From
StayCurrentMD
Traumatic Brain Injury
With Dr. Pramod Pulaamba · hosted by Dr. Ray Hankey
Part of
Traumatic Brain Injury 4 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For a patient with small epidural hematoma, immediate neurosurgical consultation is needed to determine if surgical evacuation is required.
Small epidurals may be managed with repeat CT in several hours or clinical observation for deterioration before operating.
ICP monitoring should be discussed with neurosurgeons for patients being managed for potential intracranial pressure issues.
Invasive blood pressure monitoring is needed for accurate blood pressure identification in patients with intracranial hypertension.
Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure.
ICP above 20 may require ongoing treatment and/or reevaluation with imaging.
Acute intracranial hypertension may first manifest as dilation of the ipsilateral pupil or progressive bradycardia with hypertension.
Acute ICP management includes raising the head of bed to improve venous drainage, providing oxygen, and bag valve masking.
Hyperventilation to PCO2 of around 35 helps vasoconstrict the brain and create space in acute ICP crisis.
If an ICP drain is present, opening it to evacuate fluid and reduce pressure is a first-line intervention.
3% normal saline at 5 mL per kilogram will generally increase serum sodium by 3 to 5 mEq per liter.
3% normal saline has an osmolarity limit of 360 millimoles compared to Mannitol's 320 millimoles.
Hypotension in the context of closed head injury is a very poor prognosticator and should be avoided at all costs.
In older children and teenagers, systolic blood pressure should be kept above 90 or 95; younger children should use age-appropriate norms.
Norepinephrine can be used to drive up blood pressure to maintain cerebral perfusion.
Mannitol's diuretic effect can be difficult to control and may lead to hypotension.
Mannitol's first effect within 15 to 20 minutes is changing blood vessel rheology to allow freer passage through cerebral circulation and improve oxygen delivery; the diuretic effect is secondary and occurs afterwards.
The dose of Mannitol is 0.5 g to 1 g per kilogram.
There is no role for steroids in pediatric traumatic brain injury.
Steroids are no longer considered effective therapy for suspected spinal cord injury and may cause detriment.
Decompressive craniectomy is an emerging option for patients with diffuse axonal injury and very difficult to control ICP where there is no true surgical lesion to decompress.
Patients with persistently elevated ICP above 20 with higher spikes will slowly deteriorate to the point where they are not salvageable.
In decompressive craniectomy, the bone is preserved and can be replaced after things settle down.
Major trauma centers across North America are using decompressive craniectomy more frequently.
CT scan is preferred in acute situations with very acute presentation of increased ICP because it provides the best information for determining need for OR or drain placement.
MRI is used after the first 48 hours once the patient is stable and ICP spikes are controlled, primarily as a prognosticator.
MRI provides useful information for counseling families and directing care plans when injury is very severe.
Repeat MRI in a week's time gives the true extent of injury and allows more meaningful discussions about level of disability.
CT head scan can be completed in 5 minutes versus 20-30 minutes for MRI, making CT preferable for critical patients.
Sympathetic storming is thought to occur because of an imbalance of the sympathetic and parasympathetic nervous systems as a result of head injury.
Untreated sympathetic storming can lead to secondary brain injury or potentiate ongoing injury.
Hyperventilation during sympathetic storming leads to vasoconstriction which could lead to cerebral hypoxia and further cellular injury.
Hypertension during sympathetic storming could lead to hemorrhage within areas of the brain.
Arrhythmias during sympathetic storming can lead to hemodynamic instability and hypoperfusion, worsening head injury.
Neurogenic pulmonary edema is sometimes common in patients with sympathetic storming, leading to hypoxia and difficult ventilation.
The cornerstone of sympathetic storming treatment is sedation and pain control, usually accomplished with narcotics and/or benzodiazepines as first-line medications.
Bromocriptine acts on the hypothalamus to help reduce hyperthermia, diaphoresis, and blood pressure in sympathetic storming.
Oxycodone has been used for its longer-acting effect for pain control in sympathetic storming.
Propranolol can help control arrhythmias and lower blood pressure in sympathetic storming.
Clonidine is an alpha-2 agonist that can reduce levels of catecholamines throughout the body and reduce ongoing sympathetic storm.
Traumatic brain injury caused over 837,000 visits, hospitalizations, and deaths in children in 2014.
Most guidelines suggest keeping CPP greater than 45 as the minimal acceptable, sometimes 55 in children.
Based on the most recent guidelines in Pediatric Critical Care Medicine, there is no evidence that 3% saline is better than Mannitol or vice versa.
Based on the 3rd iteration of Management of Traumatic Brain Injury in Children published in Pediatric Critical Care Medicine, there is still no clear consensus that decompressive craniectomy improves outcomes.