Vavilala MS, et al
Prehospital Arena – ED – OR - ICU
Retrospective multicenter cohort study
Each 1% increase in adherence was
associated with a 6% drop in the hazard
of death and a 1% drop in the hazard of
being severely disabled or vegetative
Monitor ICP and optimize parameters
Fluids and pressors, optimize sedation
Hypertonic saline
Mannitol
Mild hyperventilation
Coma barbiturate
Surgical measures
Summary protocol
PROTOCOL FOR MANAGEMENT OF THE SEVERE BRAIN INJURY
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
First Edition (2003) Second Edition (2012)
Corticosteroids III - The use of steroids is not recommendedfor improving outcome or reducing ICP in
severe TBI; despite two class II studies failingto show efficacy , the small sample sizes
preclude support for a treatment guidelinefor this topic
II – The use of corticosteroids is notrecommended to improve outcome or reduce
ICP in severe TBI
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
First Edition (2003) Second Edition (2012)
Analgesics, Sedative, and Neuromuscolar Blockade
III – In the absence of outcome data, the choice of dosing and sedative, analgesic,
and neuromuscolar agents should be left tothe treating phisician
III – Etomidate may be considered tocontrol severe intracranial hypertension; however the risks resulting from adrenal
suppression must be considered
- III – Thiopental may be considered tocontrol intracranial hypertension
-
In the absence of outcome data, the specific indications, choice, and dosing ofanalgesic, sedative, and neuromuscolar
agents should be left to the treatingphisician
- Continuous infusion of propofol is notrecommended
First Edition (2003) Second Edition (2012)
Temperature control III - From adult data, hyperthermia shouldbe avoided -
Temperature control III - Despite the of clinical data in children, hypothermia may be considered in
refractory intracrania pressure
II – Moderate hypothermia (32-33°C) beginning early for only 24 h duration
should be avoided
Temperature control II – Moderate hypothermia (32-33°C) beginning within 8 h for up to 48 h durationshould be considered to reduce intracranial
hypertension
Temperature control II – If hypothermia is induced, rewarmingat a rate of > 0.5 °C per h should be avoided
Temperature control III – Moderate hypothermia (32-33°C) beginning early for 48 h duration may be
considered
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
First Edition (2003) Second Edition (2012)
Hyperosmolar therapy-
II – 3% Hypertonic saline in severe TBI withintracranial hypertension: 6.5-10 ml/kg
Hyperosmolar therapy III - Continuous infusion of 3% hypertonicsaline 0.1-1.0 ml/kg/h with the minimum dose needed to maintain ICP <20 mmHg
III - The same+
serum osmolarity should be maintained below 360 mOsm/L
Hyperosmolar therapy III - Mannitol is effective with bolus dosesrange 0.25-1 gr/Kg
Although Mannitol is commonly used no studies meeting inclusion criteria were
identified for use as evidence for this topic
2010; 5:18-21Role of hypertonic saline and mannitol in the management of
raised intracranial pressure in children: A randomized comparative study
Piyush Upadhyay, VN Tripathi, RP Singh, D Sachan
Mannitolo 3%Hypertonic
First Edition (2003) Second Edition (2012)
Hyperventilation III – Mild or prophylactic hyperventilation(<35 mmHg) in children should be avoided
III – Avoidance of prophylactic severe hyperventilation to a PaCO2 < 30mmHg
may be considered in the initial 48 h afterinjury
Hyperventilation III -Mild hyperventilation (PaCO2 30-35 mmHg) may be considered for longerperiods for intracranial hypertensionrefractory to sedation and analgesia,
neuromuscolar blockade, cerebrospinalfluid drainage, and hyperosmolar therapy
III – If hyperventilation is used in the management of refractory intracranial
hypertension, advanced neuromonitoringfor evaluation of cerebral ischemia may be
considered
Hyperventilation III - Aggressive hyperventilation(PaCO2<30mmHg) may be considered as a
second-tier option for refractoryhypertension; cerebral blood flow, jugularvenous oxygen saturation, or brain tissueoxygen monitoring is suggested to help
identify cerebral ischemia
Hyperventilation III – Aggressive hyperventilation titrated toclinical effect may be necessary for briefperiods in case of cerebral herniation or
acute neurological deterioration
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent
Second Edition
Changes in recommendations from the first edition to the second edition
CPP
First Edition (2003) Second Edition (2012)
II - CPP > 40 mmHg should bemaintained
III – A minimum CPP 40 mmHgmay be considered
III – A CPP between 40 and 65 mmHg probably represent an age-related
continuum fo the optimal treatment threshold; there may be exceptions for this
range in some infants and neonates
III – A CPP threshold 40-50 mmHg may be considered; there may be age-specific
thresholds with infants at the lower end and adolescents at the upper end of this
range
III – Advanced cerebral physiologicalmonitoring may be useful to define the
optimal CPP in individual insatnces
J Neurosurgery Pediatr 2015 Mar;15(3):282-90
37 pazienti 8 mesi-18 anni
ESA PT e RA
CONCLUSIONS:
Children have a relatively high incidence of
angiographically detectable, moderate-to-severe CV.
Children rarely develop symptomatic CV and have
good long-term outcomes, perhaps due to robust
cerebral collateral blood flow.
Heffren J et al. 2015 Mar;52(3):356-60
CONCLUSIONS:
Oral nimodipine after subarachnoid hemorrhage in
children does not eliminate vasospasm, rebleeding, or
infarction and is associated with significant hypotension.
Nevertheless, clinical outcomes appear favorable relative
to the adult population who receive nimodipine. Further
study, with dose titration, is warranted.