Paediatric Traumatic Brain Injury
OVERVIEW
Priorities
- precise assessment of brain injury + associated injury
- protection against secondary brain injury
- management of ICP
ASSESSMENT
Clinical features
- mechanism of injury
- associated injuries
- paediatric GCS
- pupil diameter + reactivity
- brain stem reflexes
- signs of increased ICP
- focal neurological deficits
Investigations
- trauma series (lateral c-spine, CXR and pelvis)
- transcranial Doppler -> quantification of cerebral blood flow, can compare both sides, provides info regarding systolic, diastolic and mean blood flow velocity.
- CT (head and pan-scan for other injuries)
- arterial monitoring
- ICP monitoring -> EVD
- MRI -> done when there is a discrepancy between clinical evaluation and CT
Management
- prehospital: aim for SBP >90mmHg
- prevention of hypotension, hypoxia, hypercarbia, anaemia and hyperglycaemia
- aim for CPP >40 to 65mmHg (age dependent)
- continuous EEG monitoring (ideal)
- triggers for ICP management =
8yrs = 20mmHg
1-8 = 18
Infants = 15
- normothermia
- avoid jugular venous outflow obstruction
- normovolaemia (fluid +/- vasopressor therapy)
- normoxia (SpO2 >90%)
- normocarbia
- adequate sedation and analgesia
- 30 degrees of head up
- CSF drainage via EVD
- mannitol 0.5-1g/kg Q 6 hourly
- hypertonic saline 0.1-1mL/kg/hr
- treat seizures aggressively
- IV barbiturates
- moderate hypothermia
- decompressive craniectomy
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
- Orliaguet GA, Meyer PG, Baugnon T. Management of critically ill children with traumatic brain injury. Paediatr Anaesth. 2008 Jun;18(6):455-61. [PMID 18312508]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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