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
- 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 in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC