cerebral hypoperfusion after TBI
– Low CBF is predictive of morbidity
• Rosner et al. (1995) Journal of Neurosurgery, 83(6)
– Management aimed at maintaining CPP (70 mmHg)
improves outcomes
CPP = MAP - ICP
Lowering ICP
Brain
Blood
CSF
Mass
• Evacuate hematoma
Bone
• Drain CSF
– Intraventricular catheters use is limited by degree of
edema and ventricular effacement
• Craniotomy
– Permanence, risk of infection, questionable benefit
• Reduce edema
• Promote venous return
• Reduce cerebral metabolic rate
• Reduce activity associated with elevated ICP
Hyperosmolar Therapy: Increase Blood Osmolarity
Brain
cell
Fluid
Blood
vessel
Movement of
fluid out of cell
reduces edema
Osmosis: Fluid will move from area of lower osmolarity to an
area of higher osmolarity
Diuretic Therapy
Osmotic Diuretic
• Mannitol (0.25-1 gm / kg)
• Increases osmolarity
• Vasoconstriction (adenosine) /
less effect if autoregulation is
impaired and if CPP is < 70
• Initial increase in blood volume,
BP and ICP followed by
decrease
• Questionable mechanism of
lowering ICP
Loop Diuretic
• Furosemide
• Decreased CSF formation
• Decreased systemic and
cerebral blood volume
(impairs sodium and water
movement across blood brain
barrier)
• May have best affect in
conjunction with mannitol
• Rosner et al. (1987) Neurosurgery,
21(2)
• Pollay et al. (1983) Journal of
Neurosurgery, 59 ; Wilkinson
(1983) Neurosurgery,12(4)
Hypertonic Fluid Administration
• Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4
– Reduction in mean ICP in children 2 hours after bolus
administration of 3% saline
• Taylor et al. (1996) Journal of Pediatric Surgery,31(1)
– ICP is lowered by resuscitation with hypertonic saline vs.
lactated ringers solution in an animal model
• Qureshi et al. (1998) Critical Care Medicine, 26(3)
– Reduction in mean ICP within 12 hours of continuous infusion
of 3% saline acetate solution
– Little continued benefit after 72 hours of treatment
Hyperosmolar Therapy
Goal:
Sodium
145-155
Sodium:
square
ICP:
circle
Qureshi et al. (1998) Critical Care Medicine, 26(3)
Promote Venous Drainage
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)
Dicarlo in ALL-NET Pediatric Critical Care Textbook
www.med.ub.es/All-Net/english/neuropage/\protect/icp-tx-3.htm
Reduction of Cerebral Metabolic Rate
• Reduction in cerebral oxygen requirement
– Anticonvulsants - Prevent seizure activity
– Pentobarbital
• Adverse effects include hypotension and bone marrow
dysfunction
• Used only after unsuccessful attempts to control ICP and
maximize CPP with other therapies
• Improved outcome not fully supported by research
Traeger et al. (1983) Critical Care Medicine, 11
Ward et al. (1985) Journal of Neurosurgery, 62(3)
Reduction of Cerebral Metabolic Rate: Hypothermia
• Metz et al. (1996) Journal of Neurosurgery, 85(4)
– 32.5 C reduced cerebral metabolic rate for oxygen (CMRO2)
by 45% without change in CBF, and intracranial pressure
decreased significantly (p < 0.01)
• Marion et al. (1997) New England Journal of Medicine, 336(8)
– At 12 months, 62% of patients (GCS of 5-7) cooled to 32-33 C
have good outcomes vs. 38% of patients in control group
Side-effects:
Potassium flux
Coagulopathy
Shivering
Skin Breakdown
Slow re-warming
Close monitoring
No
pediatric
studies!
ICP management continued...
Management of Pain & Agitation
• Opiods
• Benzodiazepines
Management of Movement
• Neuromuscular blockade
Difficult to assess
neurologic exam
Monitor for
hypotension
Short acting
agents beneficial
Do opiods increase CBF?
Increased ICP with concurrent decreased MAP and CPP has been
documented. Elevation in ICP is transient and there is no resulting
ischemia from decreased MAP / CPP.
Albanese et al. (1999) Critical
Care Medicine, 27(2)
Nursing Activities and ICP
20
18
16
14
ICP
12
Turning
Suctioning
Bathing
10
8
6
4
2
0
Before
During
After
Rising (1993) Journal of Neuroscience Nursing, 25(5)
Nursing Activities and ICP
20
18
16
14
ICP
12
10
Suctioning
Turning
8
Bathing
6
4
2
0
Before
During
After
Rising (1993) Journal of Neuroscience Nursing, 25(5)
Family Contact and ICP
Presence, touch and voice of family / significant others...
•
Does not significantly increase ICP
•
Has been demonstrated to decrease ICP
Bruya (1981) Journal of Neuroscience Nursing, 13
Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)
Mitchell (1985) Nursing Administration Quarterly, 9(4)
Treolar (1991) Journal of Neuroscience Nursing, 23(5)
Summary of Recommended Practices
• Maximize oxygenation (PEEP < 10)
• Normoventilate
• Suction only as needed, limit passes, pre-oxygenate,
+/- pre-hyperventilate (not < 30), use lidocaine when
possible
• Maintain blood pressure and maintain CPP > 60
• Evacuate intracranial blood
• Drain CSF with ventriculostomy when possible
Summary of Recommended Practices
• Hyperosmolar therapy
• Avoid hyperthermia, +/- hypothermia
• Prevent seizures
• Reserve pentobarbital for refractory conditions
• Mid-line neck, elevated head of bead, ? not > 30 degrees
• Treat pain and agitation - consider pre-medication for
nursing activities
• Avoid hyperglycemia
• Allow family contact