Presentations by Eric R. Trumble, M.D.

Pediatric Head Injuries

Eric R. Trumble, MD
NEUROSURGEONS FOR KIDS
January 25, 2006

Head Injury

Introduction
Incidence
Types of Head Injury
Current Knowledge & Management
Long-term Sequellae
Prevention

TIP OF THE ICEBERG

INTRODUCTION

Motor vehicle crashes #1 cause of TBI, SCI, and seizures
600-700 children die each year
75,000 children are injured

INCIDENCE

Trauma is the leading cause of death in children.
11,000 children die from trauma annually
Of those, >80% had a severe head injury
In children ages 1-15, more died from trauma than all other causes…..COMBINED

GLASGOW COMA SCALE

ALGORITHM IN SEVERE CHI

ALGORITHM WITH ICP

CSF DRAINAGE VS ICP MONITORING

Therapeutic vs. Diagnostic
Hydrocephalus vs. Elevated ICP
Infection vs. CSF Diversion
Acute vs. Chronic

SECONDARY INJURY FIRST TIER THERAPIES

Hypoxia
Hypotension
Hypocapnea
Late Bleed
Increased Intra-cranial Pressure

HYPOXIA

Requires emergent intubation
However, person intubating must be cognizant that there is a 5% incidence of cervical spine injury
Too much oxygen is impossible in the acute phase
Minimize PEEP to minimize afterload

HYPOTENSION

Concern in reduced CPP
CPP>60 required in adults
Children may well tolerate >50mmHg
Fluid resuscitation is cornerstone in trauma

CPP = MAP - ICP

HYPOCAPNEA

Optimal pCO2 = 25-35
>35 causes vasodilation and increases ICP
<25 causes vasoconstriction and increases the incidence of cerebral ischemia from 29% to 73% as measured by Xenon CT

LATE BLEED

Abrupt increase in intracranial pressure,
- unrelated to external influences,
- poorly responsive to usual measure
Requires head CT
Treatment is surgical

INCREASED INTRACRANIAL PRESSURE

Paralysis, sedation, intubation
CSF Drainage
Mannitol (0.5-1g/kg IV)
Hyperventilate to pCO2 25-30

SECONDARY INJURY SECOND TIER THERAPIES

Hypertension
Hypothermia
Barbiturate coma
Decompressive craniectomy
Reducing blood viscosity
Reducing Hyperexcitation

HYPERTENSION

If CVP normal, next step is Phenylephrine or Dopamine
Goal is CPP>50mmHg

CPP=MAP-ICP-CVP

HYPOTHERMIA

Initially suggested by Phelps in 1897
Mild Hypothermia to 32-34 0C
Lower causes coagulopathy
5-10% CMRO2 change per 0 C
Hyperthermia injures BBB

BARBITURATE COMA

Decrease CMRO2 and CNS lactate and glutamate
EEG burst suppression or levels
Survival, but poor outcome
Arterial hypotension common
Recent success in small series

DECOMPRESSIVE CRANIECTOMY

Initially suggested by Cushing in 1905

REDUCING BLOOD VISCOSITY

Mannitol reduces blood viscosity. Concern re renal damage with serum osmolarity >320
Hypertonic saline can also be used to increase serum sodium, which artefactually drops with Mannitol
Albumin and urea are infrequently used

REDUCING HYPEREXCITATION

Felt to be significant cause of secondary injury due to increased metabolism without compensatory increased CBF
Glutamate antagonists
GABA agonists
Oxygen radical scavengers

RECENT HI TRIALS

PROGNOSIS

90% accuracy using:*
1. GCS 24hrs post-injury
2. CT revealing SAH, DAI, or brain swelling
3. Hypoxia

* Ong et al, Pediatric Neurosurg;(1996 Jun) v24 p285-91

HI Chart

CT FINDINGS IN N.A.T.

Interhemispheric falx hemorrhage
Sub-dural hemorrhage
Large, non-acute extra-axial fluid collection
Basal ganglia edema

p<0.05 for above per Hymel et al, Pediatr Radiol; (1997 Sep) v27 n9 p743-7.

SEIZURES

Increase CBF and ICP
Higher incidence with lower GCS
20% if cerebral contusion
Immediate seizures not recurrent
Prophylactic anticonvulsant use
Treat for 7-10 days

SEQUELLAE

Cognitive
Higher level comprehension
Motor
Fine motor usually more involved