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Pediatric Head Injuries

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Head Injury

  • Introduction
  • Incidence
  • Types of Head Injury
  • Current Knowledge & Management
  • Long-term Sequellae
  • Prevention

TIP OF THE ICEBERG

 

INTRODUCTION

  • Motor vehicle crashes #1 cause of TBI, SCI, and seizures
  • 600-700 children die each year
  • 75,000 children are injured

INCIDENCE

  • Trauma is the leading cause of death in children.
  • 11,000 children die from trauma annually
  • Of those, >80% had a severe head injury
  • In children ages 1-15, more died from trauma than all other causes…..COMBINED

GLASGOW COMA SCALE

ALGORITHM IN SEVERE CHI

ALGORITHM WITH ICP

 

CSF DRAINAGE VS ICP MONITORING

  • Therapeutic vs. Diagnostic
  • Hydrocephalus vs. Elevated ICP
  • Infection vs. CSF Diversion
  • Acute vs. Chronic

SECONDARY INJURY FIRST TIER THERAPIES

  • Hypoxia
  • Hypotension
  • Hypocapnea
  • Late Bleed
  • Increased Intra-cranial Pressure

HYPOXIA

  • Requires emergent intubation
  • However, person intubating must be cognizant that there is a 5% incidence of cervical spine injury
  • Too much oxygen is impossible in the acute phase
  • Minimize PEEP to minimize afterload

HYPOTENSION

  • Concern in reduced CPP
  • CPP>60 required in adults
  • Children may well tolerate >50mmHg
  • Fluid resuscitation is cornerstone in trauma
  • CPP = MAP - ICP

HYPOCAPNEA

  • Optimal pCO2 = 25-35
  • >35 causes vasodilation and increases ICP
  • <25 causes vasoconstriction and increases the incidence of cerebral ischemia from 29% to 73% as measured by Xenon CT

LATE BLEED

  • Abrupt increase in intracranial pressure,
    • unrelated to external influences,
    • poorly responsive to usual measure
  • Requires head CT
  • Treatment is surgical

INCREASED INTRACRANIAL PRESSURE

  • Paralysis, sedation, intubation
  • CSF Drainage
  • Mannitol (0.5-1g/kg IV)
  • Hyperventilate to pCO2 25-30

SECONDARY INJURY SECOND TIER THERAPIES

  • Hypertension
  • Hypothermia
  • Barbiturate coma
  • Decompressive craniectomy
  • Reducing blood viscosity
  • Reducing Hyperexcitation

HYPERTENSION

  • If CVP normal, next step is Phenylephrine or Dopamine
  • Goal is CPP>50mmHg
  • CPP=MAP-ICP-CVP

HYPOTHERMIA

  • Initially suggested by Phelps in 1897
  • Mild Hypothermia to 32-34 0C
  • Lower causes coagulopathy
  • 5-10% CMRO2 change per 0 C
  • Hyperthermia injures BBB

BARBITURATE COMA

  • Decrease CMRO2 and CNS lactate and glutamate
  • EEG burst suppression or levels
  • Survival, but poor outcome
  • Arterial hypotension common
  • Recent success in small series

DECOMPRESSIVE CRANIECTOMY

Initially suggested by Cushing in 1905

REDUCING BLOOD VISCOSITY

  • Mannitol reduces blood viscosity.  Concern re renal damage with serum osmolarity >320
  • Hypertonic saline can also be used to increase serum sodium, which artefactually drops with Mannitol
  • Albumin and urea are infrequently used

REDUCING HYPEREXCITATION

  • Felt to be significant cause of secondary injury due to increased metabolism without compensatory increased CBF
  • Glutamate antagonists
  • GABA agonists
  • Oxygen radical scavengers

RECENT HI TRIALS

PROGNOSIS

90% accuracy using:*

  • GCS 24hrs post-injury
  • CT revealing SAH, DAI, or brain swelling
  • Hypoxia

* Ong et al, Pediatric Neurosurg;(1996 Jun) v24 p285-91

 

HI Chart

CT FINDINGS IN N.A.T.

  • Interhemispheric falx hemorrhage
  • Sub-dural hemorrhage
  • Large, non-acute extra-axial fluid collection
  • Basal ganglia edema
  • p<0.05 for above per Hymel et al, Pediatr Radiol; (1997 Sep) v27 n9 p743-7.

SEIZURES

  • Increase CBF and ICP
  • Higher incidence with lower GCS
  • 20% if cerebral contusion
  • Immediate seizures not recurrent
  • Prophylactic anticonvulsant use
  • Treat for 7-10 days

SEQUELLAE

  • Cognitive
  • Higher level comprehension
  • Motor
  • Fine motor usually more involved