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 skull

Weak neck musculature

Large 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 precautions

HR: 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

bra

l B

lood 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 drainage

2. Decrease cerebral metabolism

3. Hyperosmolar therapy

4. CSF drainage

5. 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