GUIDELINES FOR THE MANAGEMENT OF PEDIATRIC TRAUMATIC BRAIN INJURY

These guidelines are to be considered in patients 21 years of age or below with traumatic brain injury. While these are only guidelines, they are based on recommendations published inPediatric Critical Care MedicineFebruary 16, 2012 Volume 13 (2) March 2012 - pg. 131-252,e64-e132

Volume 13 Supplement 1_Suppl, Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition

Endorsed by the following organizations:

International Society for Pediatric Neurosurgery

American Association for the Surgery of Trauma

Society of Critical Care Medicine

Child Neurology Society

International Trauma, Anesthesia, and Critical Care Society

The following organizations also supported those guidelines:

National Institute of Child Health and Human Development

The International Brain Injury Association

NationalCenter for Medical Rehabilitation Research

National Institute of Neurological Disorders and Stroke Synthes USA

INITIAL ER MANAGEMENT

  1. Upon arrival to the ER, an assessment will be made by the ER staff concerning the patients’ respiratory, hemodynamic, and neurologic status. Patients with poor gas exchange and/or hemodynamic instability will be first stabilized prior to any radiographic studies or neurosurgical interventions.
  1. If a patient has a GCS < or = to 8, endotracheal intubation using head injury precautions should be performed. Intubation should also be considered in cases of hemodynamic instability or if a patient needs sedation for transport. When stable, the patient should then have the appropriate studies performed. Appropriate sedation and analgesia should be used while the patient is intubated and/or transported.

GOALS FOR GAS EXCHANGE

  1. The goals for gas exchange should be normoxia (SaO2 > 90%, PaO2 > 60) and normocarbia (pCO2 ~ 40). Hyperventilation to a pCO2 ~ 30-35 should only used if there are clinical signs of intracranial hypertension as manifest by signs of herniation (pupillary dilatation, motor posturing, deteriorating mental status, etc) for the first 24 hours after injury.

HEMODYNAMIC GOALS

  1. The goal for blood pressures should be > than 5th % for age, until further physiologic parameters (i.e. CPP) can be determined. Arterial catheters and central venous catheters should be considered in patients with respiratory, hemodynamic, or neurologic instability.

SURGICAL INTERVENTIONS

  1. Patients with mild (GCS 14-15) and moderate head injuries (GCS 9-13) may have their neurologic status monitored clinically, without ICP monitoring devices (this will be at the discretion of the Attending Neurosurgeon).
  1. In cases of severe head injury an ICP monitor should be placed. Severe head injury is defined as: (a). GCS < or = 8 and an abnormal head CT scan or (b). GCS < or = 8 and motor posturing and systemic hypotension or

(c). Absence of purposeful movements and an abnormal head CT scan

  1. Those patients with moderate TBI that will undergo anesthesia for the management of extracranial injuries should also have ICP monitoring.
  1. The type of monitor used (Camino vs. EVD vs. Dual Bolt/EVD) will be determined by the Attending Neurosurgeon. Consideration should be made about the placement of a lumbar drain.
  1. If upon placement of an ICP monitor, ICPs are found to be significantly elevated, despite sedation, CSF drainage, and osmotherapy, decompressive craniectomy should be strongly considered at this point.

PICU MANAGEMENT OF HIGH ICP/LOW CPP: FIRST TIER THEAPIES

  1. Appropriate sedation and analgesia regimens for patients with secured airways will be determined by the PICU Attending, once the patient arrives in the PICU. Intravenous lidocaine may be given prior to noxious stimuli (ex. endotracheal tube suctioning).
  1. While in the PICU, the patient’s head will be elevated to 30o and in midline. The patient’s temperature will be aggressively controlled with antipyretics and will be held less than 38.5o C. Seizure prophylaxis will be administered. All patients will be given NS at a maintenance rate for the first 24-48 hours. Glucose levels will be followed and will be maintained between 80-120 when possible.
  1. Acute rises in ICP (>20) or decreased CPP (> 70 in adults, > 50 in children between 8 and 16 years of age, and > 40 in children less than 8 years of age) will be managed with sedation and/or mannitol or 3% saline. Mannitol may only be used for a serum osmolarity < or = 320. When using 3% saline, a serum osmolarity of 360 may be used as the cutoff. Mild hyperventilation (Pco2 = 30-35) may be used for acute rises in ICP while the osmotic agent is being obtained. EtCO2should be used to titrate the degree of hyperventilation.
  1. If the patient’s ICP remains stable but elevated, the PICU attending will then consider the use of vasoactive drugs to improve CPP.
  1. Should the ICP remain elevated (>20) despite medical interventions including TWO doses of mannitol within 12 hours at a minimum dose of 0.25 g/kg, surgical management should progress to the insertion of a ventricular drain.

SECOND TIER THERAPIES: SURGICAL MANAGEMENT

  1. If medical management of ICP is unsuccessful, or if the need for osmotherapy is more frequent than every 4 hours, and no drain has been placed to this point, than a ventricular drain should be placed. The patient will then be placed on prophylactic antibiotics per the Neurosurgery EVD protocol.

SECOND TIER THERAPIES: MEDICAL MANAGEMENT

  1. If the ICP continues to be > 20, despite sedation, osmotherapy, and ventricular drainage, and if the time since injury is > 24 hours, the patient can then be hyperventilated to a pCO2~ 35. End-tidal CO2may be used to titrate this therapy
  1. If the ICP continues to be > 20, despite sedation, osmotherapy, mild hyperventilation, and ventricular drainage, the patient will then be placed in a pentobarbital coma with continuous EEG monitoring until burst suppression is achieved. Burst suppression will be defined as the presence of generalized bursts of sharp and slow waves followed by generalized amplitude suppression for 8-12 seconds. Other sedating and analgesic agents should then be discontinued.

TERTIARY TIER THERAPIES

  1. If the ICP continues to be elevated, the Attending Neurosurgeon should then consider the use of decompressive craniectomy, if not already done.
  1. If ICP remains persistently high (>20), the PICU Attending should consider 3% saline infusion.

CRITICAL PATHWAY FOR THE MANAGEMENT OF PEDIATRIC TBI

Cardiopulmonary Resuscitation: See Physiologic Parameters Below*

Intubation using Head Injury Precautions

Appropriate Sedation/Analgesia for Radiographic Studies

ICP monitor and/or drain and other neurosurgical intervention for intracranial bleeding. This should include consideration of the placement of a lumbar drain as well as decompressive craniectomy if ICPs are significantly elevated despite sedation/CSF drainage/osmotherapy after insertion of a monitor in the OR

Sedation/Analgesia, Osmotherapy, Vasoactive Drugs for High ICP or Low CPP *

Consideration of 3% Saline Infusion

Ventricular Drain (if not done previously) if Medical Therapy Unsuccessful

Recommended for continued ICP’s (>20) despite two mannitol doses and continuous sedation.

Mild Hyperventilation to a pCO2 = 30-35 if > 24 hrs since injury

Pentobarbital Coma for Unrelenting High ICP or Low CPP *

Consideration of Decompressive Craniectomy (if not done previously)

Goal Physiologic Parameters:

SaO2 > 90%, PaO2 > 60

PCO2 ~ 40

Mean BP > 5 % for age

ICP < 20

CPP: >70 in patients 17 years of age or older

>50 in patients 8-16 years of age

>40 in patients < 8 years of age