TRAUMATIC BRAIN

INJURY IN CHILDREN
Marc D. Berg, M.D.
Professor of Pediatrics
Chief, Pediatric Critical Care Medicine
Medical Director, University of Arizona Physicians

OBJECTIVE
S

Review Of
Physiology, Assessment, and
Management of TBI
Outcome in Children With TBI
Correct Common Myths

Childhood Head Injuries:

Statistics
85% are mild, but
80% of children with multiple trauma
die because of severe head injury
(50% in adults)

> Head/body ratio

Softer skull
Open fontanelles

MYTH #1
MythAll Brain Injuries Are the Same
Fact Each Brain Injury Is Different

DEFINING SEVERITY
Mild Brain Injury

GCS = 13-15
Limited impaired consciousness (<30 min)
Normal CT scan
Shows signs of a concussion

Vomiting
Lethargy
Dizziness
Lacks recall about injury (<1 hr PTA)

DEFINING SEVERITY
Moderate Brain Injury

GCS = 9 - 12
Impaired Consciousness (<24)
CT scan Evidence
PTA 1-24 hr

Severe Brain Injury

GCS = 3 - 8
Impaired Consciousness (> 24 hours)
PTA > 24hr

CAUTION!!
GCS of 13 may not be so mild
SC Stein, J Trauma. 2001;50:759-760
Reviewed 14 studies (1047 adult patients with GCS of 13)
33.8% had intracranial lesions
10.8% required surgery

MYTH #2
Myth Younger children recover better
than older children.
Fact The developing brain may be at
more risk. It will take longer to see the
effects of the brain injury.

INTRACRANIAL
FLUID COMPARTMENTS
(INTRACELLULARAND
EXTRACELLULAR)

MODIFIED MONROE-KELLIE DOCTRINE

For pressure to remain constant, an increase in
volume in one compartment must be accompanied
by an equal decrease in the volume in others

C
ICP
B
A
VOLUME

CEREBRAL BLOOD FLOW/

AUTO REGULATION

May be lost after

trauma
Principles are used in
treatment strategies
but are the source of
much debate

From Shapiro HM: Anesthesiology 43:445-471, 1975

CEREBRAL PERFUSION PRESSURE

CPP = MAP - ICP
Useful Concept, But Has Limitations
Good CPP, Better Outcome In Adult Literature (>70
mmHg in adults, >40-65 mmHg ? in children)
The CPP (>70) versus the ICP(<20) As The Primary
Therapeutic End-point (Debatable Concept)

BRAIN INJURY
PATHOPHYSIOLOGY
Primary Brain Injury (occurs at time of impact)

Intracranial hemorrhage
Diffuse axonal injury
Hyperemia/edema
Ischemia, release of toxic mediators

SUBDURAL VS. EPIDURAL

LifeArt: Williams & Wilkins

http://www.lifeart.com

SUBDURAL HEMATOMA

WebPath: University of Utah

http://www-medlib.med.utah.edu

EPIDURAL HEMATOMA

SUBDURAL vs EPIDURAL HEMATOMA

EPIDURAL
Requires linear
force
Associated with
skull fracture and
torn artery. Brain
often uninjured
Lucid interval
common
Common in
accidental trauma

SUBDURAL
Requires significant
rotational forces
Associated with brain
injury and torn bridging
veins
Neurologic symptoms
from the start
Common in infants
with abusive head
trauma

PEDIATRIC FALLS FROM HEIGHTS

Falls From 1 - 3 Stories Often Not Fatal
Falls Less Than 4 Feet Often Reported in Fatal Injuries
Unwitnessed
Subdurals
Retinal Hemorrhages

Falling off a Bed or Couch Should Not Kill!

COUP - CONTRA COUP INJURY

BRAIN INJURY
PATHOPHYSIOLOGY
Secondary Brain Injury :
Occurs over hours to days (hypoxia, hypercarbia,
hypotension/ischemia, intracranial hypertension,
acidosis, seizures, hyperthermia, hypothermia,
infections
Potentially Avoidable Or Treatable With Close
Monitoring / Treatment of ABCs

UNCONTROLLED INTRACRANIAL
PRESSURE AND/OR CEREBRAL
PERFUSION

DISPLACEMENTOF
NERVOUSTISSUES

DECREASEDGLOBAL
ANDREGIONAL
OXYGENDELIVERY

HERNIATION

DEATH

WORSEFUNCTIONAL
OUTCOME

KEY POINTS
THE BRAIN NEEDS OXYGEN
OXYGEN IS CARRIED IN BLOOD

NO BLOOD, NO OXYGEN,
BRAIN CELLS DIE

Assessment

MINOR CLOSED HEAD INJURY

Evaluation and Management of Children Younger Than
Two years old With Apparently Minor Head Trauma:
Proposed Guidelines
Schutzman SA et al., Pediatrics 2001; 107:983-993

The Management of Minor Closed Head Injury in Children

AAP/AAFP, Pediatrics 1999; 104:1407-1415

IMPORTANT ISSUES FOR THE < 2 YEAR OLDS

Clinical Assessment Difficult!

Occult ICI More Common
Increased Risk of NAT
Increased Risk of Skull Fracture
Increase Sedation Risk

MYTH #3
Myth A mild brain injury has no consequences.
Fact A mild brain injury can affect a childs
ability to concentrate, learn and function at home
and in school.

CASE PRESENTATION

6 year old male

Struck by car while riding his bike
Brought in by EMS with c-spine protected
Spontaneously breathing
GCS = 8
HR = 145, RR = 25, B/P = 80/45, O 2 sats = 99%
Multiple abrasions, no other obvious injuries
Next Steps?

INITIAL ASSESSMENT
A IRWAY
B REATHING
C T SCAN

CIRCULATION

MANAGEMENT OF TBI
INITIAL MANAGEMENT
Level II and III (adult and pediatric):

AVOID HYPOTENSION AND HYPOXIA

Know Age Based Normals (For children keep BP > 5th %tile)
In adults, MBP > 90.
Intubate if GCS < 9 (peds) and Airway or Oxygenation is
Unstable (adults)

EARLY RESUSCITATION OF CHILDREN WITH

MODERATE-TO-SEVERE TRAUMATIC BRAIN INJURY
PEDIATRICS 2009;124;56-64 MICHELLE ZEBRACK, CHRISTOPHER DANDOY,
KRISTINE HANSEN, ERIC SCAIFE, N. CLAY MANN AND SUSAN L. BRATTON

CONCLUSIONS: Hypotension and hypoxia are common

events in pediatric traumatic brain injury. Approximately
one third of children are not properly monitored in the early
phases of their management. Attempts to treat
hypotension and hypoxia significantly improved outcomes.

EMERGENCY MANAGEMENT
AIRWAY

Handle Neck With Caution: Assume C-spine Injury

Use Jaw Thrust
Avoid Obstruction of Venous Drainage
Intubate If GCS < 8
May Need to Protect Airway Due to Seizures or Trauma
Intubation Should Be Oral

3 y/o boy after MVA.

Spontaneously breathing but
nasal faring present.
Atlantoaxial distraction with
severed spinal cord

atlas

odontoid

EMERGENCY MANAGEMENT
BREATHING
Even a Small Rise in PaCO2 Causes a Significant Rise in
ICP
Adequate Breathing May Not Be Enough- Aim for
PaCO2 of 35-40 Torr
Hyperventilation Is the Quickest Way to Lower ICP If
There Are Signs of Herniation

EMERGENCY MANAGEMENT
CIRCULATION
Blood Pressure Must Be Optimized to Help Maintain
Adequate CPP
Only Use Isotonic Fluids for Volume Expansion
May Need Inotropic or Pressor Support
Control Bleeding

EMERGENCY MANAGEMENT DISABILITY

Glasgow Coma Score
Modified for Children

Cranial Nerve Exam

Including Pupillary Response to Light, Eye Position and
Movement, Corneal Sensation, Gag

Motor, Sensory, Reflex Exam

Cranial Exam
Evaluate for Fractures, CSF Leak, Battles Sign Etc.

GLASGOW COMA SCALE

EYE OPENING (1-4)

1-none
2-response to pain
3-response to voice
4-spontaneous
BEST VERBAL RESPONSE (1-5)
1-none
2-incomprehensible
3-inappropriate
4-confused
5-oriented

BEST MOTOR
RESPONSE (1-6)
1-none
2-abnormal extension
3-abnormal flexion
4-withdrawal from pain
5-localization of pain
6-obeys commands

GLASGOW COMA SCALE

(MODIFIED FOR YOUNG CHILDREN)
BEST VERBAL RESPONSE (1-5)

1-none

2-restless, agitated

3-persistently irritable

4-consolable crying

5-appropriate words, smiles, fixes/follows

MANAGEMENT OF TBI
Guidelines For The Management of Severe (Adult) Head Injury
A joint venture of
The Brain Trauma Foundation
The American Association of Neurological Surgeons
The Joint Section on Neurotrauma and Critical Care

Journal of Neurotrauma, 1996; 13:626-734

Journal of Neurotrauma, 2000; 17:451-553
Journal of Neurotrauma, 2007; 24:s1-s106

GUIDELINES FOR THE ACUTE MEDICAL

MANAGEMENT OF SEVERE TRAUMATIC BRAIN
INJURY IN INFANTS, CHILDREN AND ADOLESCENTS

Crit Care Med 2003 Vol. 31, No. 6 (Suppl.)

Endorsed or supported by:
American Association for the surgery of Trauma
Child Neurology Society
International Society for Pediatric Neurosurgery
International Trauma and Critical Care Society
Society of Critical Care Medicine
World Federation of Pediatric Intensive and Critical Care Society
National Center for Medical Rehabilitation Research
National Institute of Child Health and Human Development
Syntheses USA
The International Brain Injury Association

DEVELOPMENT OF GUIDELINES
CLASSIFICATION OF
EVIDENCE
CLASS I (PRCT)
CLASS II (clearly
reliable data)
CLASS III (retrospective,
case reviews, clinical
series)
TECHNOLOGY
ASSESSMENT

DEGREES OF
CERTAINTY
STANDARDS (high
degree)
GUIDELINES (moderate
degree)
OPTIONS (unclear)

CASE CONTINUES

Pt intubated, on vent
20/Kg Saline given
B/P 115/75, HR 120, O2 sat 100%

GCS = 7 (Paralyses from RSI resolved)

Head CT = small scattered contusions, small non-surgical subdural.
Abd CT = neg
C-spine CT = neg
What next?

MANAGEMENT OF TBI
INDICATIONS FOR ICP MONITOR
OPTION (Pediatric):
Severe head injury (GCS 8)

CASE CONTINUES

Pt has ventriculostomy placed

Clear CSF flows freely
ICP = 26mmHg
MAP = 70, HR = 100, RR = 15 (on vent), O2sat=99%,
GCS = 7, PEERL

Questions? Plans?

MANAGEMENT OF TBI
HYPERVENTILATION (PEDIATRIC)
OPTIONS (no standards or guidelines):
Mild or prophylactic hyperventilation (pCO2 < 35 mmHg) should
be avoided.
Mild hyperventilation (30 - 35 mmHg) may be considered for
longer periods if ICP refractory to all other tx.
Aggressive hyperventilation (< 30mm Hg) considered second tier
for refractory hypertension.

CASE CONTINUES

ABG shows pCO2 of 45

Vent rate increased to 18/min, 20/kg NS IV bolus
Repeat pCO2 = 35
ICP still 25, MAP = 75, CPP = 50
Head of the bed elevated to 30o
Pt is sedated and paralyzed
No change in ICP or CPP

What next?

MANAGEMENT OF TBI
OSMOTHERAPY - PEDIATRIC
STANDARDS: none
GUIDELINES: none
OPTIONS: HT Saline is effective for control of raised ICP (.1-1
ml/kg/hr). Mannitol is effective therapy (0.25-1/kg) for control
of raised ICP
Keep osmolarity <320 (maybe higher for HT saline)
EUVOLEMIA MUST BE MAINTAINED!

CASE CONTINUES
Pt started on Hypertonic saline
Repeat CT shows diffuse swelling and evolution of
contusions.
ICP now 34, MAP = 70, CPP = 46, PER slugish
HR = 82
GCS = 5 when not paralyzed
What now? Time to quit? Is there a chance for good outcome?

OUTCOME IN PEDIATRIC HEAD INJURY

LIMITATIONS OF THE GLASGOW COMA SCALE IN PREDICTING
OUTCOME IN CHILDREN WITH TRAUMATIC BRAIN INJURY LIEH-LAI MW,
THEODOROU AA, ET AL. J PEDIATR 1992;120:195-9

64% with GCS5 survived

Nonsurvivors had greater incidence of shock/CPR
45 survivors with GCS3-11 had neuropsychologic testing

37% memory deficits

30% speech/language deficits
34% motor function deficits
18%attention deficits with or without hyperactivity

CASE CONTINUES
ICP now 34, MAP = 70, CPP = 46, PER sluggish
HR = 82
GCS = 5 when not paralyzed
Dopamine started, pCO2 now 30, HR = 72, pupils
becoming asymmetric

MANAGEMENT OF TBI
BARBITURATES
Option(Level II for adults): may be considered if ICP
control is refractory to other treatment and patient is
hemodynamically stable
Reduction in cerebral O2 requirement, ICP
Pentobarbital 2-4 mg/kg/dose, 1-2mg/kg/hour, burst-suppression
on EEG
Questionable effect on outcome
Disadvantages: myocardial function - use inotropes. Difficult
neuro exam

MANAGEMENT
CRANIAL DECOMPRESSION

Ventriculostomy (option)
Tumor Debulking
Hematoma Evacuation
Lobectomy
Decompressive Craniectomy (2nd tier)

MANAGEMENT OF TBI
STEROIDS
STANDARDS: NOT recommended for improving
outcome or reducing ICP in TBI
Useful for edema around brain tumors
Dexamethasone 0.4mg/kg/q 6 hours

MANAGEMENT OF TBI
SUPPORTIVE MANAGEMENT
Temperature control - Maintain low normal temp. ~35c
(hypothermia under study)
Head position - 15-30 elevated, avoid jugular
compression
Pain control- pain is bad on ICP!!!
Seizure control (prophylaxis is option)
Antibiotics
Adequate nutrition (VERY IMPORTANT!!)

CRITICAL PATHWAY FOR INCREASED ICP TREATMENT

Critical Pathway for Increased ICP Treatment

Critical Pathway for Increased ICP Treatment

CASE PROGRESSION

ICP normalizes after 2 weeks

GCS 8-9
Pt has trach and G-tube
Transferred to inpatient rehab after 1 mos
Returns to PICU to say Hi one year later

MYTH #4
Myth A Severe Brain Injury Means that the Child Will
Be Permanently and Totally Disabled.
Fact Patterns of Recovery Vary.
~80% will have some type difficulty.
The long term consequences are different for each child.

OUTCOME IN PEDIATRIC
HEAD INJURY
Better Then You Think, (For Severe Injury) So Be
Aggressive!
Do NOT Rely on Initial GCS For Prognosis
Mild Brain Injury May Have More Consequences Than
Expected
Injury Severity and Level of Family Support May Best
Predict Outcome!

MYTH # 5
Myth The brain injury cant be that serious if the child
came right home from the hospital.
Fact More children with disabilities go home upon
discharge from the hospital than to in-patient rehab.

Thank you
marcb@peds.arizona.edu

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