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An Evidence-Based Approach To Severe Traumatic Brain Injury In Children - $30.00
This issue includes 4 AMA/ACEP category 1, AAP Prescribed CME credits
Authors:
Stuart H. Friess, MD,
Mark A. Helfaer, MD, FCCM,
Ramesh Raghupathi, PhD, and
Jimmy W. Huh, MD
Peer Reviewers:
Martin I. Herman, MD, FAAP, FACEP, and
Mark A. Hostetler, MD, MPH
Publication Date:
December 1, 2007, Volume 4, Number 12
Excerpt from the issue…
A four-year-old boy is an unrestrained passenger in a motor vehicle crash and has been brought via EMS to your ED. He was not responsive at the scene, with equal and reactive pupils. Endotracheal intubation was unsuccessful at the scene and he has been receiving bag mask ventilation en route. You look at the monitor and see that his pulse is 80 and his blood pressure is 140/90 with an oxygen saturation of 100%. The resident yells out that his left pupil is 7 mm and minimally reactive and his right pupil is 3 mm and reactive. He extends to painful stimuli on the left and does not move his right side. Several questions run through your mind. How am I going to secure this patient’s airway? Do I hyperventilate this patient if so, how much? What about mannitol? Or should I use hypertonic saline? What is the likelihood of a good outcome?
Conclusion to the above case study...
You quickly identified that this patient had a GCS of 4. The patient was preoxygenated with 100% supplemental oxygen. You asked the resident to maintain the neck in neutral position and a nurse to provide gentle cricoid pressure. You then performed a modified rapid sequence induction with lidocaine (1.5 mg/kg IV), etomidate (0.3 mg/kg IV), and vecuronium (0.3 mg/kg IV). A5.0 endotracheal was successfully placed and proper placement confirmed by detection of end-tidal CO2. Hand ventilation was titrated to maintain end-tidal CO2 between 30-35 mmHg. Abolus of 3% hypertonic saline (4 mL/kg) was administered for suspected intracranial hypertension.
The resident then observed the pupils becoming equal, and both were reactive. The neurosurgeons were contacted and the patient was transported to radiology for an emergent head CT. On transport, hand ventilation was titrated to maintain end-tidal CO2 between 30-35 mmHg. CT scan demonstrated a left epidural hematoma with midline shift and uncal herniation. The patient was immediately taken to the operating room for emergent surgical decompression. The patient was extubated on post operative day one with no further episodes of intracranial hypertension.
Traumatic brain injury (TBI) is the leading cause of mortality and severe morbidity in children. Emergency medicine clinicians are the first line hospital responders for children with severe traumatic brain injury. The primary goal in the acute management of the severely head-injured pediatric patient is to prevent or ameliorate factors, such as hypoxemia, hypotension, intracranial hypertension, hypercarbia, hyper- or hypoglycemia, electrolyte abnormalities, enlarging hematomas, coagulopathy, seizures, and hyperthermia, that promote secondary brain injury. It is integral that clinicians recognize the signs and symptoms of severe pediatric TBI, initiate appropriate interventions, and activate the necessary specialty services in a timely manner. An evidence-based review of these considerations will be presented in this issue of Pediatric Emergency Medicine Practice.
