peds symposium pediatric head trauma 2011 -howard final
DESCRIPTION
Pediatric Head Injury presentation from 4/16/11TRANSCRIPT
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Management of Pediatric Head Trauma in the Emergency Department: Intracranial and Other Issues
John M. Howard, DOAssistant Director, Emergikids
Alexian Brothers Hospital NetworkApril 16, 2011
Wednesday, April 20, 2011
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Disclosure
• I have had no relevant financial relationships with any proprietary entities producing health care goods or services in the past 12 months
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Objectives
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Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
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Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
• Discuss indications for neuroimaging
Wednesday, April 20, 2011
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Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
• Discuss indications for neuroimaging
• Review management of head trauma cases in the ED: vital sign stabilization, maintenance of respiratory and circulatory parameters, preparation for neurosurgical intervention
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WELCOME TO EMERGIKIDS
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ROOM A
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ROOM A
CC: UNRESPONSIVE, POOR RESP
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ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
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ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”
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ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”
WAS “FINE” EARLIER IN THE DAY...
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ROOM B
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ROOM BC/C: MVC
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ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
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ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
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ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
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ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA
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ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA
Wednesday, April 20, 2011
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Introduction
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Introduction
• What is the leading cause of death in children and adolescents in US?
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Introduction
• What is the leading cause of death in children and adolescents in US?
• What % of these are due to traumatic brain injuries (TBI)? (40%)
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Introduction
• What is the leading cause of death in children and adolescents in US?
• What % of these are due to traumatic brain injuries (TBI)? (40%)
• Remember! These are often associated with cervical spine injuries
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Introduction
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Introduction
• Goals:
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Introduction
• Goals:
• Identify and stabilize pts with TBI
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Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
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Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
• Hypoxia
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Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
• Hypoxia
• Hypotension
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Definitions
• Defined by GCS
Mild (Concussion) 13-15*
Moderate 9-12
Severe <9
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Definitions
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Definitions• *Minor head trauma
(GCS 15):
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Definitions• *Minor head trauma
(GCS 15):
• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch
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Definitions• *Minor head trauma
(GCS 15):
• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch
• Children >/= 2 yrs: normal MS on initial exam, no focal neuro findings, no exam findings for skull fx
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Definitions
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Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
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Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.
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Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.
• Associated sx’s: HA, vomiting, amnesia, AMS
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Epidemiology
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Epidemiology
• Children 0-14 years in US, TBI accounts for:
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Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
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Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
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Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
• 29% < 4 yrs old
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Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
• 29% < 4 yrs old
• 52% 10-17 yrs old
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Epidemiology
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Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
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Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
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Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
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Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
• 4.5%
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Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
• 4.5%
• 10.4% adults
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Epidemiology: Mechanism
• Falls
• MVC
• Pedestrian/bicycle accidents
• Projectiles
• Assaults
• Sports-related
• Inflicted head injuries
• Unknown?
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Epidemiology
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Epidemiology
• Highest morbidity/mortality:
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Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
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Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
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Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
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Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
• Hyperglycemia
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Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
• Hyperglycemia
• Hypotension
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Incidence
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Incidence• True incidence: ...?
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
• Many of these pts have no clinical symptoms
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Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
• Many of these pts have no clinical symptoms
• Most have scalp hematomas
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Clinical Features
Symptom Percentage Comment
LOC 5% (< 2), 13% (>2)Longer duration of
LOC assoc with CITBI*
HA 45% Preverbal children = irritable
Vomiting 14% Assoc w/ slight risk of TBI
Sz 0.6% Smaller studies report larger %
Skull Fx 15-30% Mostly linear when assoc w/ ICI
*Clinically Important TBI
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Clinical Features
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Clinical Features
• Scalp hematomas:
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Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
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Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
• Others:
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Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
• Others:
• Transient cortical blindness or confusional states
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Types of Brain Injury
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Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
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Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
• acceleration or deceleration
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Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
• acceleration or deceleration
• mildest form = Concussion
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Types of Brain Injury
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Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
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Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
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Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
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Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
• Cerebral Contusions
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Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
• Cerebral Contusions
• Intracranial Hemorrhage
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Types of Brain Injury
http://www.braininjury.com/children.html
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Types of Brain Injury
• Focal injuries: Cerebral contusion:
http://www.braininjury.com/children.html
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Types of Brain Injury
• Focal injuries: Cerebral contusion:
• Usually due to acceleration/deceleration injury
http://www.braininjury.com/children.html
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Types of Brain Injury
• Focal injuries: Cerebral contusion:
• Usually due to acceleration/deceleration injury
• Coup, contracoup, or both
http://www.braininjury.com/children.html
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Types of Brain Injury
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Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
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Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
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Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
• Subdural hematoma: rupture of bridging veins
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Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
• Subdural hematoma: rupture of bridging veins
• Subarachnoid hematoma: tearing of small vessels in pia mater
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Associated Injuries
• Multiple trauma
• Cervical spine injury
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Pathophysiology
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Pathophysiology
• Two insult model:
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Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
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Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
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Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
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Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
• increased metabolic demand...
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Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
• increased metabolic demand...
• Secondary event--result of exogenous insults: hypoxia and hypotension
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Evaluation
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Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
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Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
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Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
• Primary survey: A, B, C’s, and identification of life-threatening conditions
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Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
• Primary survey: A, B, C’s, and identification of life-threatening conditions
• Secondary survey: Head-to-toe exam with thorough neurological evaluation
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Evaluation: History
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Evaluation: History
• Obvious vs. Subtle:
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Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
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Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
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Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
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Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
• Progression of symptoms
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Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
• Progression of symptoms
• Occult: Inflicted head injury
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Evaluation: Physical Exam
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Evaluation: Physical Exam
• General assessment
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Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
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Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
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Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
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Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
• Cervical spine immobilization!
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Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
• Cervical spine immobilization!
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Evaluation: Physical Exam
• Calculation of GCS!
• Scalp abnormalities: AF, hematoma, depression?
• Basilar skull fx? periorbital ecchymosis, Battle’s sign, hemotympanum, CSF otorrhea/rhinorrhea
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Evaluation: Physical
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Evaluation: Physical
• Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?
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Evaluation: Physical
• Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?
• Any Abnormalities noted may signal in increase in ICP or possible herniation...!
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Herniation
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Evaluation: Physical Exam
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Evaluation: Physical Exam
• Signs of herniation:
• Uncal herniation --> CN III palsy --> hemiplegia
• Changes in respiratory patterns, pupil size, vestibuloocular reflexes, posture
• Cushing’s triad
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Evaluation: Laboratory Studies
• Trauma labs: Hct, Type + Screen, UA
• Blood glucose*, serum electrolytes, osmolarity
• Coagulation studies*
• * = abnormality associated with poor outcome in TBI
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Evaluation: Imaging
• Mild TBI: Skull radiographs for:
• Unclear hx,
• R/O FB,
• Screen for fx in asymptomatic pts 3-24 mos with scalp hematomas
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Medline ® Abstract for Reference 39of 'Minor head trauma in infants and children'
39
TISkull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?AUChung S, Schamban N, Wypij D, Cleveland R, Schutzman SASOAnn Emerg Med. 2004;43(6):718. STUDY OBJECTIVE: We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs.METHODS: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized.RESULTS: Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The group's mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identified correctly less often (63%<or =5 cm versus 93%>5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs.CONCLUSION: Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.ADDivision of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA. [email protected]
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Evaluation: Imaging
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Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
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Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT
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Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT
• Imaging for mild TBI is more complex...
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THE CT DEBATE...Wednesday, April 20, 2011
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THE CT DEBATE...Wednesday, April 20, 2011
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THE CT DEBATE...Wednesday, April 20, 2011
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THE CT DEBATE...Wednesday, April 20, 2011
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Evaluation: Imaging
Wednesday, April 20, 2011
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Evaluation: Imaging
• Increased use of CT in US
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Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
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Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
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Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
• More likely to occur in community hospitals
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Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
• More likely to occur in community hospitals
• Rare, significant injuries vs risks of CT
Wednesday, April 20, 2011
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Evaluation: Imaging
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Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
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Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
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Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
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Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
• Greater sensitivity to radiation in some developing organs
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Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
• Greater sensitivity to radiation in some developing organs
• Sedation issues
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Evaluation: Imaging
• Goal: identify pts with clinically important TBI:
• neurosurgery,
• ET intubation > 24 hrs,
• hospitalized > 2 days
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Evaluation: Imaging
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Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
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Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
• Consistent: skull fx, focal neuro deficit, depressed MS
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Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
• Consistent: skull fx, focal neuro deficit, depressed MS
• Variable: sz, LOC, amnesia, vomiting, < 2 yrs, trauma mechanism, scalp swelling (pt < 1yr), HA
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FOCUS! 2 MOST IMPORTANT
SLIDES AHEAD!
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FOCUS! 2 MOST IMPORTANT
SLIDES AHEAD!
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Management: TBI
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Management: Airway and Breathing
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
• Hemodynamic instability
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Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
• Hemodynamic instability
• Use cuffed tracheal tubes to protect airway from aspiration
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Management: Airway and Breathing
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Management: Airway and Breathing
• RSI considerations:
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Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
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Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
• Sedation --> Etomidate and thiopental* = neuroprotective
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Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
• Sedation --> Etomidate and thiopental* = neuroprotective
• Paralysis --> Succinylcholine (+/-) vs. Rocuronium
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Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
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Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
HYPOPERFUSION = HYPOXIA?
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Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
HYPOPERFUSION = HYPOXIA?
IDEAL PACO2 35-38...*
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Management: Fluid Managment
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Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
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Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
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Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
• Maintain SBP > 5th percentile, as a minimum
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Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
• Maintain SBP > 5th percentile, as a minimum
• Isotonic fluids preferred (vs. hypertonic)
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Management: Other
Head positioning Hyperventilation
Sedation/paralysis AVOID HYPERGLYCEMIA
Antiseizure Corticosteroids (?)
Hyper-/Hypothermia Emergent surgery
Hyperosmolar Tx
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Management: Monitoring
• HR, BP, Pulse oximetry
• Capnography: end-tidal CO2
• ICP monitoring if abn head CT or GCS 3-8
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ED Management Decisions
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ED Management Decisions
• Immediate neurosurgical evaluation required for:
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ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
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ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
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ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
• Increased ICP
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ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
• Increased ICP
• Deteriorating clinical condition
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ED Management Decisions
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ED Management Decisions
• Children with signs of herniation:
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ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
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ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
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ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
• Mild hyperventilation (PaCO2 30-35)
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ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
• Mild hyperventilation (PaCO2 30-35)
• Immediate neurosurgical evaluation
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Disposition: Minor Head Trauma
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Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
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Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
• If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz
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Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
• If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz
• Admit: brain injury, depressed/basilar skull fracture (with Neurosurg), AMS, persistent vomiting, suspected abuse, unreliable caretakers
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Disposition: TBI
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Disposition: TBI
• Children in field with GCS < or = 12 should go directly to pediatric trauma center.
• Once stabilized, pts should be transferred from community hospital to peds trauma center if:
• GCS < or = 8
• GCS < or = 12 with associated major injuries
• Deterioration in clinical condition / GCS drop
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Return to Play Guidelines
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Return to Play Guidelines
• Children/adolescents at increased risk for Second Impact Syndrome
• Diffuse cerebral swelling after 2nd concussion -- rare, often FATAL.
• Any LOC or symptoms of concussion > 15 minutes -- no sports until asymptomatic x 7 days
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NFL Players Association
What is the cumulative effect of recurrent mild
TBI?
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Some final words...
http://www.cdc.gov/traumaticbraininjury/prevention.html
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ROOM A: 7 MO MALE
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ROOM A: 7 MO MALE
ACTIVE SZ
INTUBATED, ANTICONVULSANTS
URGENT NEUROSURG CONSULT
MANNITOL
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ROOM A: 7 MO MALE
ACTIVE SZ
INTUBATED, ANTICONVULSANTS
URGENT NEUROSURG CONSULT
MANNITOL
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ROOM B: 3 YR MALE
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ROOM B: 3 YR MALE
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ROOM B: 3 YR MALE
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bibliographyLanglois, JA, Rutland-Brown, W, Thomas, KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta 2006.
Schneier AJ, Shields BJ, Hostetler SG, et al. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118:483.
White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534.
Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988; 68:409.
Vavilala MS, Muangman S, Tontisirin N, et al. Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings. Dev Neurosci 2006; 28:348.
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160.
McCrory P. Does second impact syndrome exist? Clin J Sport Med 2001; 11:144.
Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006; 117:1359.
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QUESTIONS?Questions?
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ROOM C
Wednesday, April 20, 2011