Table of Contents
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal of the Literature
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Etiology And Pathophysiology
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Subdural Hematoma
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Epidural Hematoma
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Traumatic Subarachnoid Hemorrhage
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Cerebral Contusion
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Diffuse Axonal Injury
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Intraventricular Hemorrhage
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Penetrating Injury
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Elevated Intracranial Pressure
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The Glasgow Coma Scale And The Pediatric Glasgow Coma Scale
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Differential Diagnosis
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Prehospital Care
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Airway, Oxygenation, And Ventilation
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Blood Pressure And Perfusion Optimization
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Emergency Department Evaluation
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Focused History And Physical Examination
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Initial Stabilization
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Airway Management
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Pretreatment For Intubation
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Atropine
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Lidocaine
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Fentanyl
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Induction And Sedation
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Etomidate
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Ketamine
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Midazolam
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Paralysis
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Rocuronium
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Succinylcholine
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Ventilation Management
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Circulation Management
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Diagnostic Studies
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Laboratory Tests
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Imaging
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Noncontrast Computed Tomographic Scan Of The Head
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Computed Tomographic Angiography
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Magnetic Resonance Imaging
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Radiography - Plain Skull Films
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Brain Ultrasound
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Optic Nerve Sheath Diameter Measurement
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Management
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Management Of Herniation Syndromes
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Physical Examination Findings Concerning For Herniation
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Subfalcine Herniation
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Central Herniation
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Transtentorial Herniation
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Tonsillar Herniation
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Management Of Intracranial Pressure
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Management Of Neurologic Deterioration
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Medical And Noninvasive Treatment Of Suspected Herniation
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Osmotic Therapy
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Hypertonic Saline
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Mannitol
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Hyperventilation
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Barbiturate Therapy
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Predictors And Factors Associated With Poor Outcome
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Special Circumstances In Pediatrics
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Neonatal Patients
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Nonaccidental Trauma And Abusive Head Trauma
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Severe Traumatic Brain Injury In Sports
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Controversies And Cutting Edge
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Prophylactic Antiepileptic Medications
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Corticosteroids
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Progesterone
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Ketamine
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Hypothermia
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Antifibrinolytics
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Hyperosmolar Therapy: Hypertonic Saline Versus Mannitol
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Biomarkers
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Disposition
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Summary
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Risk Management Pitfalls In The Management Of Pediatric Severe Traumatic Brain Injury
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Time- And Cost-Effective Strategies
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Case Conclusions
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Clinical Pathway For Treatment Of Pediatric Patients With Severe Traumatic Brain Injury
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Tables and Figures
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Table 1. Types Of Primary Traumatic Brain Injuries
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Table 2. Comparison Of The Glasgow Coma Scale And Pediatric Glasgow Coma Scale
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Table 3. Age-Appropriate Minimum Systolic Blood Pressure
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Table 4. Cerebral Herniation Syndromes And Signs
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Figure 1. Subdural Hematoma ON Computed Tomography
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Figure 2. Epidural Hematoma On Computed Tomography
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Figure 3. Traumatic Subarachnoid Hemorrhage On Computed Tomography
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Figure 4. Cerebral Contusions On Computed Tomography
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Figure 5. Diffuse Axonal Injury On Computed Tomography
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Figure 6. Cerebral Herniation Syndromes
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Figure 7. Severe Retinal Hemorrhage
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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. 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.
Case Presentations
A 22-year-old mother of 3 brings her 3-month-old boy to the ED, stating that he has not been feeding well. She 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?
You then get an EMS notification that they are bringing in a 17-year-old girl who was an unrestrained front passenger in a high-speed motor vehicle crash. 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?
Introduction
Accidental injury is the primary cause of death for children and adolescents in the United States,1 and severe traumatic brain injury (TBI) is an important contributor to morbidity and mortality in trauma. Approximately 30% of trauma-related deaths are attributed to TBI. It was estimated that, between 2002 and 2006, there were more than 1.7 million TBIs occurring in adults and children each year, with an overall mortality rate of 3%, or approximately 52,000 deaths per year. Thirty percent of TBIs occur in children aged 0 to 14 years, and 92% of this group will visit an emergency department (ED) for their injury. In 2006, the overall mortality rate for children aged < 14 years suffering from any TBI was 0.42%.2
Approximately 40% of TBIs in children aged 0 to 14 years are due to falls, and 24% result from unintentional blunt trauma to the head, and the most likely mechanism is a motor vehicle crash. Assault, or nonaccidental trauma (NAT), is the third leading cause of TBI in children aged 0 to 4 years.3 While the most common cause of deadly TBI in children aged < 4 years is assault, the most common cause of death from TBI in young people aged 5 to 24 years is a motor vehicle crash. For patients who die secondary to TBI, risk factors include male sex and age < 4 years. The rate of ED visits is also highest for children aged < 4 years.
The total cost for all patients with TBI in 2010 was estimated at $76.5 billion, 90% of which was spent on patients who were hospitalized. For patients who do not die from the initial injury, approximately half are left with a severe disability. Today, there are 5.3 million people in the United States who are living with serious motor, cognitive, sensory, and/or emotional effects from TBI.4
Severe TBI represents a spectrum of diseases, resulting from both blunt and penetrating trauma, and it is most simply defined by an initial Glasgow Coma Scale (GCS) score of < 9.5 Severe pediatric TBI can be thought of as 2 distinct, but related, diseases: primary injury and secondary injury. Primary injuries are either diffuse, focal, or a combination of the two. This is the injury with which the patient presents, over which the physician has no control. Half of all patients who die from severe TBI die in the first 2 hours after the primary injury.6 Following the primary injury, there may be edema, changes in cerebral blood flow and perfusion, and decreased respiration/ hypoxia. All of these constitute and/or contribute to the complex environment that creates the patient’s secondary injury. The primary goal of emergency treatment of severe TBI is to mitigate and prevent secondary injury, specifically by avoiding hypotension and hypoxia.
Progress has been made in decreasing absolute mortality in pediatric TBI. From 2001 to 2010, there has been a 70% increase in the number of ED visits due to TBI, a slight increase in hospitalizations for patients with TBI (11%), and a decrease in mortality by 7%.7
This issue of Pediatric Emergency Medicine Practice reviews the various types of primary injuries, outlines effective measures to optimize initial resuscitation and minimize secondary injuries, provides treatment strategies for herniation syndromes and elevated intracranial pressure (ICP), and discusses novel treatment strategies for pediatric patients with severe TBI.
Critical Appraisal Of The Literature
A literature search was performed in Ovid MEDLINE® and PubMed using the search terms severe pediatric traumatic brain injury and traumatic brain injury children. A total of 230 review articles, 184 clinical trials, and 98 systematic reviews from the year 1959 to the present were reviewed. The Cochrane Database of Systematic Reviews was searched using the term traumatic brain injury pediatric; 52 reviews were identified, with 6 of those pertinent to the scope of this article, related to management, outcome, or prevention of severe TBI in children. The National Guideline Clearinghouse document titled “Head Injury - Triage, Assessment, Investigation, and Early Management of Head Injury in Children, Young People, and Adults” was also reviewed. The following guidelines released by the Brain Trauma Foundation for pediatric and adult traumatic brain injuries were also reviewed: Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents - Second Edition (2012); Guidelines for the Management of Severe Traumatic Brain Injury, Third Edition (2007); and Guidelines for the Pre-hospital Management of Severe Traumatic Brain Injury, Second Edition (2007). Information from government databases was reviewed, including the United States Centers for Disease Control and Prevention (www.cdc.gov).1-4
There are very few high-quality studies evaluating management of severe pediatric TBI. Using standard evidence-level scales, the majority of the recommendations discussed in this article fall into lower or intermediate levels of evidence, with few recommendations meeting criteria for a higher level of evidence. Other recommendations are based on consensus opinion extrapolated from adult studies or current standards of care. High-quality pediatric studies are still warranted, with many clinical questions related to pediatric TBI remaining unanswered.
Risk Management Pitfalls In The Management Of Pediatric Severe Traumatic Brain Injury
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“My teenage patient smelled like alcohol and he appeared intoxicated, but I did not suspect head trauma.”
Severe TBI is often complicated by alcohol or drug intoxication in teens and young adults. Intoxication may be a confounding factor and can result in a less reliable physical examination. A high level of suspicion should be maintained for TBI in an intoxicated patient with a history of trauma.
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“I assumed TBI was ruled out after the patient had a normal head CT scan.”
A normal initial head CT scan does not rule out TBI. Diffuse axonal injury may present with either normal or subtle findings on CT scan, but patients are at significant risk for secondary injury. A repeat CT scan or MRI may be indicated with suspected TBI, particularly if there is clinical deterioration.
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“The patient came in after a seizure and was noted to have an occipital hematoma. I assumed she fell down after she started seizing.”
It can be difficult to determine whether the seizure or the fall happened first. It is important to consider that the seizure may have occurred secondary to potential TBI. It is crucial to obtain a detailed history and thorough physical examination. Maintain a high level suspicion for TBI when a patient does not return to neurologic baseline following a seizure.
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“The mother told me that her baby fell out of his crib and that seemed like a plausible mechanism for a severe TBI.”
Very few children with accidental head injury have severe TBI. A simple fall or accidental blunt trauma rarely results in the force necessary to cause severe TBI. Make sure that the story makes sense with the current developmental stage of the child. Any bruising or injury to a child aged < 4 months or that is inconsistent with the history should be concerning for NAT.
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“I was worried about a herniation syndrome, but I wanted to get the CT before I started to treat the ICP.”
Elevated ICP and signs of imminent brain herniation require emergent therapy and should occur prior to imaging. Signs of herniation may include a decline in mental status, an acute decrease in the GCS score, Cushing triad, pupillary defects, or posturing.
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“The child briefly lost consciousness after he was hit in the head with a baseball. He was totally fine when he got here, so I assumed that his injury was not severe. While he was waiting to be seen, he quickly decompensated.”
A patient with an epidural hematoma may present with a brief loss of consciousness, followed by a lucid period, and then subsequent deterioration. This classic description of an epidural hematoma is less common in pediatric patients.
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“I was busy assessing the patient’s abdominal bruising and large open femur fracture; I didn’t notice the large scalp injury until the patient started decompensating.”
In a patient with multiple injuries, it is critical to have a high suspicion for head injury. Do not allow distracting injuries to delay diagnosis of a TBI. Always perform a careful physical and neurologic examination in every trauma patient. Always look for injury under the cervical collar.
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“I didn’t see any sign of trauma on the head of the infant, so I only looked for cardiovascular and pulmonary reasons for the patient’s decompensated status.”
Infants who present with increased ICP can present with depressed mental status, abnormal respiratory rates, bradycardia, and respiratory failure. TBI should always be on the differential for an unstable child, even if there is no reported trauma. Children with abusive head trauma may have a normal physical examination.
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“I saw the bulging fontanelle in the neonate and I was worried about meningitis, so I didn’t even have abusive head trauma or NAT on my differential.”
A bulging or full fontanelle may be the only sign that a child has suffered an intracranial injury. Children who have been victims of shaking or jerking are at high risk for intracranial injuries, but they may have no external signs of injury on examination. The majority of children who are victims of abusive head trauma will have retinal hemorrhages on a dilated ophthalmic examination.
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“I did the full physical examination and didn’t see any signs of head trauma. I was surprised to see an occipital injury on the CT.”
It is easy to miss the physical signs of trauma when the trauma is underneath the cervical collar. Always remove the collar, while maintaining cervical spine precautions, to investigate the neck and the base of the skull.
Tables And Figures
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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10 leading causes of death by age group, United States - 2010. Centers for Disease Control and Prevention; 2010. Accessed July 1, 2016. (Government report)
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Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006. Centers for Disease Control and Prevention; 2002-2006. Available at: http://www.cdc.gov/TraumaticBrainInjury/tbi_ed.html. Accessed July 1, 2016. (Government report)
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Percent distributions of TBI-related hospitalizations by age group and injury mechanism — United States, 2006–2010. Centers for Disease Control and Prevention; 2006-2010. Available at: http://www.cdc.gov/traumaticbraininjury/data/dist_hosp.html. Accessed July 1, 2016. (Government report)
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Injury Prevention & Control: traumatic brain injury. Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Severe traumatic brain injury; 2010. Available at: http://www.cdc.gov/TraumaticBrainInjury/severe.html. Accessed July 1, 2016. (Government report)
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Mtaweh H, Bell MJ. Management of pediatric traumatic brain injury. Curr Treat Options Neurol. 2015;17(5):348. (Opinion statement)
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* Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12 Suppl 1:S1-S52. (National guidelines)
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Traumatic brain injury in the United States: fact sheet. Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Injury Prevention & Control: traumatic brain injury; 2010. Available at: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed July 1, 2016. (Government report)
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* Pinto PS, Meoded A, Poretti A, et al. The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2. J Neuroimaging. 2012;22(2):e18-e41. (Basic science review)
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O’Brien NF, Maa T, Yeates KO. The epidemiology of vasospasm in children with moderate-to-severe traumatic brain injury. Crit Care Med. 2015;43(3):674-685. (Prospective study; 69 patients)
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Hinson HE, Rowell S, Schreiber M. Clinical evidence of inflammation driving secondary brain injury: a systematic review. J Trauma Acute Care Surg. 2015;78(1):184-191. (Systematic review)
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Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin. 2009;27(2):213- 240. (Review)
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Rocchi G, Caroli E, Raco A, et al. Traumatic epidural hematoma in children. J Child Neurol. 2005;20(7):569-572. (Case series; 35 patients)
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Case ME. Inflicted traumatic brain injury in infants and young children. Brain Pathol. 2008;18(4):571-582. (Review)
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Servadei F, Murray GD, Teasdale GM, et al. Traumatic subarachnoid hemorrhage: demographic and clinical study of 750 patients from the European brain injury consortium survey of head injuries. Neurosurgery. 2002;50(2):261-267. (Prospective trial; 750 patients)
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Kurland D, Hong C, Aarabi B, et al. Hemorrhagic progression of a contusion after traumatic brain injury: a review. J Neurotrauma. 2012;29(1):19-31. (Review)
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Hu CF, Fan HC, Chang CF, et al. Current approaches to the treatment of head injury in children. Pediatr Neonatol. 2013;54(2):73-81. (Review)
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Koestler J, Keshavarz R. Penetrating head injury in children: a case report and review of the literature. J Emerg Med. 2001;21(2):145-150. (Case report)
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* Kukreti V, Mohseni-Bod H, Drake J. Management of raised intracranial pressure in children with traumatic brain injury. J Pediatr Neurosci. 2014;9(3):207-215. (Review)
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Steiner LA, Andrews PJ. Monitoring the injured brain: ICP and CBF. Br J Anaesth. 2006;97(1):26-38. (Review)
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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. (National guidelines)
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Lieh-Lai MW, Theodorou AA, Sarnaik AP, et al. Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury. J Pediatr. 1992;120(2 Pt 1):195-199. (Retrospective, observational trial; 79 patients)
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Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric Glasgow Coma Scale in children with blunt head trauma. Acad Emerg Med. 2005;12(9):814-819. (Prospective comparative study; 2043 patients)
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Hinds T, Shalaby-Rana E, Jackson AM, et al. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care. 2015;45(3):71-79. (Review)
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Lumba-Brown A, Pineda J. Evidence-based assessment of severe pediatric traumatic brain injury and emergent neurocritical care. Semin Pediatr Neurol. 2014;21(4):275-283. (Review)
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Vavilala MS, Kernic MA, Wang J, et al. Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med. 2014;42(10):2258-2266. (Retrospective multicenter cohort study)
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Ehrlich PF, Seidman PS, Atallah O, et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39(9):1376-1380. (Retrospective review; 2907 patients)
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Ramaiah VK, Sharma D, Ma L, et al. Admission oxygenation and ventilation parameters associated with discharge survival in severe pediatric traumatic brain injury. Childs Nerv Syst. 2013;29(4):629-634. (Retrospective trial; 194 patients)
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* Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012;13 Suppl 1:S1-S82. (National guidelines)
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Vavilala MS, Bowen A, Lam AM, et al. Blood pressure and outcome after severe pediatric traumatic brain injury. J Trauma. 2003;55(6):1039-1044. (Retrospective study; 172 patients)
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Schweer L. Pediatric trauma resuscitation: initial fluid management. J Infus Nurs. 2008;31(2):104-111. (Review)
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Carcillo JA. Intravenous fluid choices in critically ill children. Curr Opin Crit Care. 2014;20(4):396-401. (Review)
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Chong SL, Liu N, Barbier S, et al. Predictive modeling in pediatric traumatic brain injury using machine learning. BMC Med Res Methodol. 2015;15:22. (Retrospective case-controlled study; 195 patients)
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Suz P, Vavilala MS, Souter M, et al. Clinical features of fever associated with poor outcome in severe pediatric traumatic brain injury. J Neurosurg Anesthesiol. 2006;18(1):5-10. (Retrospective study; 93 patients)
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Chiaretti A, Piastra M, Pulitano S, et al. Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst. 2002;18(3-4):129-136. (Retrospective trial; 122 patients)
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Stewart TC, Alharfi IM, Fraser DD. The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury. J Trauma Acute Care Surg. 2013;75(5):836-842. (Retrospective cohort study; 180 patients)
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Rothrock SG, Pagane J. Pediatric rapid sequence intubation incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2005;21(9):637-638. (Review)
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Pallin DJ, Dwyer RC, Walls RM, et al. Techniques and trends, success rates, and adverse events in emergency department pediatric intubations: a report from the National Emergency Airway Registry. Ann Emerg Med. 2016;67(5):610-615.e1. (Prospective observational cohort; 1053 patients)
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Barrington K. Premedication for endotracheal intubation in the newborn infant. Paediatr Child Health. 2011;16(3):159-171. (Review)
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Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004;20(10):651-655. (Retrospective cohort study; 163 patients)
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Gill H, Thoresen M, Smit E, et al. Sedation management during therapeutic hypothermia for neonatal encephalopathy: atropine premedication for endotracheal intubation causes a prolonged increase in heart rate. Resuscitation. 2014;85(10):1394-1398. (Randomized pilot study; 32 patients)
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Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance and atropine. Arch Dis Child. 2012;97(2):139-144. (Review)
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Bean A, Jones J. Atropine: re-evaluating its use during paediatric RSI. Emerg Med J. 2007;24(5):361-362. (Review)
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Gausche-Hill M. Pediatric airway management update. Presented at: Advanced Pediatric Emergency Medicine Assembly; March 7, 2016; Lake Buena Vista, FL. (Lecture, review)
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Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011;68(14):1320-1330. (Review)
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Caldwell CD, Watterberg KL. Effect of premedication regimen on infant pain and stress response to endotracheal intubation. J Perinatol. 2015;35(6):415-418. (Prospective observational; 166 patients)
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Bilotta F, Stazi E, Zlotnik A, et al. Neuroprotective effects of intravenous anesthetics: a new critical perspective. Curr Pharm Des. 2014;20(34):5469-5475. (Review)
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van den Heuvel I, Wurmb TE, Bottiger BW, et al. Pros and cons of etomidate--more discussion than evidence? Curr Opin Anaesthesiol. 2013;26(4):404-408. (Review)
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* Stollings JL, Diedrich DA, Oyen LJ, et al. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014;48(1):62-76. (Review)
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Wang X, Ding X, Tong Y, et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth. 2014;28(6):821-827. (Meta-analysis review; 198 patients)
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Zeiler FA, Teitelbaum J, West M, et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014;21(1):163- 173. (Review; 101 adult patients, 55 pediatric patients)
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Janda M, Bajorat J, Kudlik C, et al. Comparison of heart rate variability response in children undergoing elective endotracheal intubation with and without neuromuscular blockade: a randomized controlled trial. Paediatr Anaesth. 2013;23(12):1153- 1159. (Prospective randomized trial; 38 patients)
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Ching KY, Baum CR. Newer agents for rapid sequence intubation: etomidate and rocuronium. Pediatr Emerg Care. 2009;25(3):200-207. (Review)
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Tarquinio KM, Howell JD, Montgomery V, et al. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015;16(3):210-218. (Prospective observational cohort; 3366 patients)
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Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg. 1994;78(3):469-473. (Observational study; 10 patients)
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Curry R, Hollingworth W, Ellenbogen RG, et al. Incidence of hypo- and hypercarbia in severe traumatic brain injury before and after 2003 pediatric guidelines. Pediatr Crit Care Med. 2008;9(2):141-146. (Retrospective cohort analysis; 375 patients)
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Turner DA, Arnold JH. Insights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning. Curr Opin Crit Care. 2007;13(1):57-63. (Review)
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National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome ARDS Network. Publications. http:// www.ardsnet.org/publications.shtml. Accessed August 21, 2016. (Web publication, network database)
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Lo TY, Jones PA, Freeman JA, et al. The role of high frequency oscillatory ventilation in the management of children with severe traumatic brain injury and concomitant lung pathology. Pediatr Crit Care Med. 2008;9(5):e38-e42. (Case report; 2 patients)
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Pigula FA, Wald SL, Shackford SR, et al. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg. 1993;28(3):310-314. (Prospective observational study; 58 patients)
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Samant UB 4th, Mack CD, Koepsell T, et al. Time of hypotension and discharge outcome in children with severe traumatic brain injury. J Neurotrauma. 2008;25(5):495-502. (Retrospective study; 146 patients)
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Di Gennaro JL, Mack CD, Malakouti A, et al. Use and effect of vasopressors after pediatric traumatic brain injury. Dev Neurosci. 2010;32(5-6):420-430. (Retrospective cohort; 82 patients)
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Adams ES. A critical appraisal of “Transfusion strategies for patients in pediatric intensive care units” by Lacroix J, Hebert PC, Hutchison, et al (N Engl J Med 2007; 356:1609-1619). Pediatr Crit Care Med. 2009;10(3):393-396. (Critical appraisal of a randomized controlled trial with literature review)
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Azarakhsh N, Grimes S, Notrica DM, et al. Blunt cerebrovascular injury in children: underreported or underrecognized?: A multicenter ATOMAC study. J Trauma Acute Care Surg. 2013;75(6):1006-1011. (Multicenter retrospective cohort study; 892 patients)
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Ravindra VM, Riva-Cambrin J, Sivakumar W, et al. Risk factors for traumatic blunt cerebrovascular injury diagnosed by computed tomography angiography in the pediatric population: a retrospective cohort study. J Neurosurg Pediatr. 2015;15(6):599-606. (Retrospective trial; 234 patients)
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Pinto PS, Poretti A, Meoded A, et al. The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings- -part 1. J Neuroimaging. 2012;22(2):e1-e17. (Review)
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Leijser LM, de Vries LS, Cowan FM. Using cerebral ultrasound effectively in the newborn infant. Early Hum Dev. 2006;82(12):827-835. (Review)
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Elkhunovich M, Sirody J, McCormick T, et al. The utility of cranial ultrasound for detection of intracranial hemorrhage in infants. Pediatr Emerg Care. 2016 Mar 18. Epub ahead of print. (Retrospective; 283 patients)
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McCormick T, Chilstrom M, Childs J, et al. Point-of-care ultrasound for the detection of traumatic intracranial hemorrhage in infants: a pilot study. Pediatr Emerg Care. 2015. Epub ahead of print. (Prospective trial, pilot study; 12 patients)
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Dubourg J, Javouhey E, Geeraerts T, et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059-1068. (Systematic review and meta-analysis; 6 studies, 231 patients)
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Tsung JW, Blaivas M, Cooper A, et al. A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department. Pediatr Emerg Care. 2005;21(2):94-98. (Case report; 3 patients)
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