Traumatic Brain Injury
Children
Torsten Lauritsen
Rigshospitalet Copenhagen
Aim
To give an overview of severe traumatic brain injury in
children
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focus on resuscitation
first line treatment
guidelines
To improve the care of children with severe traumatic
brain injury
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Traumatic Brain Injury in Children
TBI
Epidural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Contusions
Cerebral edema
Ischemic injury
Diffuse Axonal Injury
Abusive Head Trauma –
Shaken Baby Syndrome
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Traumatic Brain Injury in Children
Head trauma - physiology
Primary brain damage
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Direct following the trauma
Irreversibel– Diffuse Axonal Injury
Treatment does not improve prognosis
Secundary brain injury
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Proper resuscitation will improve prognosis and prevent further
damage
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Hypoxemia
Convulsions
Hypotension
Hyperthermia
Raised ICP
Hypoglycemia
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Decreased cerebral
perfussion
Cerebral oxygen delivery
Increased oxygen
consumption
Increased
ischemia
Neuroprotective agents
pH
Electrolytes
Glucose
ROS
Temperature
ICP
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Sedation
Cerebral perfusion
Chalkias A in J of Neurological Sciences 2012
Cerebral edema
Intracellular – hypoxia
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Cellular metabolism
Cellular retention of
sodium and water
Apoptosis
Vasogenic
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Rupture of BBB leads to
leakage from capillaries
Traumatic Brain Injury in Children
Paediatric trauma care
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Traumatic Brain Injury in Children
Hypotension is bad
131/299 = 44% had hypoxia
118/299 = 39% had hypotension
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Absense of BP monitoring
=> OR of death 4.5
Traumatic Brain Injury in Children
Hypotension is bad
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Traumatic Brain Injury in Children
Guidelines
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Guidelines for the acute
medical management of
severe traumatic brain
injury in infants, children,
and adolescents
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Traumatic Brain Injury in Children
Treatment
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Resuscitation
A
B
C
D
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Traumatic Brain Injury in Children
Treatment - Airway
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Early intubation
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Modified Rapid Sequenze Induction
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Traumatic Brain Injury in Children
Rapid Sequence Induction
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Premedication with spontaneous ventilation
Preoxygenation
Induction
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Propofol/Tiopental (Ketamin/Etomidat)
Rocuronium
Fentanyl (Rapifen)
Mask ventilation (10-12 cm H2O)
Intubation
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Treatment - Breathing
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Oxygen
Maintain oxygenation within normal range
PEEP might increase ICP
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Traumatic Brain Injury in Children
Hypoxia is worse
OR 1,92
OR 1,25
Mortality risk lowest at O2 8 – 10 kPa (60 – 75 mmHg)
Mortality risk increase with hypoxia and hyperoxia
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Hyperventilation
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Hyperventilation =>
hypocapnia =>
vasoconstriction =>
lower CBF and CBV =>
lower ICP
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Vasoconstriction worsen cerebral ischemia
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Hyperventilation only after neurosurgical consultation
and if herniation is impending
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Traumatic Brain Injury in Children
Circulation
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Systolic BP > 70 + 2 x age
Haemorrhage control
Fluid resuscitation
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Krystalloid 20 ml/kg
SAGM 10-20 ml/kg
FFP 10-20 ml/kg
TC 5-10 ml/kg
Vasopressors?
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Traumatic Brain Injury in Children
Resuscitation - fluids
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Albumin vs saline
Ringers Lactate vs Saline
osmolality 270 vs 308
Sodium 130 vs 154
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Traumatic Brain Injury in Children
Physiology – cerebral perfusion
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Cerebral perfusion pressure (CPP)
Mean arterial pressure (MAP)
Intra cerebral Pressure (ICP)
CPP = MAP - ICP
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Level 3 evidence
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CPP > 40 mmHg
ICP < 20 mmHg
Traumatic Brain Injury in Children
Disability - ICP monitoring
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ICP < 20 mmHg
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No evidence directly in favor of ICP monitoring – but:
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Children with severe TBI have high ICP
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Poor outcome with intracranial hypertension
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Better outcome with protocols for treatment of ICP
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Better outcome with succesful ICP lowering therapies
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Traumatic Brain Injury in Children
Anaesthesia
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Ketamin
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Propofol
Tiopental
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Etomidat
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Increase HR
Increase BP
Bronchodilatation
Decrease cerebral metabolism
Cerebral vasoconstriction
Induce systemic hypotension => lower CPP
Traumatic Brain Injury in Children
Anaesthesia
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Sevoflurane and Isoflurane
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Nitrous oxide
Decrease cerebral metabolism
Vasodilatation => CBF and CBV
Increase cerebral metabolism
Increase CBF => ICP
Should be avoided
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Traumatic Brain Injury in Children
Neuromuscular blocking agents
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Succinylcholine
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Increase ICP
Provide rapid optimal conditions for intubation
Cardiac arrytmias
Rocuronium
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Optimal drug for paediatric intubation
Reversal with Sugammadex
0,6-1,0 mg/kg
Traumatic Brain Injury in Children
Positioning
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Improve venous drainage
Elevate head 15-30o
Avoid flexion or rotation
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Traumatic Brain Injury in Children
Mannitol
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Mannitol 1g/kg - reduce ICP by
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Reduces blood viscosity rapidly but transiently < 75 min
Slow osmotic effect over 15-30 min
Movement of water from the brain to the systemic circulation.
Effect up to 6 h, but requires a intact BBB
May cause hypotension (osmotic diuresis)
Rebound effect
Traumatic Brain Injury in Children
Hypertonic Saline 3 %
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5 ml/kg
513 mmol/l Na+,
Osmolality 1027 mOsm/l
Osmotic action in the brain
Restores intravascular volume
Increased inotopy
Increase MAP and CPP
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Traumatic Brain Injury in Children
Hyperosmolar therapy
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Recommendation level 2
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Hypertonic saline should be considered for treatment of TBI
associated with intracranial hypertension. Effective dose for
acute use range between 6,5-10ml/kg.
Recommendation level 3
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Hypertonic saline for treatment of intracranial hypertension
3% saline as a continous infusion range between 0,1-1,0
ml/kg/hour.
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Mannitol is commonly used but no RCI exists
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Traumatic Brain Injury in Children
Hypothermia
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Level 2
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Moderate hypothermia (32-33C) beginning early after TBI for
only 24 hrs’ duration shold be avoided
Traumatic Brain Injury in Children
Hypothermia
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Hypothermia – adverse effects
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Hypotension
Bradycardia
Arrhytmias
Sepsis
Coagulopathy
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Traumatic Brain Injury in Children
Treatment - Conclusion
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Resuscitation
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Triage – expeditious
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Surgical treatment
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ICP monitoring and control
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Optimization of organ systems
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Traumatic Brain Injury in Children
Resuscitation
Airway
Breathing
Circulation
Primary intervention for TBI
Elevate head
Normothermia
ICP monitor
CT - scan
Sedation
Surgical evacuation
ICP raised
CSF drainage
Neuromuscular blockade
Hyperosmolar therapy
Saline 3 %
Mannitol
ICP raised – impending herniation
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Hyperventilation
Traumatic Brain Injury
in Children
Craniotomy
Tiopental
Hypothermia
Traumatic Brain Injury in Children