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Evidenced-Based Care of the Child with Traumatic Head Injury

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Presentation on theme: "Evidenced-Based Care of the Child with Traumatic Head Injury"— 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 Concussion Contusion Intracerebral hemorrhage
Rhoads & Pflanzer (1996) Human Physiology p. 213

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

11 Cerebral Blood Flow Regulation of Cerebral Vascular Resistance CBF
Normal ml / min PaCo2 (mmHg) MAP (mmHg) Normal 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 Neuronal Response to Injury
Primary mechanical injury & secondary hypoxic-ischemic injury Inflammation: Vasoreactivity Thrombosis Neutrophils Ca+ ATP Lactate Acidosis Glucose NMDA O2 - Edema Glutamate Cyclooxygenase Lipoxygenase Arachidonic Acid Leukotriene Thromboxane Prostaglandin Fluid

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
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 Serial neurologic examinations Circulation / Respiration Intracranial Pressure Radiologic Studies Laboratory Studies 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? Originally adapted from Skippen et al. (1997) Critical Care Medicine, 25 ALL-NET Pediatric Critical Care Textbook

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 cmH20 --- Moderate and transient

23 Suctioning Hyper-oxygenation Mild / moderate hyperventilation
53% 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 Percent increase in ICP with suctioning 0% 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
Brain Blood CSF Mass 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 Bone

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

28 Diuretic Therapy Osmotic Diuretic Mannitol (0.25-1 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 Hyperosmolar Therapy Goal: Sodium 145-155 Sodium: square ICP: circle
Qureshi et al. (1998) Critical Care Medicine, 26(3)

31 Promote Venous Drainage
Keep neck mid-line and elevate head of bed …. To what degree? 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) Dicarlo in ALL-NET Pediatric Critical Care Textbook

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 No pediatric studies! Slow re-warming Close monitoring

34 Management of Pain & Agitation
ICP management continued... Management of Pain & Agitation Difficult to assess neurologic exam Monitor for hypotension Short acting agents beneficial Opiods Benzodiazepines Management of Movement Neuromuscular blockade 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)

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

37 Family Contact and ICP Presence, touch and voice of family / significant others... Does not significantly increase ICP Has been demonstrated to decrease 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)

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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