Severe Traumatic Brain Injury in Children: An Evidence-Based Review of Emergency Department Management -Trauma EXTRA Supplement - (Trauma CME)

Table of Contents

 

About This Issue

In children with severe traumatic brain injuries (TBI), early intervention is critical to prevent further injury. In the emergency department, the initial focus is on maintaining stable blood pressure and oxygen levels to improve outcomes, then identifying and addressing primary injuries. In this issue, you will learn:

How to recognize severe TBI and identify primary versus secondary injuries

The pathophysiology of the most common primary injuries in severe TBI, including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, cerebral contusions, diffuse axonal injury, intraventricular hemorrhage, and penetrating injury

Which initial resuscitation strategies are preferred in the setting of severe TBI, including for airway stabilization and blood pressure optimization

The neuroprotective strategies that improve outcomes

How to recognize the signs of neurologic deterioration

How to treat elevated intracranial pressure and herniation syndromes

The signs that raise suspicion for nonaccidental trauma in pediatric head injuries

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Subdural Hematoma
   2. Epidural Hematoma
   3. Traumatic Subarachnoid Hemorrhage
   4. Cerebral Contusion
   5. Diffuse Axonal Injury
   6. Intraventricular Hemorrhage
   7. Penetrating Injury
   8. Elevated Intracranial Pressure
   9. The Glasgow Coma Scale and the Pediatric Glasgow Coma Scale
7. Differential Diagnosis
8. Prehospital Care
   1. Airway, Oxygenation, and Ventilation
   2. Blood Pressure and Perfusion Optimization
9. Emergency Department Evaluation
   1. Focused History and Physical Examination
   2. Initial Stabilization
   3. Airway Management
      1. Pretreatment for Intubation
         1. Atropine
         2. Lidocaine
         3. Fentanyl
      2. Induction and Sedation
         1. Etomidate
         2. Ketamine
         3. Midazolam
      3. Paralysis
         1. Rocuronium
         2. Succinylcholine
      4. Ventilation Management
   4. Circulation Management
10. Diagnostic Studies
    1. Laboratory Tests
    2. Imaging
       1. Noncontrast Computed Tomographic Scan of the Head
       2. Computed Tomographic Angiography
       3. Magnetic Resonance Imaging
       4. Radiography - Plain Skull Films
    3. Brain Ultrasound
    4. Multimodal Imaging
11. Management
    1. Management of Herniation Syndromes
       1. Physical Examination Findings Concerning for Herniation
          1. Subfalcine Herniation
          2. Central Herniation
          3. Transtentorial Herniation
          4. Tonsillar Herniation
    2. Management of Intracranial Pressure
    3. Management of Neurologic Deterioration
       1. Medical and Noninvasive Treatment of Suspected Herniation
          1. Osmotic Therapy
             • Hypertonic Saline
             • Mannitol
          2. Hyperventilation
          3. Barbiturate Therapy
    4. Decompressive Craniectomy
    5. Prophylactic Antiepileptic Medications
    6. Corticosteroids
    7. Predictors and Factors Associated With Poor Outcome
12. Special Circumstances in Pediatrics
    1. Neonatal Patients
    2. Nonaccidental Trauma and Abusive Head Trauma
    3. Severe Traumatic Brain Injury in Sports
13. Controversies and Cutting Edge
    1. Progesterone
    2. N-Acetylcysteine
    3. Novel Neuropharmacologic Strategies
    4. Hypothermia
    5. Antifibrinolytics
    6. Biomarkers
    7. Ultrasound-Guided Noninvasive Intracranial Pressure Monitoring
14. Time- and Cost-Effective Strategies
15. Disposition
16. Long-Term Outcomes
17. Summary
18. Risk Management Pitfalls in the Management of Pediatric Severe Traumatic Brain Injury
19. Case Conclusions
20. Clinical Pathway for Treatment of Pediatric Patients With Severe Traumatic Brain Injury
21. Tables and Figures
22. References

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. The early management of severe traumatic brain injury is focused on mitigation and prevention of secondary injury, specifically by avoiding hypotension and hypoxia, which have been associated with poorer outcomes. This review 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.

Case Presentations

A 3-month-old boy is brought to the ED by his mother, who states that he has not been feeding well...

The mother, who is 22 years old and has 2 other children, is vague in her description of the child’s symptoms. The nurse calls you into triage because she notes the child appears unresponsive. The mother denies any trauma. The infant’s vital signs are as follows: afebrile; heart rate, 160 beats/min; blood pressure, 70/40 mm Hg; respiratory rate, 30 breaths/min; and oxygen saturation, 93% on room air. You struggle to calculate a GCS score, as this patient is not yet verbal. On physical examination, the child is minimally responsive and has irregular and shallow respiration, so you prepare to intubate. During placement of an IV line, the child flexes his left arm in response to pain, but no spontaneous movement of the right arm or leg is noted. During the secondary survey, you note a bulging fontanelle and a dilated left pupil, with deviation of the left eye both downward and peripherally. You have the clerk page neurosurgery emergently. The respiratory therapist asks you if you would like to hyperventilate the patient.

What should your target PaCO₂ level be? What medication(s) should be given immediately? Once stabilized, are there any other services or specialists that should be involved with this patient, based on the history?

A 17-year-old girl who was an unrestrained front passenger in a high-speed motor vehicle crash is brought in by EMS…

When the patient arrives, you quickly calculate a GCS score of 7 (E1, M4, V2), and you page the trauma surgery team to the ED. The patient's vital signs are as follows: afebrile; heart rate, 115 beats/min; blood pressure, 110/60 mm Hg; respiratory rate, 10 breaths/min; and oxygen saturation, 90% on room air. She has obvious right-sided head trauma and is in cervical spine immobilization. You immediately place a nonrebreather mask on the patient and call for rapid sequence intubation medications and equipment. You intubate the patient while maintaining cervical spine precautions. The neurosurgeon calls you back and states that he is on his way to the hospital.

What initial steps should be taken to stabilize this patient? How will you determine the disposition for this patient?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Treatment of Pediatric Patients With Severe Traumatic Brain Injury

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

11. * Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the Brain Trauma Foundation Guidelines, executive summary. Neurosurgery. 2019;84(6):1169-1178. (Guidelines) DOI: 10.1093/neuros/nyz051

12. * Kochanek PM, Tasker RC, Bell MJ, et al. Management of pediatric severe traumatic brain injury: 2019 consensus and guidelines-based algorithm for first and second tier therapies. Pediatr Crit Care Med. 2019;20(3):269-279. (Treatment algorithm) DOI: 10.1097/PCC.0000000000001737

13. * American College of Surgeons. Chapter 10 - Pediatric Trauma. Advanced Trauma Life Support Student Course Manual. 10th ed. American College of Surgeons; 2018. (Course manual chapter)

27. * Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1:S1-S106. (Practice guidelines) DOI: 10.1089/neu.2007.9999

28. * Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019;20(3S Suppl 1):S1-S82. (Guidelines) DOI: 10.1097/PCC.0000000000001735

97. * Kochanek PM, Adelson PD, Rosario BL, et al. Comparison of intracranial pressure measurements before and after hypertonic saline or mannitol treatment in children with severe traumatic brain injury. JAMA Netw Open. 2022;5(3):e220891. (Comparative effectiveness study; 518 patients) DOI: 10.1001/jamanetworkopen.2022.0891

107. * Kolias AG, Adams H, Timofeev IS, et al. Evaluation of outcomes among patients with traumatic intracranial hypertension treated with decompressive craniectomy vs standard medical care at 24 months: a secondary analysis of the RESCUEicp randomized clinical trial. JAMA Neurol. 2022;79(7):664-671. (Randomized controlled trial; 408 patients aged 10 years to adult) DOI: 10.1001/jamaneurol.2022.1070

126. * Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021;4(4):e215832. (Prospective trial; 2161 patients) DOI: 10.1001/jamanetworkopen.2021.5832

143. * Utsumi S, Amagasa S, Yasuda H, et al. Targeted temperature management in pediatric traumatic brain injury: a systematic review and network meta-analysis. World Neurosurg. 2023;173:158-166. (Met-analysis; 6 trials, 448 patients) DOI: 10.1016/j.wneu.2023.01.056

144. * Adelson PD, Ragheb J, Kanev P, et al. Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery. 2005;56(4):740-754. (Prospective, phase II randomized controlled trial; 48 patients)

147. * Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358(23):2447-2456. (Prospective, randomized controlled trial; 225 patients) DOI: 10.1056/NEJMoa0706930

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Keywords: TBI, severe traumatic brain injury, severe TBI, subdural hematoma, epidural hematoma, subarachnoid hemorrhage, cerebral contusion, diffuse axonal injury, intraventricular hemorrhage, intracranial pressure, ICP, subfalcine herniation, central herniation, transtentorial herniation, tonsillar herniation, nonaccidental trauma, shaken baby syndrome, abusive head trauma