1. Traumatic Brain Injury Children Torsten Lauritsen Rigshospitalet Copenhagen

2. Aim Traumatic Brain Injury in Children2  To give an overview of severe traumatic brain injury in children  focus on resuscitation  first line treatment  guidelines  To improve the care of children with severe traumatic brain injury

3. TBI Traumatic Brain Injury in Children3  Epidural hemorrhage  Subdural hemorrhage  Subarachnoid hemorrhage  Contusions  Cerebral edema  Ischemic injury  Diffuse Axonal Injury  Abusive Head Trauma – Shaken Baby Syndrome

4. Head trauma - physiology Primary brain damage  Direct following the trauma  Irreversibel– Diffuse Axonal Injury  Treatment does not improve prognosis Secundary brain injury  Proper resuscitation will improve prognosis and prevent further damage  Hypoxemia  Convulsions  Hypotension  Hyperthermia  Raised ICP  Hypoglycemia Decreased cerebral perfussion Cerebral oxygen delivery Increased oxygen consumption Increased ischemia

5. 5 Glucose Temperature pH Electrolytes Sedation Cerebral perfusion Chalkias A in J of Neurological Sciences 2012 Neuroprotective agents ICP ROS

6. Cerebral edema Traumatic Brain Injury in Children6  Intracellular – hypoxia  Cellular metabolism  Cellular retention of sodium and water  Apoptosis  Vasogenic  Rupture of BBB leads to leakage from capillaries

7. Paediatric trauma care Traumatic Brain Injury in Children7

8. Hypotension is bad Traumatic Brain Injury in Children8 131/299 = 44% had hypoxia 118/299 = 39% had hypotension Absense of BP monitoring => OR of death 4.5

9. Hypotension is bad Traumatic Brain Injury in Children9

10. Guidelines Traumatic Brain Injury in Children10  Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents

11. Treatment Traumatic Brain Injury in Children 11  Resuscitation A B C D

12. Treatment - Airway Traumatic Brain Injury in Children12  Early intubation  Modified Rapid Sequenze Induction

13. Rapid Sequence Induction  Premedication with spontaneous ventilation  Preoxygenation  Induction  Propofol/Tiopental (Ketamin/Etomidat)  Rocuronium  Fentanyl (Rapifen)  Mask ventilation (10-12 cm H 2 O)  Intubation 13

14. Treatment - Breathing Traumatic Brain Injury in Children14  Oxygen  Maintain oxygenation within normal range  PEEP might increase ICP

15. Hypoxia is worse 15 Mortality risk lowest at O 2 8 – 10 kPa (60 – 75 mmHg) Mortality risk increase with hypoxia and hyperoxia OR 1,92 OR 1,25

16. Hyperventilation Traumatic Brain Injury in Children16  Hyperventilation => hypocapnia => vasoconstriction => lower CBF and CBV => lower ICP  Vasoconstriction worsen cerebral ischemia  Hyperventilation only after neurosurgical consultation and if herniation is impending

17. Circulation Traumatic Brain Injury in Children17  Systolic BP > 70 + 2 x age  Haemorrhage control  Fluid resuscitation  Krystalloid 20 ml/kg  SAGM 10-20 ml/kg  FFP 10-20 ml/kg  TC 5-10 ml/kg  Vasopressors?

18. Resuscitation - fluids Traumatic Brain Injury in Children18  Albumin vs saline  Ringers Lactate vs Saline osmolality 270 vs 308 Sodium 130 vs 154

19. Physiology – cerebral perfusion Traumatic Brain Injury in Children19  Cerebral perfusion pressure (CPP)  Mean arterial pressure (MAP)  Intra cerebral Pressure (ICP) CPP = MAP - ICP  Level 3 evidence  CPP > 40 mmHg  ICP < 20 mmHg

20. Disability - ICP monitoring Traumatic Brain Injury in Children20  ICP < 20 mmHg  No evidence directly in favor of ICP monitoring – but: 1. Children with severe TBI have high ICP 2. Poor outcome with intracranial hypertension 3. Better outcome with protocols for treatment of ICP 4. Better outcome with succesful ICP lowering therapies

21. Anaesthesia Traumatic Brain Injury in Children21  Ketamin  Propofol  Tiopental  Etomidat Increase HR Increase BP Bronchodilatation Decrease cerebral metabolism Cerebral vasoconstriction Induce systemic hypotension => lower CPP

22. Anaesthesia Traumatic Brain Injury in Children22  Sevoflurane and Isoflurane  Nitrous oxide Decrease cerebral metabolism Vasodilatation => CBF and CBV Increase cerebral metabolism Increase CBF => ICP Should be avoided

23. Neuromuscular blocking agents Traumatic Brain Injury in Children23  Succinylcholine  Increase ICP  Provide rapid optimal conditions for intubation  Cardiac arrytmias  Rocuronium  Optimal drug for paediatric intubation  Reversal with Sugammadex  0,6-1,0 mg/kg

24. Positioning Traumatic Brain Injury in Children24  Improve venous drainage  Elevate head 15-30 o  Avoid flexion or rotation

25. Mannitol Traumatic Brain Injury in Children25  Mannitol 1g/kg - reduce ICP by  Reduces blood viscosity rapidly but transiently < 75 min  Slow osmotic effect over 15-30 min  Movement of water from the brain to the systemic circulation. Effect up to 6 h, but requires a intact BBB  May cause hypotension (osmotic diuresis)  Rebound effect

26. Hypertonic Saline 3 % Traumatic Brain Injury in Children26  5 ml/kg  513 mmol/l Na+,  Osmolality 1027 mOsm/l  Osmotic action in the brain  Restores intravascular volume  Increased inotopy  Increase MAP and CPP

27. Hyperosmolar therapy Traumatic Brain Injury in Children27  Recommendation level 2  Hypertonic saline should be considered for treatment of TBI associated with intracranial hypertension. Effective dose for acute use range between 6,5-10ml/kg.  Recommendation level 3  Hypertonic saline for treatment of intracranial hypertension 3% saline as a continous infusion range between 0,1-1,0 ml/kg/hour.  Mannitol is commonly used but no RCI exists

28. Hypothermia Traumatic Brain Injury in Children28  Level 2  Moderate hypothermia (32-33C) beginning early after TBI for only 24 hrs’ duration shold be avoided

29. Hypothermia 29

30. Hypothermia – adverse effects Traumatic Brain Injury in Children30  Hypotension  Bradycardia  Arrhytmias  Sepsis  Coagulopathy

31. Treatment - Conclusion Traumatic Brain Injury in Children31  Resuscitation  Triage – expeditious  Surgical treatment  ICP monitoring and control  Optimization of organ systems

32. Traumatic Brain Injury in Children32 ICP raised – impending herniation HyperventilationCraniotomyTiopentalHypothermia Hyperosmolar therapy Saline 3 %Mannitol ICP raised CSF drainageNeuromuscular blockade CT - scan ICP monitorSurgical evacuation Primary intervention for TBI Elevate headNormothermiaSedation Resuscitation AirwayBreathingCirculation

33. Traumatic Brain Injury in Children