Evaluation and

Treatment of Severe
Brain Injury in Children

Laura Ibsen, M.D.

Marvin N. Hall, M.D.
 Categorization of Brain Injury

 Traumatic Brain Injury


isolated

multi-system injuries
 Hypoxic-ischemic injury
 Toxic/metabolic injury
 Epidemiology

 200 per 100,000 children per year

 Mild (GCS > 12) 82%
 Moderate to severe (GCS <12) 14%
 Fatal 5%, 7000 deaths per year (1987)
 200,000 children hospitalized/year
 1-2 % of all ED presentations in children
 Epidemiology

 Children with severe head injuries have a lower

rate of mass lesions requiring intervention than
adults (25 vs 46%).
 Even those with low GCS generally survive and
achieve social rehabilitation.

(Lieh-Lai, 1992) GCS 3-5, 55% “satisfactory”

(Bruce 1978) GCS 3-4, 80% good recovery or
moderate disability
 How patients present

 Obvious--motor vehicle accident, car

vs pedestrian, fall from height, etc
 Less obvious--sports injuries (football),
delayed deterioration (epidural)
 Hidden--shaken baby syndrome, older
child maltreatment
 Caveats in Brain Injury

 Neurologic examination - the most

important information you have
 Accurate history is often unavailable or
inaccurate
 Potential for associated injuries or
illness (cardiovascular, respiratory, c-
spine)
 Cerebral Resuscitation
 Primary survey - airway, breathing,
and circulation
 Neurologic evaluation
 Secondary survey - “head to toe”
 Neuroradiologic evaluation
 Ongoing evaluation and transport
Pathophysiology
 Mechanisms of injury-Primary

 Impact: epidural, subdural, contusion,

intracerebral hemorrhage, skull
fractures
 Inertial: concussion, diffuse axonal
injury
 Hypoxic\Ischemic
Mechanisms of injury-Secondary
 Global

Hypoxia and ischemia of brain

Decreased cerebral blood flow due to
increased intracranial pressure
 Local

impairment of cerebral blood flow or
extracellular milieu due to the presence of
injured brain
 Monro-Kellie Doctrine
Vintracranial vault=Vbrain+Vblood +Vcsf
Brain: Cerebral Edema-vasogenic
Brain: Cerebral Edema-cytotoxic
Blood: Cerebral Blood Flow


The brain has the ability
to control its blood
supply to match its
metabolic requirements

Chemical or metabolic
byproducts of cerebral
metabolism can alter
blood vessel caliber and
behavior
 Blood: Cerebral Blood Flow
(volume)
 Increases in cerebral metabolic rate

Hyperthermia

Seizures

Pain, anxiety
 CSF: Cerebrospinal Fluid

 10% of intracranial volume

 Initial displacement of CSF from
ventricles
 Ventriculostomy to drain CSF
Evaluation
 Initial Evaluation
 Airway- any evidence of trauma, airway
protection, attention to c-spine
 Breathing- chest trauma, aspiration,
adequate respiratory effort?
 Circulation- hypovolemia, hemorrhage,
associated injury, myocardial ischemia,
“spinal shock”
 Neurologic assessment
GCS and Traumatic Brain Injury

 13-15 mild TBI

 9-12 moderate TBI
 < 8 severe TBI
 The rest of the story...
 First, history and physical
exam is an important
monitor at the beginning
and throughout the course
of illness.
 Imaging, management, and
ongoing care of children
with head trauma requires
continual evaluation.
 Severe TBI
 Indications for Intubation

GCS< 8

Fall in GCS of 3

Unequal pupils

Inadequate respiratory effort or
significant lung/chest injury

Loss of gag

apnea
 Intubation of the Patient With
Brain Injury
 Considerations:

Increased intracranial pressure

Cardiorespiratory instability

Cervical spine status may be unknown

Unknown, traumatized airway

Aspiration risk

Unknown medical history
 Intubation of the patient with
Brain Injury--How to...
 Most qualified, experienced person
available should perform procedure
 Ideally, two qualified, experienced
people should be present
 Have adequate nursing and respiratory
assistance
 Intubation of the patient with
Brain Injury--How to...
 Rapid Sequence Orotracheal Intubation

Axial stabilization if C-spine in question

Pre-oxygenation with 100% O2

Induction: thiopental, etomidate, benzo

Consider Fentanyl, Lidocaine, defasciculation

Neuromuscular blockade

Intubation
 After Tracheal Intubation
 EtCO2, check ETT placement
 Ventilate, aiming for pCO2 35-40
 Oxygenate, using PEEP if necessary
 Cardiovascular assessment and
stabilization

use VOLUME (normal saline) if necessary.

Obtain adequate access.
 Here or There?
 Any child with more than minor head
trauma should be cared for in a hospital
equipped to deal with both ICU and
neurosurgical issues on an emergent
basis.
 If these criteria are not met, the patient
should be transferred
 Initial Approach
 Physical exam is an important monitor at
the beginning and throughout the course of
illness.
 CT scan is initial imaging modality of
choice for moderate and severe head injury
 Look for: blood, ventricle size, basilar
cisterns
 ICU Management

 Surgical management
 Medical management

General ICU care

Prevent secondary injury

Manage intracranial pressure
 Hypoxemia and Hypotension

 Common

each occurs in up to 1/3 of severe head
injury patients
 Important

powerful predictors of outcome

single episode of hypotension doubles
mortality rate
 ICP
Monitoring:
when, why and
how
 Indications for ICP monitoring
 Glasgow coma scale <8
 Clinical or radiographic evidence of
increased ICP
 Post-surgical removal of intracranial
hematoma
 Less severe brain injury in the setting
which requires deep sedation or anesthesia
 Why Monitor?

 Detect “events”
 Manage intracranial pressure
 Manage cerebral perfusion pressure
 How?
 Ventriculostomy
 Intraparenchymal fiberoptic catheter
 Subarachnoid monitor
 Useful adjuncts:

Arterial line

Central venous line

Foley catheter
 What to do with the
information...
 Goal: adequate oxygen delivery to maintain
the metabolic needs of the brain.
 Intracranial pressure <20
 Cerebral perfusion pressure >50-70 mm Hg
CPP=MAP-ICP
 Manipulation of ICP
Brain
 Mannitol

dehydrate the brain, not the patient!

monitor osmolality
 Hypertonic saline
 Decompressive craniectomy
 Manipulation of ICP
Blood
 Decrease cerebral metabolic demand

sedation, analgesia, barbiturates

avoid hyperthermia

avoid seizures
 Hyperventilation

decreases blood flow to brain

only acutely for impending herniation
 Mannitol
 Manipulation of ICP
CSF
 External drainage

therapeutic as well as diagnostic

technical issues

infectious issues
 Manipulation of ICP
Unproven or Harmful Therapies
 Steroids
 Routine, prophylactic
hyperventilation
 Induced hypothermia
 Specific pharmacological
therapies
 Manipulation of CPP
CPP = MAP -
ICP
 Maintain adequate intravascular volume

CVP

replace losses - urine, CSF, blood
 Increase MAP

alpha agonist--dopamine, phenylephrine, norepinephrine

potential toxicity
 What is appropriate goal for children?
 And a Word About...
 “Routine” ICU care

nutrition

fluids and electrolytes

skin care

pulmonary care
 Neuromuscular blockade
 Abusive head trauma in infants
 Prevention
 Selected References
 picuBOOK an on-line resource for pediatric
critical care

http://pedsccm.wustl.edu/All-Net/english/
neurpage/trauma/head-1.htm
 Brain Trauma Foundation, Management and
Prognosis of Severe Traumatic Brain Injury.

http://www.braintrauma.org/
 Chestnut RM, Prough DS eds. Critical Care of
Severe Head Injury. New Horizons 3 (3) 365-593.
 Selected References
 Ashwal S, Stringer W, et al, Cerebral blood flow
and carbon dioxide reactivity in children with
bacterial meningitis, J. Pediatr 117:523, 1990.
 Skippen P, Seear M, et al, Effect of hyperventilation
on regional cerebral blood flow in head-injured
children, Critical Care Medicine, 25:1402, 1997
 Chesnut R, Hyperventilation in traumatic brain
injury: friend or foe, Critical Care Medicine, 25:
1275, 1997 (editorial)