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Evidenced-Based Care of the Child with Traumatic Head Injury A. Student The Children’s Hospital of Philadelphia.

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Presentation on theme: "Evidenced-Based Care of the Child with Traumatic Head Injury A. Student The Children’s Hospital of Philadelphia."— Presentation transcript:

1 Evidenced-Based Care of the Child with Traumatic Head Injury A. Student The Children’s Hospital of Philadelphia

2 Objectives Describe the pathophysiology of traumatic brain injury Discuss the scientific rationale for the therapeutic interventions used in the care of brain injured children Provide research based recommendations for the care of children with traumatic brain injury

3 Rhoads & Pflanzer (1996) Human Physiology p. 211

4 Traumatic Head Injury ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins.

5 Layers of the Cranial Vault Anatomy of the Brain

6 Epidural and Subdural Hematoma ALL-NET Pediatric Critical Care Textbook - Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins.

7 Subarachnoid Hemorrhage Rogers (1996) Textbook of Pediatric Intensive Care pp. 829

8 Cerebral Spinal Fluid Produced by the choroid plexus Average volume ml –(0.35 ml / minute or 500 ml / day) Reabsorbed through the arachnoid villi Drainage may be blocked by inflammation of the arachnoid villi, diffuse cerebral edema, mass effect of hemorrhage or intraventricular hemorrhage

9 Brain Cells Rhoads & Pflanzer (1996) Human Physiology p. 213 Concussion Contusion Intracerebral hemorrhage

10 Neurons Diffuse Axonal Injury Shearing injury of axons Deep cerebral cortex, thalamus, basal ganglia Punctate hemorrhage and paranchymal edema Neuroscience for Kids

11 CBF MAP (mmHg) Normal ml / min Normal mmHg Cerebral Blood Flow Regulation of Cerebral Vascular Resistance PaCo 2 (mmHg) Normal mmHg Rogers (1996) Textbook of Pediatric Intensive Care pp

12 Cerebral Edema Cellular response to injury –Primary injury Secondary injury –Hypoxic-ischemic injury Injured neurons have increased metabolic needs Concurrent hypotension and hypoxemia Inflammatory response

13 Primary mechanical injury & secondary hypoxic-ischemic injury Neuronal Response to Injury ATP Glucose Lactate Acidosis O 2 - NMDA Ca+ Glutamate Fluid Arachidonic Acid Leukotriene Thromboxane Prostaglandin Edema Cyclooxygenase Lipoxygenase Inflammation: Vasoreactivity Thrombosis Neutrophils

14 Monitoring Brain Metabolism Jugular Venous Catheter Jugular Venous Oxygen Saturation (SJVO2) Arteriojugular Venous Oxygen Difference (AJVO2) Cerebral Metabolic Rate For Oxygen (CMRO2) Possible better outcome in adults Cruz (1998) Critical Care Medicine, 26(2) Brain Sensors Brain tissue pH, PaO2, PcO2, lactate Kiening (1997) Neurology Research, 19(3)

15 Cerebral Edema after Head Trauma ALL-NET Pediatric Critical Care Textbook Source: Research by Samuel Neff MD.

16 Monroe- Kellie Principle Rogers (1996) Textbook of Pediatric Intensive Care p. 646

17 Management of Traumatic Head Injury Maximize oxygenation and ventilation Support circulation / maximize cerebral perfusion pressure Decrease intracranial pressure Decrease cerebral metabolic rate

18 Monitoring Serial neurologic examinations Circulation / Respiration Intracranial Pressure Radiologic Studies Laboratory Studies Ong et al. (1996) Pediatric Neurosurgery, 24(6) GCS, hypoxemia and radiologic evidence of SAH, edema and DAI predict morbidity GCS alone does not predict morbidity Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2) Hypotension is predictive of morbidity GCS and PTS are not predictive of outcome Scherer & Spangenberg (1998) Critical Care Medicine, 26(1) Fibrinogen and platelets are significantly decreased in TBI patients

19 Respiratory Support: Maximize Oxygenation Hypoxemia is predictive of morbidity –Ong et al. (1996) Pediatric Neurosurgery, 24(6) Neurogenic pulmonary edema / concurrent lung injury –Positive End Expiratory Pressure May impair cerebral venous return –Cooper et al. (1985) Journal of Neurosurgery, 63 –Feldman et al. (1997) Journal of Neurosurgical Anesthesiology, 9(2) PEEP > 10 cm H2O increases ICP

20 Respiratory Support: Normoventilation Hyperventilation : Historical management more harm than good? ALL-NET Pediatric Critical Care Textbook Originally adapted from Skippen et al. (1997) Critical Care Medicine, 25

21 Evidence Supporting Normoventilation Forbes et al. (1998) Journal of Neurosurgery, 88(3) Marion et al. (1995) New Horizons, 3(3) McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5) Muizelaar et al. (1991) Journal of Neurosurgery, 75(5) Newell et al. (1996) Neurosurgery, 39(1) Skippen et al. (1997) Critical Care Medicine, 25(8) Yundt & Diringer (1997) Critical Care Clinics, 13(1)

22 Use of Hyperventilation... Management of very acute elevation of intracranial pressure Preemptive for activities known to increase intracranial pressure No lower than cmH Moderate and transient

23 Suctioning Hyper-oxygenation Mild / moderate hyperventilation Brown & Peeples (1992) Heart & Lung, 21 Parsons & Shogan (1982) Heart & Lung, 13 Intratracheal / intravenous lidocaine Donegan & Bedford (1980) Anesthesiology, 52 Wainright & Gould (1996) Intensive & Critical Care Nursing, 12 As needed basis and individualize according to patient response 53% 0% Percent increase in ICP with suctioning Wainright & Gould (1996)

24 Circulatory Support: Maintain Cerebral Perfusion Pressure Number of Hypotensive Episodes Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

25 Circulatory Support: Maintain Cerebral Perfusion Pressure Adelson et al. (1997) Pediatric Neurosurgery, 26(4) –Children (particularly < 24 months old) are at increased risk of cerebral hypoperfusion after TBI –Low CBF is predictive of morbidity Rosner et al. (1995) Journal of Neurosurgery, 83(6) –Management aimed at maintaining CPP (70 mmHg) improves outcomes CPP = MAP - ICP

26 Lowering ICP Evacuate hematoma Drain CSF –Intraventricular catheters use is limited by degree of edema and ventricular effacement Craniotomy –Permanence, risk of infection, questionable benefit Reduce edema Promote venous return Reduce cerebral metabolic rate Reduce activity associated with elevated ICP BrainBlood CSFMass Bone

27 Hyperosmolar Therapy: Increase Blood Osmolarity Fluid Osmosis: Fluid will move from area of lower osmolarity to an area of higher osmolarity Movement of fluid out of cell reduces edema Brain cell Blood vessel

28 Diuretic Therapy Osmotic Diuretic Mannitol ( gm / kg) Increases osmolarity Vasoconstriction (adenosine) / less effect if autoregulation is impaired and if CPP is < 70 Initial increase in blood volume, BP and ICP followed by decrease Questionable mechanism of lowering ICP Rosner et al. (1987) Neurosurgery, 21(2) Loop Diuretic Furosemide Decreased CSF formation Decreased systemic and cerebral blood volume (impairs sodium and water movement across blood brain barrier) May have best affect in conjunction with mannitol Pollay et al. (1983) Journal of Neurosurgery, 59 ; Wilkinson (1983) Neurosurgery,12(4)

29 Hypertonic Fluid Administration Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4 –Reduction in mean ICP in children 2 hours after bolus administration of 3% saline Taylor et al. (1996) Journal of Pediatric Surgery,31(1) –ICP is lowered by resuscitation with hypertonic saline vs. lactated ringers solution in an animal model Qureshi et al. (1998) Critical Care Medicine, 26(3) –Reduction in mean ICP within 12 hours of continuous infusion of 3% saline acetate solution –Little continued benefit after 72 hours of treatment

30 Qureshi et al. (1998) Critical Care Medicine, 26(3) Goal: Sodium Hyperosmolar Therapy Sodium: square ICP: circle

31 Promote Venous Drainage Keep neck mid-line and elevate head of bed …. To what degree? Dicarlo in ALL-NET Pediatric Critical Care Textbook Feldman et al. (1992) Journal of Neurosurgery, 76 March et al. (1990) Journal of Neuroscience Nursing, 22(6) Parsons & Wilson (1984) Nursing Research, 33(2)

32 Reduction of Cerebral Metabolic Rate Reduction in cerebral oxygen requirement –Anticonvulsants - Prevent seizure activity –Pentobarbital Adverse effects include hypotension and bone marrow dysfunction Used only after unsuccessful attempts to control ICP and maximize CPP with other therapies Improved outcome not fully supported by research Traeger et al. (1983) Critical Care Medicine, 11 Ward et al. (1985) Journal of Neurosurgery, 62(3)

33 Reduction of Cerebral Metabolic Rate: Hypothermia Metz et al. (1996) Journal of Neurosurgery, 85(4) –32.5 C reduced cerebral metabolic rate for oxygen (CMRO2) by 45% without change in CBF, and intracranial pressure decreased significantly (p < 0.01) Marion et al. (1997) New England Journal of Medicine, 336(8) –At 12 months, 62% of patients (GCS of 5-7) cooled to C have good outcomes vs. 38% of patients in control group Side-effects: Potassium flux Coagulopathy Shivering Skin Breakdown Slow re-warming Close monitoring No pediatric studies!

34 Management of Pain & Agitation Opiods Benzodiazepines Management of Movement Neuromuscular blockade Difficult to assess neurologic exam Monitor for hypotension Short acting agents beneficial ICP management continued... Do opiods increase CBF? Increased ICP with concurrent decreased MAP and CPP has been documented. Elevation in ICP is transient and there is no resulting ischemia from decreased MAP / CPP. Albanese et al. (1999) Critical Care Medicine, 27(2)

35 Nursing Activities and ICP Rising (1993) Journal of Neuroscience Nursing, 25(5) ICP

36 Nursing Activities and ICP Rising (1993) Journal of Neuroscience Nursing, 25(5) ICP Bathing

37 Family Contact and ICP Bruya (1981) Journal of Neuroscience Nursing, 13 Hendrickson (1987) Journal of Neuroscience Nursing, 19(1) Mitchell (1985) Nursing Administration Quarterly, 9(4) Treolar (1991) Journal of Neuroscience Nursing, 23(5) Presence, touch and voice of family / significant others... Does not significantly increase ICP Has been demonstrated to decrease ICP

38 Summary of Recommended Practices Maximize oxygenation (PEEP < 10) Normoventilate Suction only as needed, limit passes, pre-oxygenate, +/- pre-hyperventilate (not < 30), use lidocaine when possible Maintain blood pressure and maintain CPP > 60 Evacuate intracranial blood Drain CSF with ventriculostomy when possible

39 Summary of Recommended Practices Hyperosmolar therapy Avoid hyperthermia, +/- hypothermia Prevent seizures Reserve pentobarbital for refractory conditions Mid-line neck, elevated head of bead, ? not > 30 degrees Treat pain and agitation - consider pre-medication for nursing activities Avoid hyperglycemia Allow family contact


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