evidenced-based care of the child with traumatic head injury
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Evidenced-Based Care of the Child with Traumatic Head Injury. A. Student The Children’s Hospital of Philadelphia Dr. Abdul-Monim Batiha. Objectives. Describe the pathophysiology of traumatic brain injury - PowerPoint PPT PresentationTRANSCRIPT
Evidenced-Based Care of the Child with Traumatic Head Injury
A. StudentThe Children’s Hospital of Philadelphia
Dr. Abdul-Monim BatihaDr. Abdul-Monim Batiha
Objectives
• Describe the pathophysiology of traumatic brain injury
• Discuss the scientific rationale for the therapeutic interventions used in the care of brain injured children
• Provide research based recommendations for the care of children with traumatic brain injury
Traumatic Head Injury
ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
Layers of the Cranial Vault
Anatomy of the Brain www.neurosurgery.org/pubpgages/patres/anatofbrain.html#micro
Epidural and Subdural Hematoma
ALL-NET Pediatric Critical Care Textbook - Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
Cerebral Spinal Fluid
• Produced by the choroid plexus
• Average volume 90 - 150 ml
– (0.35 ml / minute or 500 ml / day)
• Reabsorbed through the arachnoid villi
• Drainage may be blocked by inflammation of the arachnoid
villi, diffuse cerebral edema, mass effect of hemorrhage or
intraventricular hemorrhage
Brain Cells
Rhoads & Pflanzer (1996) Human Physiology p. 213
Concussion
Contusion
Intracerebral hemorrhage
Neurons
Diffuse Axonal Injury• Shearing injury of axons
Deep cerebral cortex, thalamus, basal ganglia• Punctate hemorrhage and paranchymal edema
Neuroscience for Kids www.faculty.washington.edu/chudler/cells/html
CBF
MAP(mmHg)
Normal 50 - 100 ml / min
Normal 60 - 150 mmHg
Cerebral Blood FlowRegulation of Cerebral Vascular Resistance
PaCo2 (mmHg)
Normal 30 - 50 mmHg
Rogers (1996) Textbook of Pediatric Intensive Care pp. 648 - 651
Cerebral Edema
• Cellular response to injury
– Primary injury
• Secondary injury
– Hypoxic-ischemic injury
• Injured neurons have increased metabolic needs
• Concurrent hypotension and hypoxemia
• Inflammatory response
Primary mechanical injury & secondary hypoxic-ischemic injury
Neuronal Response to Injury
ATP
Glucose
Lactate
Acidosis
O2 -NMDA
Ca+
Glutamate
Fluid
Arachidonic Acid
Leukotriene Thromboxane Prostaglandin
Edema
Cyclooxygenase Lipoxygenase
Inflammation: Vasoreactivity Thrombosis Neutrophils
Monitoring Brain Metabolism
Jugular Venous Catheter
Jugular Venous Oxygen Saturation (SJVO2)
Arteriojugular Venous Oxygen Difference (AJVO2)
Cerebral Metabolic Rate For Oxygen (CMRO2)
Possible better outcome in adults
Cruz (1998) Critical Care Medicine, 26(2)
Brain Sensors
Brain tissue pH, PaO2, PcO2, lactate
Kiening (1997) Neurology Research, 19(3)
Cerebral Edema after Head Trauma
ALL-NET Pediatric Critical Care Textbook Source: Research by Samuel Neff MD. www.med.ub.es/All-Net/english/neuropage/trauma/head-10htm
Management of Traumatic Head Injury
• Maximize oxygenation and ventilation
• Support circulation / maximize cerebral perfusion
pressure
• Decrease intracranial pressure
• Decrease cerebral metabolic rate
Monitoring
• Serial neurologic examinations
• Circulation / Respiration
• Intracranial Pressure
• Radiologic Studies
• Laboratory Studies
Ong et al. (1996) Pediatric Neurosurgery, 24(6)
GCS, hypoxemia and radiologic evidence of SAH, edema and DAI predict morbidity
GCS alone does not predict morbidity
Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
Hypotension is predictive of morbidity
GCS and PTS are not predictive of outcome
Scherer & Spangenberg (1998) Critical Care Medicine, 26(1)
Fibrinogen and platelets are significantly decreased in TBI patients
Respiratory Support: Maximize Oxygenation
• Hypoxemia is predictive of morbidity
– Ong et al. (1996) Pediatric Neurosurgery, 24(6)
• Neurogenic pulmonary edema / concurrent lung injury
– Positive End Expiratory Pressure
• May impair cerebral venous return– Cooper et al. (1985) Journal of Neurosurgery, 63
– Feldman et al. (1997) Journal of Neurosurgical Anesthesiology, 9(2)
• PEEP > 10 cm H2O increases ICP
Respiratory Support: NormoventilationHyperventilation : Historical management more harm than good?
ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/vent-5htm
Originally adapted from Skippen et al. (1997) Critical Care Medicine, 25
Evidence Supporting Normoventilation
• Forbes et al. (1998) Journal of Neurosurgery, 88(3)
• Marion et al. (1995) New Horizons, 3(3)
• McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5)
• Muizelaar et al. (1991) Journal of Neurosurgery, 75(5)
• Newell et al. (1996) Neurosurgery, 39(1)
• Skippen et al. (1997) Critical Care Medicine, 25(8)
• Yundt & Diringer (1997) Critical Care Clinics, 13(1)
Use of Hyperventilation ...
• Management of very acute elevation of intracranial pressure
• Preemptive for activities known to increase intracranial
pressure
• No lower than 32-35 cmH20
--- Moderate and transient
Suctioning
• Hyper-oxygenation• Mild / moderate hyperventilation
Brown & Peeples (1992) Heart & Lung, 21Parsons & Shogan (1982) Heart & Lung, 13
• Intratracheal / intravenous lidocaineDonegan & Bedford (1980) Anesthesiology, 52Wainright & Gould (1996) Intensive & Critical Care Nursing, 12
• As needed basis and individualize according to patient response
HyperventIV lidoIT lido
53%
0%
Percent increase in ICP with suctioning
Wainright & Gould (1996)
Circulatory Support: Maintain Cerebral Perfusion Pressure
0
1
2
3
4
5
6
Outcome
Good
Moderate
Severe
Vegetative
Dead
Number of Hypotensive Episodes
Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
Circulatory Support: Maintain Cerebral Perfusion Pressure
• Adelson et al. (1997) Pediatric Neurosurgery, 26(4)
– Children (particularly < 24 months old) are at increased risk of cerebral hypoperfusion after TBI
– Low CBF is predictive of morbidity
• Rosner et al. (1995) Journal of Neurosurgery, 83(6)
– Management aimed at maintaining CPP (70 mmHg) improves outcomes
CPP = MAP - ICP
Lowering ICP
• Evacuate hematoma• Drain CSF
– Intraventricular catheters use is limited by degree of edema and ventricular effacement
• Craniotomy– Permanence, risk of infection, questionable benefit
• Reduce edema• Promote venous return• Reduce cerebral metabolic rate• Reduce activity associated with elevated ICP
Brain Blood
CSF MassBone
Hyperosmolar Therapy: Increase Blood Osmolarity
Fluid
Osmosis: Fluid will move from area of lower osmolarity to an area of higher osmolarity
Movement of fluid out of cell reduces edema
Brain cell
Blood vessel
Diuretic Therapy
Osmotic Diuretic• Mannitol (0.25-1 gm / kg) • Increases osmolarity• Vasoconstriction (adenosine) / less
effect if autoregulation is impaired and if CPP is < 70
• Initial increase in blood volume, BP and ICP followed by decrease
• Questionable mechanism of lowering ICP
• Rosner et al. (1987) Neurosurgery, 21(2)
Loop Diuretic• Furosemide• Decreased CSF formation• Decreased systemic and
cerebral blood volume (impairs sodium and water movement across blood brain barrier)
• May have best affect in conjunction with mannitol
• Pollay et al. (1983) Journal of Neurosurgery, 59 ; Wilkinson (1983) Neurosurgery,12(4)
Hypertonic Fluid Administration
• Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4– Reduction in mean ICP in children 2 hours after bolus administration of
3% saline
• Taylor et al. (1996) Journal of Pediatric Surgery,31(1)– ICP is lowered by resuscitation with hypertonic saline vs. lactated ringers
solution in an animal model
• Qureshi et al. (1998) Critical Care Medicine, 26(3)– Reduction in mean ICP within 12 hours of continuous infusion of 3%
saline acetate solution– Little continued benefit after 72 hours of treatment
Qureshi et al. (1998) Critical Care Medicine, 26(3)
Goal: Sodium 145-155
Hyperosmolar Therapy
Sodium: square
ICP: circle
Promote Venous DrainageKeep neck mid-line and elevate head of bed …. To what degree?
Dicarlo in ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/icp-tx-3.htm
Feldman et al. (1992) Journal of Neurosurgery, 76
March et al. (1990) Journal of Neuroscience Nursing, 22(6)
Parsons & Wilson (1984) Nursing Research, 33(2)
Reduction of Cerebral Metabolic Rate
• Reduction in cerebral oxygen requirement
– Anticonvulsants - Prevent seizure activity
– Pentobarbital
• Adverse effects include hypotension and bone marrow dysfunction
• Used only after unsuccessful attempts to control ICP and maximize CPP with other therapies
• Improved outcome not fully supported by research
Traeger et al. (1983) Critical Care Medicine, 11Ward et al. (1985) Journal of Neurosurgery, 62(3)
Reduction of Cerebral Metabolic Rate: Hypothermia
• Metz et al. (1996) Journal of Neurosurgery, 85(4)– 32.5 C reduced cerebral metabolic rate for oxygen (CMRO2)
by 45% without change in CBF, and intracranial pressure decreased significantly (p < 0.01)
• Marion et al. (1997) New England Journal of Medicine, 336(8)– At 12 months, 62% of patients (GCS of 5-7) cooled to 32-33 C
have good outcomes vs. 38% of patients in control group
Side-effects:Potassium fluxCoagulopathyShiveringSkin Breakdown
Slow re-warming
Close monitoring
No pediatric studies!
Management of Pain & Agitation• Opiods
• Benzodiazepines
Management of Movement
• Neuromuscular blockade
Difficult to assess neurologic exam
Monitor for hypotension
Short acting agents beneficial
ICP management continued...
Do opiods increase CBF?
Increased ICP with concurrent decreased MAP and CPP has been documented. Elevation in ICP is transient and there is no resulting ischemia from decreased MAP / CPP.
Albanese et al. (1999) Critical Care Medicine, 27(2)
0
2
4
6
8
10
12
14
16
18
20
Before During After
TurningSuctioningBathing
Nursing Activities and ICP
Rising (1993) Journal of Neuroscience Nursing, 25(5)
ICP
0
2
4
6
8
10
12
14
16
18
20
Before During After
SuctioningTurning
Nursing Activities and ICP
Rising (1993) Journal of Neuroscience Nursing, 25(5)
ICP
Bathing
Family Contact and ICP
Bruya (1981) Journal of Neuroscience Nursing, 13
Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)
Mitchell (1985) Nursing Administration Quarterly, 9(4)
Treolar (1991) Journal of Neuroscience Nursing, 23(5)
Presence, touch and voice of family / significant others...
• Does not significantly increase ICP
• Has been demonstrated to decrease ICP
Summary of Recommended Practices
• Maximize oxygenation (PEEP < 10)
• Normoventilate
• Suction only as needed, limit passes, pre-oxygenate, +/- pre-hyperventilate (not < 30), use lidocaine when possible
• Maintain blood pressure and maintain CPP > 60
• Evacuate intracranial blood
• Drain CSF with ventriculostomy when possible
Summary of Recommended Practices
• Hyperosmolar therapy
• Avoid hyperthermia, +/- hypothermia
• Prevent seizures
• Reserve pentobarbital for refractory conditions
• Mid-line neck, elevated head of bead, ? not > 30 degrees
• Treat pain and agitation - consider pre-medication for nursing activities
• Avoid hyperglycemia
• Allow family contact