Emergency Treatment Options for Pediatric Traumatic Brain Injury

J Exo; C Smith; R Smith; MJ Bell

Disclosures

Pediatr Health. 2009;3(6):533-541. 

In This Article

General Care

Scrupulous monitoring and correction of hemodynamic, respiratory and other systemic derangements is essential to maximize outcome after TBI in children in order to maintain proper nutrient and oxygen supply to the brain during an evolving injury. Since hypoxic and ischemic injury is frequently found on autopsy of children and adults after TBI and have been linked to adverse outcome,[6–9] current recommendations stress institution of mechanical ventilation with endotracheal intubation when Glasgow Coma Scale is less than 8 or when severe brain injury is suspected. Current guidelines suggest that hypoxia should be avoided by maintaining partial pressure of oxygen in arterial blood (PaO2) above 60–65 mmHg and oxygen saturation (hemoglobin [SaO2]) above 90%, but some evidence suggests targeting brain tissue oxygen tension (PbO2) of greater than 25 mmHg may be more closely linked to outcome in adults.[10] There is some preliminary evidence to support using PbO2 as a threshold for oxygenation in children, but definitive studies have not yet been reported. Finally, in supporting adequate oxygenation, positive end-expiratory pressure should be limited since increases in intrathoracic pressure may impede jugular venous drainage and diminish compensatory mechanisms based on the Munro–Kellie doctrine.

Maintenance of cardiovascular performance is also essential in the treatment of TBI in children. This includes adequate fluid resuscitation and maintenance of blood pressure to ensure cerebral perfusion and resolve shock. Fluid resuscitation should be initiated in all cases of TBI as traumatically injured children often have significant fluid losses as a result of their injury, and failure to maintain adequate hemodynamic support is associated with poorer clinical outcomes.[11–13] The choice of resuscitation fluid – colloid, crystalloid, hypertonic or experimental – has been a matter of intense debate for adults after TBI. However, little is known at this time regarding the superiority of any agent, but avoidance of disturbances in serum osmolarity (particularly hyponatremia with use of hypo-osmolar solutions) is recommended. Resuscitation should have a goal of maintenance of adequate blood pressure to provide cerebral perfusion and prevent secondary organ damage. Cerebral perfusion pressure (CPP) is defined as the difference between MAP and ICP [CPP = MAP – ICP]. The range of optimal CPP is age-dependent in children, as reflected by recent recommendations (children > 60 mmHg; infants and toddlers > 45 mmHg), and prolonged CPP below 40 mmHg predicts mortality in a relatively large series.[14] When intravascular volume is restored (generally when central venous pressure [CVP] is at least 10mmHg), administration of vasopressor agents should be instituted to maintain CPP and cardiovascular performance. The choice of vasopressor is greatly dependent upon the systemic condition of the child, as many factors should be considered in individual children. A host of other factors, including sedation, neuromuscular paralysis, nutrition, deep vein thrombosis, prophylaxis, seizure prophylaxis, and prehospital and rehabilitation care among others, are extremely important to achieve maximal neurological recovery. This review will be limited to acute therapies for treatment of intracranial emergencies after TBI.

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