Major Traumatic Brain Injury

Traumatic Brain Injury - TBI Initial ManagementWhile the weird, wild, and unusual conditions that affect our pediatric patients deserve our attention, traumatic injuries unquestionably demand much of our clinical attention.  We have certainly discussed many trauma topics previously (ex, Abdominal Trauma, Aortic Trauma, Damage Control ResuscitationDental Trauma), but the one region of the body that, when injured, leads to the most significant problem is the head. While much of the time we are afforded the opportunity to discuss limiting medical radiation in the setting of Minor Head Injury, there are times when it isn’t a minor problem. Let us take a minute to ensure we are taking simple steps to help those with Major Traumatic Brain Injury:

 

Not Minor. TBI is a Major Problem!

  • In the USA, traumatic brain injury (TBI) leads to > $1 billion in total hospital charges annually. [Schneier, 2006]
  • Adolescents develop TBI primarily from motor vehicle collisions.
  • Younger children are exposed to TBI often from falls.
  • Sadly, non-accidental trauma must always be consider as well.

 

Prevent Secondary Injury!

Much of the work done for pediatric closed head injury has focused on how to risk stratify those who have had minor head impacts and are at Low Risk for having a substantial intracranial injury. While this is important, Major Traumatic Brain Injury is devastating and we need to know some basic steps to help these patients.

  • Primary Injury vs Secondary Injury
    • The primary insult (ex, blunt impact, penetrating missile, blast, rapid acceleration-deceleration) can create a severe injury.
      • Some will lead to Epidural or Subdural hematomas that warrant neurosurgical intervention.
      • Some will lead to irreversible damage (ex, Diffuse Axonal Injury).
    • The secondary insult evolves as a consequence of the primary insult and is what clinicians need to be mindful to prevent.
      • The injured brain is very susceptible to additional injury.
      • Hypotension and/or hypoxia will further stress the tenuous regions around the primary injury.
  • Prevent Hypotension and Hypoxemia.
    • Both will worsen secondary brain injury.
    • RSI with C-Spine stabilization should be done early.
    • Get access! Give fluids. Stop Bleeding.
    • Consider Hypertonic Saline for volume resuscitation.
  • Consider Head Positioning
    • Head of Bed at 30 degrees will aid in venous drainage.
    • Ensure head is Midline to ensure one side’s venous flow is not being constricted.
  • Avoid additional physiologic stressors that can increase mortality risk! [Smith, 2012; Davis, 2009; McHugh, 2007]
    • Avoid Hyperthermia
    • Avoid Hypoglycemia and Hyperglycemia
    • Avoid Hypocapnea
    • Avoid Hyperoxia
  • Make the patient sedated and paralyzed!
    • The patient fighting and struggling will increase ICP.
    • Agitation, anxiety and stress will all exacerbate the problem.
    • Be mindful, though, of inducing hypotension.
      • Consider Etomidate if lower BPs
      • Ketamine has also been shown to be safe for patients with TBI. [Bar-Joseph, 2009].
      • Thiopental is an alternative for patients who have higher BPs.
  • Many will choose to use Lidocaine as a pretreatment medication for RSI.
    • Good idea… but really needs to be given several minutes before intubation.
    • If you have time to use it, feel free to.  If you don’t, don’t waste time waiting for it. {that’s my 2 cents}

 

Moral of the Morsel

  • While avoiding unnecessary CT in patients with Low Risk for significant traumatic brain injury is important, remembering to do some rather basic steps is crucial for our patients who have major TBI!
  • Basics are Best! Check that Head of Bed angle.
  • Keep that ICP low and that BP normal! Cerebral Perfusion depends on it!

 

References

Brenkert TE1, Estrada CM, McMorrow SP, Abramo TJ. Intravenous hypertonic saline use in the pediatric emergency department. Pediatr Emerg Care. 2013 Jan;29(1):71-3. PMID: 23283268. [PubMed] [Read by QxMD]

Agbeko RS1, Pearson S, Peters MJ, McNames J, Goldstein B. Intracranial pressure and cerebral perfusion pressure responses to head elevation changes in pediatric traumatic brain injury. Pediatr Crit Care Med. 2012 Jan;13(1):e39-47. PMID: 21242856. [PubMed] [Read by QxMD]

Smith RL1, Lin JC, Adelson PD, Kochanek PM, Fink EL, Wisniewski SR, Bayir H, Tyler-Kabara EC, Clark RS, Brown SD, Bell MJ. Relationship between hyperglycemia and outcome in children with severe traumatic brain injury. Pediatr Crit Care Med. 2012 Jan;13(1):85-91. PMID: 21499170. [PubMed] [Read by QxMD]

Bar-Joseph G1, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009 Jul;4(1):40-6. PMID: 19569909. [PubMed] [Read by QxMD]

Davis DP1, Meade W, Sise MJ, Kennedy F, Simon F, Tominaga G, Steele J, Coimbra R. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma. 2009 Dec;26(12):2217-23. PMID: 19811093. [PubMed] [Read by QxMD]

McHugh GS1, Engel DC, Butcher I, Steyerberg EW, Lu J, Mushkudiani N, Hernández AV, Marmarou A, Maas AI, Murray GD. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007 Feb;24(2):287-93. PMID: 17375993. [PubMed] [Read by QxMD]

Schneier AJ1, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics. 2006 Aug;118(2):483-92. PMID: 16882799. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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