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Head injury - management of severe traumatic brain injury in PICU

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Identify children with severe traumatic brain injury

  • GCS 3-8
  • Abnormal CT of brain and/or abnormal clinical presentation

Assessment of GCS

  • Apply pain in the cranial nerve distribution
  • Record the total GCS and the individual components (e.g. GCS 7=M5 E1 V1)
  • Reassess the GCS once shock has been corrected.

Initial management/ resuscitation

Many of these will be concurrent:

Trauma Evaluation Oral intubation/ oro- gastric tube/ trauma films/ trauma bloods
Oxygenation Maintain PaO2 13.2 - 20 kPa and/or SaO2 ≥ 98%
Ventilation EtCO2 monitoring, PaC02 4.7-5.3 kPa 
Circulation Appropriate MAP for age; avoid hypotension
Sedation/Analgesia Morphine, diazepam/midazolam
Muscle relaxants To facilitate instrumentation and imaging
Neurological deterioration Signs of deterioration/ impending herniation?
Decreasing motor score, dilated pupils, focal signs, posturing, Cushing's reflex2

1. Treat with 3% saline 3mls/kg
2. Consider short term hyperventilation until stabilised
3. Mannitol 1g/kg ( 5mls/kg 20% Mannitol)
C- Spine Remove collar, use manual stabilisation
Imaging Urgent CT brain/ C-spine then neurosurgery if indicated or to PICU
Trauma surgery If urgently indicated needs ICP monitor insertion

PICU treatment objectives

  1. Identify monitoring parameters for child
  2. Enhance cerebral oxygen delivery
  3. Optimise cerebral perfusion pressure
  4. Control ICP

Monitoring Parameters

* USE CPP instead of MAP ONCE ICP MONITORING ESTABLISHED*

Age Goal MAP mmHg Goal CPP mmHg Goal ICP mmHg
< 2 years >55 40 - 50 <18
2- 6 years >60 45 -55 <18
>6 years >70 50- 60 <20

PICU guidelines

Monitoring  Place Arterial & CV lines3; EtCO2 monitoring, oesophageal/bladder temperature probes
ICP monitoring4 Placement of Codman fibreoptic monitor or external ventricular drain (EVD) by neurosurgery.
EVD preferred to allow drainage of CSF5 
Head Position HOB elevated to 30,° avoid hip flexion, keep head in midline
C-Spine Remove hard collar and stabilise the spine using sandbags and manual stabilisation for log rolls.
Continue c -spine stabilisation and log rolls until formally cleared. See spinal cares RBP
Ventilation & Oxygenation Volume control mode to prioritise CO2 control
PaCO2 4.7 -5.3 kPa note correlation of EtCO2 & PaCO2
PaO2 ≥ 13.2 - 20 kPa
Circulation6 Hypotension should be considered an emergency as it compromises cerebral blood flow and doubles mortality & morbidity.
Titrate therapy to maintain goal CPP once ICP monitoring established
Use crystalloid to maintain CVP 4-8 mmHg
Only give Albumin with consultant authorisation
If euvolaemic use noradrenaline 0.05 -0.3mcg/kg/min
Temperature Rewarming Actively manage temperature to 36 - 37° for a minimum of 72 hours and then until ICP is stable7
Continuously monitor core temperature - never use rectal probe
Oesphageal probe: position in lower third of oesophagus prior to CXR
Bladder thermistor: available sizes 8 Fr and above (remove IDC for MRI)
Give regular paracetamol as charted
Children who present hypothermic or are rewarming from induced hypothermia are allowed to rewarm no faster than 1°C every 6 hours
See PICU Targeted Temperature Management (TTM) Guideline
Analgesia/sedation
Paralysis
As per PICU Sedation and Analgesia protocol
Goal is to maintain deep sedation and analgesia
Consider Fentanyl bolus prior to turns and suction
Consider Phenobarbitone 10mg/kg boluses to max 30-40 mg/kg
Continue paralysis during targeted temperature control or if child presents hypothermic
or to control ICP (Tier 1 intervention for raised ICP )
Sodium & Osmolality8 Maintain serum sodium > 140mmol
If <140 restrict to 50% maintenance fluids
Consider 3mls/kg of 3% saline over one hour via CVL
Maintain serum osmolality > 280 mOsm/kg -check with daily bloods
Fluids/Glucose 70% maintenance fluid as isotonic saline ± potassium9
Do not add glucose in first 48 hours unless
< 2 years < 4.4 mmol
>2 years  < 3.9 mmol
* Infusions made up in 5% Glucose as per usual PICU RBP
Nutrition Commence enteral feeding within 24 hours, aim for full feeds by 7 days
If gastric not tolerated use jejunal
If enteral feeding unlikely to be established by 5-7 days consider TPN
Commence PICU bowel protocol on second day of enteral feeds
Anticonvulsants Give routinely for seven days post injury
Phenytoin 20mg/kg loading dose
IV Maintenance dose 3mg/kg 8 hourly for 7 days.
Maintain therapeutic levels 40 -80 μmol/l
Routine bloods as per PICU protocol 6 hourly: ABG
Daily: magnesium, phosphate, osmolality
Daily: FBC, coagulation ( if abnormal previous day)
Imaging & Neurophysiology CT: repeat if clinically indicated
MRI: as indicated when ICP stable (include neck to exclude ligamentous injury). Note that Codman catheters cannot currently go in the Starship 3T MRI scanner
SEPs: Somatosensory evoked potentials: perform on day one and repeat after 24-48 hours if absent10. Consider EEG.

Notes

  1. Most, if not all, of the predictive power of the GCS comes from the motor score and in particular the motor response with the arms.
  2. Cushing's reflex: hypertension, bradycardia, irregular respirations
  3. Arterial and ICP transducers are levelled at the tragus, CVP levelled at mid-axillary line
  4. ICP monitoring indicated if GCS ≤ 8 with abnormal CT scan. If CT normal but motor score 4 or 5 a short period of observation may be appropriate then rescan at 24 hours. If no improvement or CT scan becomes abnormal ICP monitoring is indicated
  5. EVD positioned 20cmH2O (15mmHg) above tragus. Three way tap is closed to drain and open to transducer. For EVD care see RBP: Raised Intracranial Pressure
  6. Hypotension is rarely due to head injury; look for concealed blood loss.
  7. Hypothermia for ICP control - refer Tier 1 interventions for raised ICP
  8. Do not use frusemide during first 5 days unless pulmonary oedema develops. Risk of hypovolaemia and decreased cerebral blood flow
  9. If blood glucose > 11 mmol on two occasions start insulin infusion on consultant order.
  10. SEPs: only prognostic if bilaterally absent (predictive of death, severe disablement, persistent vegetative state). Abnormal but present SEPs are of limited prognostic significance.

Reference

  1. Adelson, PD., Bratton, SL., Carey, NA., et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Paediatric Critical Care Medicine, 2012; Vol13 No1 (Suppl)
  2. http://journals.lww.com/pccmjournal/toc/2012/01001
  3. https://www.braintrauma.org/pdf/guidelines_pediatric2.pdf

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Document Control

  • Date last published: 06 October 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Editor: John Beca
  • Review frequency: 2 years