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

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. 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
6. Differential Diagnosis
7. Prehospital Care
   1. Airway, Oxygenation, And Ventilation
   2. Blood Pressure And Perfusion Optimization
8. Emergency Department Evaluation
   1. Focused History And Physical Examination
   2. Initial Stabilization
   3. Airway Management
      1. Pretreatment For Intubation
         • Atropine
         • Lidocaine
         • Fentanyl
      2. Induction And Sedation
         • Etomidate
         • Ketamine
         • Midazolam
      3. Paralysis
      • Rocuronium
      • Succinylcholine
   4. Ventilation Management
   5. Circulation Management
9. 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. Optic Nerve Sheath Diameter Measurement
10. Management
    1. Management Of Herniation Syndromes
       1. Physical Examination Findings Concerning For Herniation
       2. Subfalcine Herniation
       3. Central Herniation
       4. Transtentorial Herniation
       5. Tonsillar Herniation
    2. Management Of Intracranial Pressure
    3. Management Of Neurologic Deterioration
    4. Medical And Noninvasive Treatment Of Suspected Herniation
       1. Osmotic Therapy
          • Hypertonic Saline
          • Mannitol
       2. Hyperventilation
       3. Barbiturate Therapy
    5. Predictors And Factors Associated With Poor Outcome
11. Special Circumstances In Pediatrics
    1. Neonatal Patients
    2. Nonaccidental Trauma And Abusive Head Trauma
    3. Severe Traumatic Brain Injury In Sports
12. Controversies And Cutting Edge
    1. Prophylactic Antiepileptic Medications
    2. Corticosteroids
    3. Progesterone
    4. Ketamine
    5. Hypothermia
    6. Antifibrinolytics
    7. Hyperosmolar Therapy: Hypertonic Saline Versus Mannitol
    8. Biomarkers
13. Disposition
14. Summary
15. Risk Management Pitfalls In The Management Of Pediatric Severe Traumatic Brain Injury
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Treatment Of Pediatric Patients With Severe Traumatic Brain Injury
19. Tables and Figures
    1. Table 1. Types Of Primary Traumatic Brain Injuries
    2. Table 2. Comparison Of The Glasgow Coma Scale And Pediatric Glasgow Coma Scale
    3. Table 3. Age-Appropriate Minimum Systolic Blood Pressure
    4. Table 4. Cerebral Herniation Syndromes And Signs
    5. Figure 1. Subdural Hematoma ON Computed Tomography
    6. Figure 2. Epidural Hematoma On Computed Tomography
    7. Figure 3. Traumatic Subarachnoid Hemorrhage On Computed Tomography
    8. Figure 4. Cerebral Contusions On Computed Tomography
    9. Figure 5. Diffuse Axonal Injury On Computed Tomography
    10. Figure 6. Cerebral Herniation Syndromes
    11. Figure 7. Severe Retinal Hemorrhage
20. 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

1. “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.
    
2. “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.
    
3. “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.
    
4. “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.
    
5. “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.
    
6. “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.
    
7. “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.
    
8. “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.
    
9. “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.
    
10. “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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3. 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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