TRAUMATIC BRAIN INJURY IN CHILDREN

Marc D. Berg, M.D.Professor of PediatricsChief, Pediatric Critical Care MedicineMedical Director, University of Arizona Physicians*

OBJECTIVESReview OfPhysiology, Assessment, and Management of TBIOutcome in Children With TBICorrect Common Myths

Childhood Head Injuries: Statistics85% are mild, but80% of children with multiple trauma die because of severe head injury (50% in adults)> Head/body ratioSofter skullOpen fontanelles

MYTH #1MythAll Brain Injuries Are the Same

Fact Each Brain Injury Is Different

DEFINING SEVERITYMild Brain InjuryGCS = 13-15Limited impaired consciousness (

DEFINING SEVERITYModerate Brain InjuryGCS = 9 - 12Impaired Consciousness ( 24 hours)PTA > 24hr

CAUTION!!GCS of 13 may not be so mildSC Stein, J Trauma. 2001;50:759-760Reviewed 14 studies (1047 adult patients with GCS of 13) 33.8% had intracranial lesions10.8% required surgery

MYTH #2Myth Younger children recover better than older children.

Fact The developing brain may be at more risk. It will take longer to see the effects of the brain injury.

INTRACRANIAL FLUID COMPARTMENTS(INTRACELLULAR ANDEXTRACELLULAR)

MODIFIED MONROE-KELLIE DOCTRINEABC VOLUMEICPFor pressure to remain constant, an increase in volume in one compartment must be accompanied by an equal decrease in the volume in others

CEREBRAL BLOOD FLOW/AUTO REGULATIONMay be lost after traumaPrinciples are used in treatment strategies but are the source of much debateFrom Shapiro HM: Anesthesiology 43:445-471, 1975

CEREBRAL PERFUSION PRESSURECPP = MAP - ICP

Useful Concept, But Has Limitations

Good CPP, Better Outcome In Adult Literature (>70 mmHg in adults, >40-65 mmHg ? in children)

The CPP (>70) versus the ICP(

BRAIN INJURYPATHOPHYSIOLOGYPrimary Brain Injury (occurs at time of impact)Intracranial hemorrhageDiffuse axonal injuryHyperemia/edemaIschemia, release of toxic mediators

SUBDURAL VS. EPIDURALLifeArt: Williams & Wilkinshttp://www.lifeart.com

SUBDURAL HEMATOMAWebPath: University of Utahhttp://www-medlib.med.utah.edu

EPIDURAL HEMATOMA

SUBDURAL vs EPIDURAL HEMATOMA EPIDURALRequires linear forceAssociated with skull fracture and torn artery. Brain often uninjuredLucid interval commonCommon in accidental traumaSUBDURALRequires significant rotational forcesAssociated with brain injury and torn bridging veinsNeurologic symptoms from the startCommon in infants with abusive head trauma

PEDIATRIC FALLS FROM HEIGHTSFalls From 1 - 3 Stories Often Not FatalFalls Less Than 4 Feet Often Reported in Fatal InjuriesUnwitnessedSubduralsRetinal HemorrhagesFalling off a Bed or Couch Should Not Kill!

COUP - CONTRA COUP INJURY

BRAIN INJURY PATHOPHYSIOLOGYSecondary Brain Injury : Occurs over hours to days (hypoxia, hypercarbia, hypotension/ischemia, intracranial hypertension, acidosis, seizures, hyperthermia, hypothermia, infectionsPotentially Avoidable Or Treatable With Close Monitoring / Treatment of ABCs

UNCONTROLLED INTRACRANIAL PRESSURE AND/OR CEREBRAL PERFUSIONDISPLACEMENT OF NERVOUS TISSUES

DECREASED GLOBALAND REGIONALOXYGEN DELIVERY

HERNIATIONWORSE FUNCTIONAL OUTCOMEDEATH

KEY POINTSTHE BRAIN NEEDS OXYGENOXYGEN IS CARRIED IN BLOOD

NO BLOOD, NO OXYGEN, BRAIN CELLS DIE

Assessment

MINOR CLOSED HEAD INJURYEvaluation and Management of Children Younger Than Two years old With Apparently Minor Head Trauma: Proposed GuidelinesSchutzman SA et al., Pediatrics 2001; 107:983-993

The Management of Minor Closed Head Injury in ChildrenAAP/AAFP, Pediatrics 1999; 104:1407-1415

IMPORTANT ISSUES FOR THE < 2 YEAR OLDSClinical Assessment Difficult!Occult ICI More CommonIncreased Risk of NATIncreased Risk of Skull FractureIncrease Sedation Risk

MYTH #3Myth A mild brain injury has no consequences.

Fact A mild brain injury can affect a childs ability to concentrate, learn and function at home and in school.

CASE PRESENTATION6 year old maleStruck by car while riding his bikeBrought in by EMS with c-spine protectedSpontaneously breathingGCS = 8HR = 145, RR = 25, B/P = 80/45, O2 sats = 99%Multiple abrasions, no other obvious injuriesNext Steps?

INITIAL ASSESSMENTA IRWAY

B REATHING

C T SCAN CIRCULATION

MANAGEMENT OF TBIINITIAL MANAGEMENTLevel II and III (adult and pediatric): AVOID HYPOTENSION AND HYPOXIAKnow Age Based Normals (For children keep BP > 5th %tile)In adults, MBP > 90.Intubate if GCS < 9 (peds) and Airway or Oxygenation is Unstable (adults)

EARLY RESUSCITATION OF CHILDREN WITH MODERATE-TO-SEVERE TRAUMATIC BRAIN INJURY PEDIATRICS 2009;124;56-64 MICHELLE ZEBRACK, CHRISTOPHER DANDOY, KRISTINE HANSEN, ERIC SCAIFE, N. CLAY MANN AND SUSAN L. BRATTON CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved out-comes.

EMERGENCY MANAGEMENT AIRWAYHandle Neck With Caution: Assume C-spine InjuryUse Jaw ThrustAvoid Obstruction of Venous DrainageIntubate If GCS < 8May Need to Protect Airway Due to Seizures or TraumaIntubation Should Be Oral

3 y/o boy after MVA. Spontaneously breathing but nasal flaring present. Atlantoaxial distraction with severed spinal cordodontoidatlas

EMERGENCY MANAGEMENTBREATHINGEven a Small Rise in PaCO2 Causes a Significant Rise in ICPAdequate Breathing May Not Be Enough- Aim for PaCO2 of 35-40 TorrHyperventilation Is the Quickest Way to Lower ICP If There Are Signs of Herniation

EMERGENCY MANAGEMENT CIRCULATION

Blood Pressure Must Be Optimized to Help Maintain Adequate CPPOnly Use Isotonic Fluids for Volume ExpansionMay Need Inotropic or Pressor SupportControl Bleeding

EMERGENCY MANAGEMENT DISABILITYGlasgow Coma ScoreModified for ChildrenCranial Nerve ExamIncluding Pupillary Response to Light, Eye Position and Movement, Corneal Sensation, Gag Motor, Sensory, Reflex ExamCranial Exam Evaluate for Fractures, CSF Leak, Battles Sign Etc.

GLASGOW COMA SCALEEYE OPENING (1-4)1-none2-response to pain3-response to voice4-spontaneous

BEST VERBAL RESPONSE (1-5)1-none2-incomprehensible3-inappropriate4-confused5-oriented

BEST MOTOR RESPONSE (1-6)1-none2-abnormal extension3-abnormal flexion4-withdrawal from pain5-localization of pain6-obeys commands

GLASGOW COMA SCALE (MODIFIED FOR YOUNG CHILDREN)

BEST VERBAL RESPONSE (1-5)1-none2-restless, agitated3-persistently irritable4-consolable crying5-appropriate words, smiles, fixes/follows

MANAGEMENT OF TBIGuidelines For The Management of Severe (Adult) Head Injury

A joint venture ofThe Brain Trauma FoundationThe American Association of Neurological SurgeonsThe Joint Section on Neurotrauma and Critical Care

Journal of Neurotrauma, 1996; 13:626-734Journal of Neurotrauma, 2000; 17:451-553Journal of Neurotrauma, 2007; 24:s1-s106

GUIDELINES FOR THE ACUTE MEDICAL MANAGEMENT OF SEVERE TRAUMATIC BRAIN INJURY IN INFANTS, CHILDREN AND ADOLESCENTSCrit Care Med 2003 Vol. 31, No. 6 (Suppl.)Endorsed or supported by:American Association for the surgery of TraumaChild Neurology SocietyInternational Society for Pediatric NeurosurgeryInternational Trauma and Critical Care SocietySociety of Critical Care MedicineWorld Federation of Pediatric Intensive and Critical Care SocietyNational Center for Medical Rehabilitation ResearchNational Institute of Child Health and Human DevelopmentSyntheses USAThe International Brain Injury Association

DEVELOPMENT OF GUIDELINESCLASSIFICATION OF EVIDENCECLASS I (PRCT)CLASS II (clearly reliable data)CLASS III (retrospective, case reviews, clinical series)TECHNOLOGY ASSESSMENTDEGREES OF CERTAINTYSTANDARDS (high degree)GUIDELINES (moderate degree)OPTIONS (unclear)

CASE CONTINUESPt intubated, on vent20/Kg Saline givenB/P 115/75, HR 120, O2 sat 100%GCS = 7 (Paralyses from RSI resolved)Head CT = small scattered contusions, small non-surgical sub-dural.Abd CT = negC-spine CT = negWhat next?

MANAGEMENT OF TBIINDICATIONS FOR ICP MONITOROPTION (Pediatric): Severe head injury (GCS 8)

CASE CONTINUESPt has ventriculostomy placedClear CSF flows freelyICP = 26mmHgMAP = 70, HR = 100, RR = 15 (on vent), O2sat=99%, GCS = 7, PEERL

Questions? Plans?

MANAGEMENT OF TBIHYPERVENTILATION (PEDIATRIC) OPTIONS (no standards or guidelines): Mild or prophylactic hyperventilation (pCO2 < 35 mmHg) should be avoided. Mild hyperventilation (30 - 35 mmHg) may be considered for longer periods if ICP refractory to all other tx.Aggressive hyperventilation (< 30mm Hg) considered second tier for refractory hypertension.

CASE CONTINUESABG shows pCO2 of 45Vent rate increased to 18/min, 20/kg NS IV bolusRepeat pCO2 = 35ICP still 25, MAP = 75, CPP = 50Head of the bed elevated to 30oPt is sedated and paralyzedNo change in ICP or CPP What next?

MANAGEMENT OF TBIOSMOTHERAPY - PEDIATRICSTANDARDS: none

GUIDELINES: none

OPTIONS: HT Saline is effective for control of raised ICP (.1-1 ml/kg/hr). Mannitol is effective therapy (0.25-1/kg) for control of raised ICPKeep osmolarity

CASE CONTINUESPt started on Hypertonic salineRepeat CT shows diffuse swelling and evolution of contusions.ICP now 34, MAP = 70, CPP = 46, PER slugishHR = 82GCS = 5 when not paralyzed

What now? Time to quit? Is there a chance for good outcome?

OUTCOME IN PEDIATRIC HEAD INJURY

LIMITATIONS OF THE GLASGOW COMA SCALE IN PREDICTING OUTCOME IN CHILDREN WITH TRAUMATIC BRAIN INJURY LIEH-LAI MW, THEODOROU AA, ET AL. J PEDIATR 1992;120:195-964% with GCS5 survivedNonsurvivors had greater incidence of shock/CPR45 survivors with GCS3-11 had neuropsychologic testing37% memory deficits30% speech/language deficits34% motor function deficits18%attention deficits with or without hyperactivity

CASE CONTINUESICP now 34, MAP = 70, CPP = 46, PER sluggishHR = 82GCS = 5 when not paralyzed

Dopamine started, pCO2 now 30, HR = 72, pupils becoming asymmetric

MANAGEMENT OF TBIBARBITURATESOption(Level II for adults): may be considered if ICP control is refractory to other treatment and patient is hemodynamically stableReduction in cerebral O2 requirement, ICPPentobarbital 2-4 mg/kg/dose, 1-2mg/kg/hour, burst-suppression on EEGQuestionable effect on outcomeDisadvantages: myocardial function - use inotropes. Difficult neuro exam

MANAGEMENTCRANIAL DECOMPRESSIONVentriculostomy (option)Tumor DebulkingHematoma EvacuationLobectomyDecompressive Craniectomy (2nd tier)

MANAGEMENT OF TBI STEROIDSSTANDARDS: NOT recommended for improving outcome or reducing ICP in TBI

Useful for edema around brain tumorsDexamethasone 0.4mg/kg/q 6 hours

MANAGEMENT OF TBISUPPORTIVE MANAGEMENTTemperature control - Maintain low normal temp. ~35c (hypothermia under study)Head position - 15-30 elevated, avoid jugular compressionPain control- pain is bad on ICP!!!Seizure control (prophylaxis is option)AntibioticsAdequate nutrition (VERY IMPORTANT!!)

CRITICAL PATHWAY FOR INCREASED ICP TREATMENT

Critical Pathway for Increased ICP Treatment

Critical Pathway for Increased ICP Treatment

CASE PROGRESSIONICP normalizes after 2 weeksGCS 8-9Pt has trach and G-tubeTransferred to inpatient rehab after 1 mosReturns to PICU to say Hi one year later

MYTH #4Myth A Severe Brain Injury Means that the Child Will Be Permanently and Totally Disabled.

Fact Patterns of Recovery Vary.~80% will have some type difficulty.The long term consequences are different for each child.

OUTCOME IN PEDIATRIC HEAD INJURYBetter Then You Think, (For Severe Injury) So Be Aggressive!Do NOT Rely on Initial GCS For PrognosisMild Brain Injury May Have More Consequences Than ExpectedInjury Severity and Level of Family Support May Best Predict Outcome!

MYTH # 5Myth The brain injury cant be that serious if the child came right home from the hospital.Fact More children with disabilities go home upon discharge from the hospital than to in-patient rehab.

Thank youmarcb@peds.arizona.edu*

Subdural vs.. epidural hematoma

A subdural hematoma is venous in origin, with the bridging veins being the usual source. Bridging veins are more susceptible to tearing when there is pre-existent cortical atrophy. Occasionally the source is a cortical artery. Outcome is reasonable if removed early, but subdural hematomata in the unconscious patient are often associated with severe parenchymal injury and therefore a poor outcome.

Acute and chronic subdural hematomata are highly associated with child abuse.

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