severe pediatric head injury – tips and tricks
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Severe Pediatric Head Injury – tips and tricks. Jonathan Duff MD Division of Pediatric Critical Care University of Alberta. Conflicts of Interest. Nothing to declare. “…children exhibit almost limitless creativity with regard to sustaining injury”. Kids aren’t little adults. - PowerPoint PPT PresentationTRANSCRIPT
Severe Pediatric Head Injury – tips
and tricksJonathan Duff MD
Division of Pediatric Critical CareUniversity of Alberta
Conflicts of InterestNothing to declare
“…children exhibit almost limitless creativity with
regard to sustaining injury”
Kids aren’t little adults
Immature/pliable skullWeak neck musculatureLarge head:body ratio
A four-year-old boy is involved in a MVC – car is T-boned at high speeds
On arrival of medics, child is found restrained in the car. Unresponsive, moaning and with stiffening movements
What’s his GCS? And why do we care?
Severe TBI: GCS < 9Standard GCS for verbal patients
Non-verbal patients4 Coos/babbles3 Irritable/cries2 Cries to pain1 Moans to pain
Motor testingMost important prognostic factor – get a
history!!
Assessment is key
Arrival to ED
Child arrives in full spinal precautionsHR: 143; BP 74/33; Sats 99% on 15lpm; RR 8
Prevention of secondary injury is the key
Hypoxia, hypotension, hypercarbia, hyperthermia
Cerebral Autoregulation
Pressure (mmHg)
Cere
bral
Blo
od F
low
50 180
PaCO2
CPP
PaO2
Mono-Kellie Doctrine
Intubation ConsiderationsC-spine precautions
Medications:Usual recommendation:
Propofol vs. fentanyl/midazolam
Etomidate?Ketamine?
Intubation Considerations
How fast do we bag?
The role of hyperventilation
pCO2 45 pCO2 30
Back to the caseChild has been intubated and fluid resuscitated
Taken to CT scanner – reported as normal
Management of high ICPRemember – avoid secondary injury
CPP = MAP – ICP
Target CPP > 40 – 50 mmHgAdult > 65-70 mmHg
Minimize cerebral metabolism
5 ways to decrease ICP
1. Increase venous drainage2. Decrease cerebral metabolism3. Hyperosmolar therapy4. CSF drainage5. Decompression
5 ways to decrease ICP
1. Increase venous drainage Elevate the head of the bed (if you can) Watch for a tight cervical collar
5 ways to decrease ICP
2. Decrease cerebral metabolism Need to decrease cerebral oxygen requirements
Hypothermia
Seizure control
5 ways to decrease ICP
3. Hyperosmolar therapyMannitol
3% Saline
5 ways to decrease ICP
4. CSF drainageExternal ventricular drainAllows measurement of ICP and treatment
5 ways to decrease ICP
5. Decompression
SummaryTraumatic brain injury is an important cause of
pediatric morbidity and mortality
If you can’t prevent it, the key is to prevent secondary injury