Moderate-to-Severe Traumatic Brain Injury in Children

Complications and Rehabilitation Strategies

Myra L. Popernack, MSN, RN, CPNP; Nicola Gray, BSN, RN; Karin Reuter-Rice, PhD, CPNP-AC, FCCM, FAAN

Disclosures

J Pediatr Health Care. 2015;29(3):e1-e7. 

In This Article

Acute and Rehabilitative Management Goals for TBI

In 2012, the Society of Critical Care Medicine released updated Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition (Kochanek et al., 2012) These guidelines reflected the latest research and best practice recommendations to optimize recovery and outcomes. Clinicians now have a nationally standardized, evidence-based, goal-directed approach to care.

The first acute injury management goal is to promote neuroprotection and cerebral perfusion. Medical modalities are focused on the prevention of intracranial hypertension, systemic hypotension, hypoxemia, hypocarbia or hypercarbia, and hypoglycemia. Additionally, therapies that promote normothermia and prevent of seizures are used, and devices that monitor and/or reduce intracranial pressure are standard of care. When intracranial pressure is refractory to medical management or the risk of uncal herniation is eminent, surgical intervention by a decompressive craniectomy may be required. By resecting a segment of cranial bone in the parietotemporal area and by opening the dura mater, alleviation of pressure and evacuation of hematomas is possible. A decompressive craniectomy may be performed unilaterally or bilaterally. The dura mater is then closed with synthetic material and the resected bone segment is cultured and placed in sterile frozen storage for a future cranioplasty. Complications associated with craniectomy are hygromas, infection, hydrocephalus, or paradoxical brain herniation. When the brain edema is resolved as indicated by computerized tomography, the harvested bone segment is surgically replaced at about 6 to 12 weeks, based on the neurosurgeon's assessment. If the autologous bone flap is unable to be used, alternative implant materials such as titanium may be used (Beauchamp et al., 2010, Suarez et al., 2011) Bone flap replacement is preferred as soon as deemed possible by the neurosurgical and rehabilitative team. The wearing of protective head gear until replacement is based on physician preference and patient safety needs. Prior to cranioplasty, the site of absent bone flap must be monitored for fluctuations in fluid levels, which may indicate complications as previously listed. The absent bone flap and subsequent replacement of the bone segment may produce significant anxiety for families, requiring both reassurance and education about the procedure and process for reconstruction.

Rehabilitation goals are established upon admission and re-evaluated throughout recovery. The long-term goal is to maximize the child's functional independence and neurocognitive abilities in developmental age-appropriate activities of daily living. Strategies are used to meet these goals within physical and cognitive limitations while utilizing the child's strengths. Two theories for the mechanism of recovery from TBI have been suggested: restitution and substitution. Restitution reflects the early postinjury natural course of physiologic healing and recovery that occurs with reactivation of neural pathways and restoration of function. Substitution reflects the transmission of neural function from injured to noninjured brain tissue so that structural reorganization and compensation occur. Although an overlap of these two mechanisms occurs in the acute phases, substitution is thought to be the predominant mechanism after 6 months when new learning occurs (Catroppa & Anderson, 2006). Interesting research has been done regarding time to follow commands and duration of posttraumatic amnesia as predictors of overall functional outcomes as measured by WeeFIMII scores (Suskauer et al., 2009).

Rehabilitation is focused on using alternative strategies to compensate for cognitive deficits, facilitate neurocognitive recovery and motor skill development, manage comorbidities and minimize complications, and maximize potential for functional independence at the level of impairment. Reintegration into the child's home, school, and community is a common goal, which is influenced by parental/caregiver education as well as available online resources (Table). Reintegration into the child's previous school system begins in acute care with initiation of contact with educators to gather information about the child's previous level of functioning. This information will be very useful to provide the proper support with consideration of prior learning needs. Discharge planning begins upon admission as well to establish a medical home and ongoing outpatient care in the child's local area.

Once the child achieves hemodynamic stability and remains stable in the acute care unit, initial rehabilitation needs are addressed by the acute care therapists. Upon admission to inpatient rehabilitation, evaluation of the child's functional independence is made using the WeeFIM II System (Uniform Data System of Medical Rehabilitation, Amherst, NY). This 18-item performance-based instrument assesses the child's mobility, self-care, and cognitive abilities compared with peers of similar age for ages 6 months to 7 years of age. The instrument may be used as well for patients up to 21 years of age who have delayed development of functional abilities. Scores range from level 1 (complete dependence for skills) up to level 7 (complete independence). Items include self-care, sphincter control, transfers, locomotion, communication, and social cognition. A baseline evaluation is performed every 8 hours of the first 24 hours (three assessments) to allow for variation in fatigue or participation. The lowest score is used to compare with a single measurement taken at discharge. The difference between scores reflects total functional gain achieved during the rehabilitation stay. The length of hospital stay is also documented to interpret functional gains per patient days. These data are tabulated by the Uniform Data System of Medical Rehabilitation (UDS) for use in comparing rehabilitation facilities nationwide for the purposes of benchmarking (UDS, 2006).

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