Metabolic Stress with Nutrition Support

Pediatric Traumatic Brain Injury:

Zach Pfirrman and Taylor Pond

Traumatic Brain Injury: Definition

• Two types:• Penetrating brain injury• Penetration of skull and direct damage to brain tissue

• Closed head injury• Mild traumatic brain injury• No penetration of skull• Concussions

• Injury• Primary• Initial injury of brain hitting the interior of skull

• Secondary• The resulting physiological changes

• Cerebral edema, hemorrhage, hematoma, and infection

Traumatic Brain Injury: Etiology

TBIs occur about 1.7 million times a year in the United States.

35.2% contributed by falls

17.2% contributed by Motor vehicle accidents

http://www.cdc.gov/traumaticbraininjury/causes.html

Diagnostic Measures

• A variety of neuroimaging techniques:• X-rays • CT scans• To find location and type of injury

• SPECT scan• PET scan• DTI

• Glasgow coma scale

Glasgow Coma Scale

•The Glasgow coma scale is a neurological scale that measures the conscious state of a person for an initial assessment. The scale has three components: eye response (1-4), verbal response (1-5), and motor response (1-6). Chelsea's initial score was 10 out of 15, 4 points from eye response, 2 from verbal, and 4 from motor. A score of 10 out of 15 puts Chelsea in the “moderate head injury” range.

Glasgow coma Scale

Patient History

Chelsea Montgomery is an 8-year-old 2nd grade student. Healthy except for severe myopia (nearsightedness). She participates in a variety of activities including gymnastics, softball, and Girl Scouts.

No Medical history No medications Family History: CAD- Grandfather

Diabetes- Older Brother

Diagnosis

Chelsea was admitted to through the ER after being injured as a restrained front-seat passenger in a motor vehicle accident. She is transferred to the pediatric intensive care unit with a traumatic brain injury

MRI showed areas of hemorrhagic edema in deep white matter of L frontal lobe anteriorly. Additionally, heme and edema found in the splenium of corpus callosum.

CT scan showed 2 areas of increased density in L frontal lobe near vertex and possibly left central modality.

Treatment

Emergency care for moderate to severe TBI has a main focus on ensuring that the patient is getting a sufficient supply of oxygenated blood to the brain, maintaining blood pressure, and preventing any further damage to the head or neck.

Secondary focuses would be on minimizing the damage caused by inflammation, bleeding, and decreased oxygen supply to the brain.

Treatment (cont.)

Depending on how severe the trauma is would determine if surgical intervention is needed.

In some bad cases of brain edema(swelling), the skull must be opened to relieve pressure. The procedure is called decompressive craniectomy

Similar is a Ventriculostomy, where a hole is cut into the skull and a tube is inserted to drain cerebral fluid.

Medications can be used to in some cases to relieve brain edema or slow the body's response to the swelling.

A rarely used treatment due to it's difficulty in preforming correctly is deliberate hypothermia. Lowering the body temperature has been found to relieve brain swelling and helps in the healing of the brain.

PES Statements

• Swallowing Difficulty (NC-1.1) related to neurological damage to the frontal lobe as evidenced by radiology and failed speech/swallowing evaluation.

• Unintentional Weight Loss (NC-3.2) related to decreased ability to consume sufficient energy as evidenced by a weight loss of 10 pounds in 12 days which is about a 15% of her original weight.

Medical Nutrition Therapy

• Chelsea’s nutritional needs:• Protein• 1.5g/kg – 2.0g/kg x 27.7kg = 42g - 55g of PRO

• Kilocalories• EER: 88.5 – 61.9 x 8 + 1.31 x (10 x 27.7 + 903 x 1.3) + 20 x

1.4 = 2119 kcal (TBI patients need 140%REE)

• Fluids• 2119kcal x 1 mL/kcal = 2119 mL

Medical Nutrition Therapy

• Initial Nutrition Intervention:• Enteral feeding Pediasure 1.5 at 10 cc/hour continuous

drip• 360 kcal

• Free water 200 mL four times daily to meet fluid requirements when IV is disconnected

• Goal rate of 57 cc/hr• At a goal rate of 57 cc/hr, Chelsea will receive 2052

kcal and 80.8 g protein. • This is adequate!

Important nutrients

• Glutamine• BCAAs• Isoleuicine, leucine, and valine

• Vitamin E• Vitamin C• Selenium• Copper• Zinc

Pediasure 1.5

FEES/Swallowing Evaluation

• Two weeks after accident:• Accepted Macaroni and Cheese• Choked after 5-7 ice chips• Oral skills appropriate• Signs of fatigue after a few seconds• No evidence of penetration or aspiration• PO inhibited, but signs of progress• Continue enteral feeding

• Sent to rehab

Prognosis

• Disabilities depend on severity• Cognition-thinking, memory, reasoning• Sensory processing- sight, hearing, touch, taste, and

smell• Communication- expression and understanding• Behavior or mental health- depression, anxiety,

presonality changes, aggression, acting out, and social inappropriateness

• severe cases can result in:• Stupor• Unresponsive state• Coma

Rehabilitation

Most TBI patients must go through high amounts of extensive rehabilitation to relearn basic skills and abilities to preform daily activities.

Occupational therapy helps patients relearn or improve skills used in one's everyday activities

Physical therapy helps with mobility and relearning balance, movement patterns, and walking

Language or Speech pathologists help with the relearning and improvement of communication skills, chewing ability, and swallowing ability.

Psychiatrists may be needed to help in emotional and psychological well being. This may include behavior management, coping strategies, and talk therapy.

Work Cited

• Nelms, M. (2013). Medical nutrition therapy: a case study approach (4th ed.).

Stamford, Connecticut: Cengage Learning.

• Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA:

Wadsworth, Cengage Learning.

• Severe Traumatic Brain Injury . (2012, September 21). Centers for Disease Control and

Prevention. Retrieved October 30, 2013, from

http://www.cdc.gov/TraumaticBrainInjury/severe.html

• staff, M. (2012, October 12). Definition. Mayo Clinic. Retrieved October 30, 2013, from

http://www.mayoclinic.com

/health/traumatic-brain-injury/DS00552/DSECTION=treatments-and-drugs