Treatment of traumatic brain injury in pediatrics

Abstract

The primary goal in treating any pediatric patient with severe traumatic brain injury (TBI) is the prevention of secondary insults such as hypotension, hypoxia, and cerebral edema. Despite the publication of guidelines, significant variations in the treatment of severe TBI continue to exist, especially in regards to intracranial pressure (ICP)-guided therapy. This variability in treatment results mainly from a paucity of data from which to create standards and from the heterogeneity inherent in pediatric TBI. The approach to management of severe TBI based on the published guidelines should be focused on ICP control, which should ultimately improve cerebral perfusion pressure. After identifying and surgically evacuating expanding hematomas, the first-tier treatment approach requires placing an ICP monitor. This is accompanied by medical management of elevated ICP, initially with simple maneuvers such as elevating the head of the bed to improve venous drainage, instituting sedation and analgesia to decrease metabolic demands of the brain, and draining cerebrospinal fluid. If these measures fail, then further first-tier interventions include hyperosmolar therapy to decrease cerebral edema and controlled ventilation to decrease cerebral blood volume. For elevations of ICP resistant to first-tier therapies, treatment escalates to second-tier therapy, which includes more aggressive measures such as placing jugular catheters to measure cerebral oxygenation with moderate hyperventilation, placing lumbar drains to remove more cerebrospinal fluid, administering high-dose barbiturates to suppress cerebral electrical activity, inducing hypothermia as a protective measure, and performing decompressive craniectomy to open the cranial vault. To properly execute these interventions, appropriate neuromonitoring is essential, starting from standard physiological parameters such as ICP, mean arterial blood pressure, and temperature. Additional modalities of neurologic monitoring are becoming more readily available and can provide additional clinically useful information about the pediatric patient with TBI; these include cerebral oxygenation, continuous electroencephalography, noninvasive blood flow monitoring, and advanced neuroimaging.

Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery

“…Most guidelines focus on ICP control as a means to maintain adequate CPP. 34 Current medical treatments to reduce ICP include hyperosmolar therapy (such as mannitol or hypertonic saline), 53 hyperventilation, 15,47 sedation and paralytics, and head of bed elevation. In addition, barbiturate-induced coma 2 and hypothermia 7 have been shown to reduce cerebral metabolic rate and oxygen demands, offering a protective role.…”

Traumatic brain injury

“…Many of the treatments of TBI are aimed at decreasing ICP, "ICP-guided" therapy, and/or maintaining adequate CPP, "CPP-guided" therapy (Madikians and Giza, 2009). The interventions are based on maintaining either normal ICP or normal CPP.…”

“…One pilot study suggested improved outcome in the CPP-guided therapy group when compared to the ICP-guided therapy group (Prabhakaran et al, 2004). Figures 95.6 and 95.7 demonstrate the first-and second-tier management strategies based on the guidelines for the management of pediatric severe TBI (Adelson et al, 2003b;Madikians and Giza, 2009). Although low CPP is associated with poor outcome, it is not clear which factor is more relevant: the total exposure to low CPP or a threshold value.…”

Management and Rehabilitation of Traumatic Brain Injury in Children

“…Notably, inflicted brain injuries have worse outcomes and are the most common cause of head injury deaths. (16) Prognosis worsens with the severity of injury.46 Permanent disability is thought to occur in 10% of mild injuries, 66% of moderate injuries, and 100% of severe injuries.47 Prognosis differs depending on the lesion type. Subarachnoid hemorrhage approximately doubles mortality.…”