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?
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.
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.
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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Kirsten Morrissey, MD, FAAP;Hilary Fairbrother, MD, MPH, FACEP;
October 2, 2016
November 2, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 1 Pharmacology CME credits
Upon completion of this article, you should be able to:
Date of Original Release: October 1, 2016. Date of most recent review: September 15, 2016. Termination date: October 1, 2019.
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ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
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Other Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 1 Pharmacology CME credits, subject to your state and institutional requirements.
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Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
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