Pediatric Traumatic Brain
Injury:
Metabolic Stress with Nutrition Support
Zach Pfirrman and Taylor Pond
Traumatic Brain Injury: Definition
• Two types:
• Penetrating brain injury
• Penetration of skull and direct damage to brain tissue
• Closed head injury
• Mild traumatic brain injury
• No penetration of skull
• Concussions
• Injury
• Primary
• Initial injury of brain hitting the interior of skull
• Secondary
• The resulting physiological changes
• Cerebral edema, hemorrhage, hematoma, and infection
Traumatic Brain Injury: Etiology

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TBIs occur about 1.7
million times a year in
the United States.
35.2% contributed by
falls
17.2% contributed by
Motor vehicle
accidents
http://www.cdc.gov/trau
maticbraininjury/cause
s.html
Diagnostic Measures
• A variety of neuroimaging techniques:
• X-rays
• CT scans
• To find location and type of injury
• SPECT scan
• PET scan
• DTI
• Glasgow coma scale
Glasgow Coma Scale
•The Glasgow coma scale is a neurological scale
that measures the conscious state of a person for
an initial assessment. The scale has three
components: eye response (1-4), verbal response
(1-5), and motor response (1-6). Chelsea's initial
score was 10 out of 15, 4 points from eye response,
2 from verbal, and 4 from motor. A score of 10 out
of 15 puts Chelsea in the “moderate head injury”
range.
Glasgow coma Scale
Patient History
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Chelsea Montgomery is an 8-year-old 2nd grade
student. Healthy except for severe myopia
(nearsightedness). She participates in a variety
of activities including gymnastics, softball, and
Girl Scouts.
No Medical history
No medications
Family History: CAD- Grandfather
Diabetes- Older Brother
Diagnosis
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Chelsea was admitted to through the ER after
being injured as a restrained front-seat
passenger in a motor vehicle accident. She is
transferred to the pediatric intensive care unit
with a traumatic brain injury
MRI showed areas of hemorrhagic edema in
deep white matter of L frontal lobe anteriorly.
Additionally, heme and edema found in the
splenium of corpus callosum.
CT scan showed 2 areas of increased density in
L frontal lobe near vertex and possibly left
central modality.
Treatment

Emergency care for moderate to severe TBI has a
main focus on ensuring that the patient is getting a
sufficient supply of oxygenated blood to the brain,
maintaining blood pressure, and preventing any
further damage to the head or neck.

Secondary focuses would be on minimizing the
damage caused by inflammation, bleeding, and
decreased oxygen supply to the brain.
Treatment (cont.)
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Depending on how severe the trauma is would
determine if surgical intervention is needed.
In some bad cases of brain edema(swelling), the skull
must be opened to relieve pressure. The procedure is
called decompressive craniectomy
Similar is a Ventriculostomy, where a hole is cut into the
skull and a tube is inserted to drain cerebral fluid.
Medications can be used to in some cases to relieve
brain edema or slow the body's response to the swelling.
A rarely used treatment due to it's difficulty in preforming
correctly is deliberate hypothermia. Lowering the body
temperature has been found to relieve brain swelling
and helps in the healing of the brain.
PES Statements
• Swallowing Difficulty (NC-1.1) related to neurological
damage to the frontal lobe as evidenced by
radiology and failed speech/swallowing evaluation.
• Unintentional Weight Loss (NC-3.2) related to
decreased ability to consume sufficient energy as
evidenced by a weight loss of 10 pounds in 12 days
which is about a 15% of her original weight.
Medical Nutrition Therapy
• Chelsea’s nutritional needs:
• Protein
• 1.5g/kg – 2.0g/kg x 27.7kg = 42g - 55g of PRO
• Kilocalories
• EER: 88.5 – 61.9 x 8 + 1.31 x (10 x 27.7 + 903 x 1.3) + 20 x 1.4 =
2119 kcal (TBI patients need 140%REE)
• Fluids
• 2119kcal x 1 mL/kcal = 2119 mL
Medical Nutrition Therapy
• Initial Nutrition Intervention:
• Enteral feeding Pediasure 1.5 at 10 cc/hour continuous drip
• 360 kcal
• Free water 200 mL four times daily to meet fluid
requirements when IV is disconnected
• Goal rate of 57 cc/hr
• At a goal rate of 57 cc/hr, Chelsea will receive 2052
kcal and 80.8 g protein.
• This is adequate!
Important nutrients
• Glutamine
• BCAAs
• Isoleuicine, leucine, and valine
•
•
•
•
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Vitamin E
Vitamin C
Selenium
Copper
Zinc
Pediasure 1.5
FEES/Swallowing Evaluation
• Two weeks after accident:
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Accepted Macaroni and Cheese
Choked after 5-7 ice chips
Oral skills appropriate
Signs of fatigue after a few seconds
No evidence of penetration or aspiration
PO inhibited, but signs of progress
• Continue enteral feeding
• Sent to rehab
Prognosis
• Disabilities depend on severity
•
•
•
•
Cognition-thinking, memory, reasoning
Sensory processing- sight, hearing, touch, taste, and smell
Communication- expression and understanding
Behavior or mental health- depression, anxiety, presonality
changes, aggression, acting out, and social
inappropriateness
• severe cases can result in:
• Stupor
• Unresponsive state
• Coma
Rehabilitation
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Most TBI patients must go through high amounts of
extensive rehabilitation to relearn basic skills and abilities
to preform daily activities.
Occupational therapy helps patients relearn or improve
skills used in one's everyday activities
Physical therapy helps with mobility and relearning
balance, movement patterns, and walking
Language or Speech pathologists help with the
relearning and improvement of communication skills,
chewing ability, and swallowing ability.
Psychiatrists may be needed to help in emotional and
psychological well being. This may include behavior
management, coping strategies, and talk therapy.
Work Cited
•
Nelms, M. (2013). Medical nutrition therapy: a case study approach (4th ed.). Stamford,
Connecticut: Cengage Learning.
•
Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA:
Wadsworth, Cengage Learning.
•
Severe Traumatic Brain Injury . (2012, September 21). Centers for Disease Control and
Prevention. Retrieved October 30, 2013, from
http://www.cdc.gov/TraumaticBrainInjury/severe.html
•
staff, M. (2012, October 12). Definition. Mayo Clinic. Retrieved October 30, 2013, from
http://www.mayoclinic.com/health/traumatic-brain-
injury/DS00552/DSECTION=treatments-and-drugs