traumatic brain injury children
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Traumatic Brain Injury Children. Torsten Lauritsen Rigshospitalet Copenhagen. Aim. To give an overview of severe traumatic brain injury in children focus on resuscitation first line treatment guidelines To improve the care of children with severe traumatic brain injury. - PowerPoint PPT PresentationTRANSCRIPT
Traumatic Brain Injury Children
Torsten Lauritsen Rigshospitalet Copenhagen
Aim
Traumatic Brain Injury in Children2
To give an overview of severe traumatic brain injury in children focus on resuscitation first line treatment guidelines
To improve the care of children with severe traumatic brain injury
TBI
Traumatic Brain Injury in Children3
Epidural hemorrhage Subdural hemorrhage Subarachnoid
hemorrhage Contusions Cerebral edema Ischemic injury Diffuse Axonal Injury Abusive Head Trauma –
Shaken Baby Syndrome
Head trauma - physiologyPrimary brain damage
Direct following the trauma Irreversibel– Diffuse Axonal Injury Treatment does not improve prognosis
Secundary brain injury Proper resuscitation will improve prognosis and prevent
further damage
Hypoxemia Convulsions Hypotension Hyperthermia Raised ICP Hypoglycemia
Decreased cerebral perfussionCerebral oxygen deliveryIncreased oxygen consumption
Increased ischemia
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Glucose
Temperature
pH
Electrolytes
Sedation
Cerebral perfusion
Chalkias A in J of Neurological Sciences 2012
Neuroprotective agents
ICP
ROS
Cerebral edema
Traumatic Brain Injury in Children6
Intracellular – hypoxia Cellular metabolism Cellular retention of
sodium and water Apoptosis
Vasogenic Rupture of BBB leads
to leakage from capillaries
Paediatric trauma care
Traumatic Brain Injury in Children7
Hypotension is bad
Traumatic Brain Injury in Children8
131/299 = 44% had hypoxia118/299 = 39% had hypotension
Absense of BP monitoring => OR of death 4.5
Hypotension is bad
Traumatic Brain Injury in Children9
Guidelines
Traumatic Brain Injury in Children10
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents
Treatment
Traumatic Brain Injury in Children11
Resuscitation A
B C D
Treatment - Airway
Traumatic Brain Injury in Children12
Early intubation
Modified Rapid Sequenze Induction
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Rapid Sequence Induction Premedication with spontaneous ventilation Preoxygenation Induction
Propofol/Tiopental (Ketamin/Etomidat) Rocuronium Fentanyl (Rapifen)
Mask ventilation (10-12 cm H2O) Intubation
Treatment - Breathing
Traumatic Brain Injury in Children14
Oxygen Maintain oxygenation within normal range PEEP might increase ICP
Hypoxia is worse
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Mortality risk lowest at O2 8 – 10 kPa (60 – 75 mmHg)
Mortality risk increase with hypoxia and hyperoxia
OR 1,92
OR 1,25
Hyperventilation
Traumatic Brain Injury in Children16
Hyperventilation => hypocapnia => vasoconstriction => lower CBF and CBV =>lower ICP
Vasoconstriction worsen cerebral ischemia
Hyperventilation only after neurosurgical consultation and if herniation is impending
Circulation
Traumatic Brain Injury in Children17
Systolic BP > 70 + 2 x age Haemorrhage control Fluid resuscitation
Krystalloid 20 ml/kg SAGM 10-20 ml/kg FFP 10-20 ml/kg TC 5-10 ml/kg
Vasopressors?
Resuscitation - fluids
Traumatic Brain Injury in Children18
Albumin vs saline Ringers Lactate vs Saline
osmolality 270 vs 308Sodium 130 vs 154
Physiology – cerebral perfusion
Traumatic Brain Injury in Children19
Cerebral perfusion pressure (CPP) Mean arterial pressure (MAP) Intra cerebral Pressure (ICP)
CPP = MAP - ICP Level 3 evidence
CPP > 40 mmHg ICP < 20 mmHg
Disability - ICP monitoring
Traumatic Brain Injury in Children20
ICP < 20 mmHg
No evidence directly in favor of ICP monitoring – but:1. Children with severe TBI have high ICP2. Poor outcome with intracranial hypertension3. Better outcome with protocols for treatment of
ICP4. Better outcome with succesful ICP lowering
therapies
Anaesthesia
Traumatic Brain Injury in Children21
Ketamin
Propofol Tiopental
Etomidat
Increase HRIncrease BPBronchodilatation
Decrease cerebral metabolismCerebral vasoconstrictionInduce systemic hypotension => lower CPP
Anaesthesia
Traumatic Brain Injury in Children22
Sevoflurane and Isoflurane
Nitrous oxide
Decrease cerebral metabolismVasodilatation => CBF and CBV
Increase cerebral metabolismIncrease CBF => ICPShould be avoided
Neuromuscular blocking agents
Traumatic Brain Injury in Children23
Succinylcholine Increase ICP Provide rapid optimal conditions for intubation Cardiac arrytmias
Rocuronium Optimal drug for paediatric intubation Reversal with Sugammadex 0,6-1,0 mg/kg
Positioning
Traumatic Brain Injury in Children24
Improve venous drainage Elevate head 15-30o
Avoid flexion or rotation
Mannitol
Traumatic Brain Injury in Children25
Mannitol 1g/kg - reduce ICP by Reduces blood viscosity rapidly but transiently <
75 min Slow osmotic effect over 15-30 min Movement of water from the brain to the systemic
circulation. Effect up to 6 h, but requires a intact BBB
May cause hypotension (osmotic diuresis) Rebound effect
Hypertonic Saline 3 %
Traumatic Brain Injury in Children26
5 ml/kg 513 mmol/l Na+, Osmolality 1027 mOsm/l
Osmotic action in the brain Restores intravascular volume Increased inotopy Increase MAP and CPP
Hyperosmolar therapy
Traumatic Brain Injury in Children27
Recommendation level 2 Hypertonic saline should be considered for
treatment of TBI associated with intracranial hypertension. Effective dose for acute use range between 6,5-10ml/kg.
Recommendation level 3 Hypertonic saline for treatment of intracranial
hypertension 3% saline as a continous infusion range between 0,1-1,0 ml/kg/hour.
Mannitol is commonly used but no RCI exists
Hypothermia
Traumatic Brain Injury in Children28
Level 2 Moderate hypothermia (32-33C) beginning early
after TBI for only 24 hrs’ duration shold be avoided
Hypothermia
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Hypothermia – adverse effects
Traumatic Brain Injury in Children30
Hypotension Bradycardia Arrhytmias Sepsis Coagulopathy
Treatment - Conclusion
Traumatic Brain Injury in Children31
Resuscitation
Triage – expeditious
Surgical treatment
ICP monitoring and control
Optimization of organ systems
Traumatic Brain Injury in Children32ICP raised – impending herniationHyperventilat
ion Craniotomy Tiopental Hypothermia
Hyperosmolar therapySaline 3 % Mannitol
ICP raisedCSF drainage Neuromuscular blockade
CT - scanICP monitor Surgical evacuation
Primary intervention for TBIElevate head Normothermia Sedation
ResuscitationAirway Breathing Circulation
Traumatic Brain Injury in Children