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Severe Traumatic Brain Injury In Children: An Evidence-Based Review Of Emergency Department Management (Trauma CME)

October 2016

Abstract

More than 1.7 million traumatic brain injuries occur in adults and children each year in the United States, with approximately 30% occurring in children aged < 14 years. Traumatic brain injury is a significant cause of morbidity and mortality in pediatric trauma patients. Early identification and management of severe traumatic brain injury is crucial in decreasing the risk of secondary brain injury and optimizing outcome. The main focus for early management of severe traumatic brain injury is to mitigate and prevent secondary injury, specifically by avoiding hypotension and hypoxia, which have been associated with poorer outcomes. This issue discusses methods to maintain adequate oxygenation, maximize management of intracranial hypertension, and optimize blood pressure in the emergency department to improve neurologic outcomes following pediatric severe traumatic brain injury.

Key words: severe traumatic brain injury, severe TBI, subdural hematoma, epidural hematoma, subarachnoid hemorrhage, cerebral contusion, diffuse axonal injury, intraventricular hemorrhage, penetrating injury, intracranial pressure, ICP, Glasgow Coma Scale, GCS, pediatric Glasgow Coma Scale, pGCS, hypotension, hypoxia, subfalcine herniation, central herniation, transtentorial herniation, tonsillar herniation, hypertonic saline, nonaccidental trauma, NAT, pediatric, children

Points:

  • Traumatic brain injury (TBI) should be considered if any of the following have occurred: motor vehicle crash, fall from significant height (> 5 feet for patients aged ≥ 2 years or > 3 feet for patients < 2 years), penetrating trauma to the skull, loss of consciousness, signs of basilar skull fracture, and/or persistent vomiting.
  • Severe TBI can be divided into 2 distinct categories: primary injury and secondary injury. Primary injury is directly related to the initial impact and external force. Secondary injury is a complication of the primary injury that may develop over a period of hours to months and may be acute or chronic.
  • Noncontrast head CT remains the initial study of choice for rapid evaluation and diagnosis. For some injuries, including diffuse axonal injury, the initial CT scan may be negative. A normal CT scan does not rule out a significant injury, and repeat CT scans or an MRI may be required.

Pearl:

  • The primary goal in treating severe TBI is to avoid secondary injury, specifically hypotension and hypoxia, as both are associated with poor outcomes.
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