TBI Children

8/8/2019 TBI Children

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Alarming StatisticsAlarming Statistics TBI: leading cause of death and disability in

children

-- in USin US: 79/ 100000 admission for head injury,

chidren: 200000 head injury /year: 10%severe TBI

Nationa l Centers for Injury Prevention and Control.

-- in KSAin KSA: NGH: 1598 admissions :664MVA: 378: TBI:

24% severe TBI: 30 diedCrankson SJ; mo tor vehic le injuries in childhoo d: a hospita l-based study in Saud i Arabia, Ped iatr Surg Int 2006

Mortality : 22% severe TBIDucrocq. Epidem iology a nd predic tive fact ors of mo rtality and o utco me in children

with traumat ic severe b rain injury: experience of a French p ediat ric trauma ce nter.Pediat ric C rit Care Me d. 2006



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Result of the direct mechanical damage that occurs at

the time of trauma→ focal lesions: skull fracture, epidural hematoma, sub

ura ema oma, n racere ra ema oma

→ Diffuse axonal injury

Occurs after the initial trauma: the damage to neuronsdue to the systemic physiologic response to the initial injury

→ Release of cytokines, free radicals, glutamate:

→ deleterious cascade of continued cell membrane

break down that further harm the injured brain→ Hypotension and hypoxia are majors causes of

secondary brain injuryBishop . Curr Probl Pediatr Adolesc Health Ca re Oct 2006

PediatricPed iatric CritCrit Care MedCare Med 20032003Vol.Vol. 44, No., No. 33 (Suppl.)(Suppl.)



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Objectives

Review the new developments and

advances in the field pediatric TBI since

the 2003 guidelines

Beyond the 2003 Pediatric TBIBeyond the 2003 Pediatric TBIGuidelinesGuidelines

y y

Neuromonitoring

Biomarkers



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Beyond theBeyond the 20032003 Pediatric TBIPediatric TBIGuidelinesGuidelines

a op ys o ogy

Neuromonitoring

Biomarkers

Optimal CPP

Guidelines Guidelines .

CPP in children with TBI should be

maintained > 40mmHg



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9-year retrospective review of patients with STBIwho required ICP monitoring:156 child/ GOS 12M

Catala- Temp rano. Intrac ranial p ressure and c ereb ral pe rfusion pressure as risk fac torsin children with trauma tic brain injury. J Neurosurg. 2007

CPP: age dependent

Prospective study 235 children with TBI:

CPP during first 6H / outcome at 12 weeks

- 2-6 years: 50mmHg

- 7-10 years: 60mmHg CPP targets

- 11-16 years: 65mmHg

Cha mb ers IR et a l. Age related d ifferenc es in intrac ranial p ressures and c ereb ra l perfusion pressure in the first 6 ho urs of mo nitoring a fter c hild ren’ s hea d injury: assoc ia tion w ith out com e. Childs NervSyst 2005



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a op ys o ogy

Neuromonitoring

erapy

Biomarkers



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ICP monitoring

Options Options . ICP monitoring is appropriate in

infants and children with severe

traumatic brain in ur

ICP monitoring :

WHY ?

- Strong evidence supports the association of Increased ICP

- ICP monitoring and aggressive treatment of increased ICPare associated with the best reported clinical outcome

- guideline level in the adult literature

When ?

- GCS≤ 8 - with abnormal CT scan

--- GCS 8 patient sedated or on neuromuscular blockade.

How ?

- intraventricular ICP

- intraparenchymal ICP….



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Aim:Aim:

to monitor the effect of intervention

( hyperventila tion to test fo r auto-reg ula tory c apab ilities within the bra in…)

to detect significant cerebral hypoxia



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PbO2 > 25mmHg +

( ICP< 20mmHg, CPP> 60mmHg): decreasedmortalit 44%vs 25%, <0.O5

Stiefel MF et a l. Red uce d m ortality rat e in pa tient with sever trauma tic b rain injury trea ted with b rain tissue oxygen m onito ring. J Neurosurg 2005

- PbO2 < 20mmHg in 11/14 after standardresuscitation to ICP and CPP goals

- PbO2 respond to O2

- PbO2 was increased in survivors (p=0.009)Narotam PK et a l cerebral oxygenation in ma jor ped iatric trauma a nd its relevance to trauma severity and outco me . J ped Surg 2006

- mean (Vm> 30cm/s) diastolic (Vd>20cm/s) blood flow velocity /MCA

- Pulsatility index( PI= (Vs-Vd/Vm<1.4)

CPPni = MBP x Vd/Vm +14

Reactivity to CO2 : cerebral autoregulation



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TCD «TCD « goalgoal-- directed therapydirected therapy »»

Assess Vm, Vd, PI at T0 and treat with mannitol andnorepinephrine:

46% abnormal TCD value and 2 @ the time of

insertion of ICP monitoring

ICP was greater in patients with abnormal TCD @admission

CPP and SjvO2 were normal: more adequatecere ra resusc a on

Rac t C et al. Transc ranial Dopple r ultrasound goal-direc ted therapy for the ea rly ma nage ment of severe traumatic brain injury.Intensive Ca re Me d. 2007

The specificity of PI for detecting an ICP≥ 20mmHg is high, but the sensitivity is verylow.

The relationship between PI and the CPPappears to be stronger.

Figag i AA et al. Transc ranial Dop pler pulsat ility index is not a reliab le indic a to r of intrac rania l p ressure in ch ild ren with severe TBI.

Surgic a l Ne urolog y 2009



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Detection of convulsion:

-

convulsive seizure in adult TBI/ increased

ICP and interstitial Lactate/pyruvate

Vespa PM. Et al. Nonc onvulsive elec trograp hic seizures aft er

traum at ic brain injury result in a d elayed , prolonged inc rease in intrac ranial pressure and m eta bolic c risis. Crit Ca re Med . 2007

Evaluation of brain function by analysisof the synchronous nature of cEEG

EEGEEG Prognostic value in patient with disorder of

consciousness post TBI.

Bag at o S et a l. Prognostic va lue of stand ard EEG in trauma tic

and non traum at ic d isorders of c onsiousness following co ma . Clin Neurop hysiol 2010

EEG-SEP changes identify brain function

deterioration. changes can precede an ICPincrease and they can constitute acomplementary tool to interpret ICP trends.

Am an tini A e ta l. Co ntinuous EEG-SEP monito ring in seve re bra in injury. Neurop hysiol Clin. 2009



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Beyond the 2003 Pediatric TBIBeyond the 2003 Pediatric TBIGuidelinesGuidelines

a op ys o ogy

Neuromonitoring

Biomarkers



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RecommendationsRecommendations

Option.Option.

CSF drainage can be considered as in

option in the management of elevated

ICP in children with severe closed head

injury



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continuous CSF drainage > intermittentcontinuous CSF drainage > intermittentCSF drainage ?CSF drainage ?

ompare o c ra nage, ra nage wasassociated with :

- 2 fold greater CSF concentrations of CSF

mediator (p < 0.05)

- ≈1/2 the volume of CSF removal (p = 0.002).

- Higher mean ICPs (21.8 vs13.6 mm Hg, p < 0.0001).

Shore PM e t a l . Continuous versus intermittent

c ereb rospina l fluid drainage aft er seve re trauma tic b rain injury in c hildren: effec t o n b ioc hemica l markers. J Neurotrauma . 2004.

RecommendationsRecommendations

Options.Options.

Decompressive craniectomy should be

considered in pediatric patients with

severe TBI, diffuse cerebral swelling, and

intracranial hypertension refractory to

intensive medical management



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Decompressive craniectomy

Indications:Indications:

Diffuse cerebral swelling on CT brain

Within 48hrs of injury

No episodes of sustained ICP>40mmHg

GCS>3 at some point subsequent toinjury

Secondary clinical deterioration Evolving cerebral herniation

Dec omp ressive c raniectomy As Rescue therapyAs Rescue therapy:

Jaganna than J et al. Outc ome following dec omp ressive craniec tomy in children with severe TBI: a10-year single cente r experience with long term follow up . J Neurosurg 2007

As Early intervention:As Early intervention:

- Survival rate : 100% craniectomy group vs 33% in

the non-operative group.

- 1 year GOS was better in the craniectomy group.

Josan VA Sgouros S. Early dec omp ressive craniec tomy ma y be effec tive in the treat ment of refracto ry intracranial hypertension after trauma tic b rain injury .Ch ilds Nerv Syst. 2006



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Recommendations

Options.Options.

- Extrapolated from the adult data, hyperthermia

should be avoided in children with severe TBI

- Despite the lack of clinical data in children,

hypothermia may be considered in the setting of

refractory intracranial hypertension

Mechanisms of action

Antioxidant effect

Decrease metabolism and O2

consumption

Risk: coagulop athy , IC hemorrhage,

arrhythmia



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Phase II c linica l trial- Moderate HYPO after severe TBI in children was found

to be safe- early hypothermia : better mortality rate

Adelson PD Phase II clinical trial of mod erate hyp othermia a fter severe traumatic brain injury in children. Neurosurgery 2005

CANADIAN Phase III clinical trial:- Hypothermia group had worse outcome

- Methodology?

Hutchison J et al. Hy -HIT Investigators anad canad ian critical c are trial group . Hypotherm ia the rapy after TBI in child ren. N.Engl.j.Med .2008

Ongoing US Phase III TRIAL: Cool Kids TrialAdelson PD. Hypo thermia following ped iatric traum atic b rain injury.

J Neurotraum a. 2009 .

AntiAnti--seizure Prophylaxisseizure Prophylaxis

Recommendations:Recommendations:

Guidelines.Guidelines.

Prophylactic anti-seizure therapy may beconsidered to prevent early PTS in pediatric patient

Options.Options.

Prophylactic use of anti-seizure therapy is notrecommended for children with severe TBI for

Indications from adult guidelinesIndications from adult guidelines

Use of phenytoin has been shown to decrease therisk of early PTS. There is no evidence that outcomeis improved.



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New anti-epileptics drugs

LEV patients/ PHT patients:

- better long-term outcomes :

lower Disability Rating Scale score at 3 months

(P = 0.042) and higher GOS at 6 months (P = 0.039).

-occurrence during cEEG or at 6 months

and in mortality .

Szaflarski JP et al. Prospe c tive, rand om ized , single-blinded c om pa rative trial of intravenous levetirac eta m versus phe nytoin for

seizure prop hylaxis. Neuroc rit Ca re 2010


y y

Neuromonitoring

Biomarkers



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Assesses neuronal death

Early peak level after TBI(<12h)Delayed in inflected neurotrauma

Marker of astrocyte death or injury

Maximal early peak after the insult

Biomarker of axonal injury

Increased only in TBI and inflectedneurotrauma and not HIE

Serum biomarker:- Adjunct to clinical examination in case of

inflicted trauma

- Prognostic factors

Berger s et a l Serum bioma rker c onc entrations and

outc ome afte r pe diatric trauma tic b rain injury. J Neurotraum a. 2007

Multiplex methods: /CSF analysis

- Assessments of multi le markers(cytokines)

- Assess the effect of therapy on the

biochemical response to TBI

Urine: source for biomarkers



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Dash KP. Biom arkers fo r the Diag nosis, Prognosis, and Evalua tion o f Trea tm ent Effica c y for Traumat ic Brain Injury. Neurotherap eut ics 2010

Dash KP. Biom arkers fo r the Diag nosis, Prognosis, and Evalua tion o f Trea tm ent Effica c y for Traumat ic Brain Injury. Neurotherap eut ics 2010



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Secondary prophylaxis: secondary injury

More study since 2003 guidelines

Need more pediatric study

Documents

TBI Children