Traumatic Brain Injury Children

1. Traumatic Brain Injury Children Torsten Lauritsen Rigshospitalet Copenhagen

2. Aim • To give an overview of severetraumaticbraininjury in children • focus on resuscitation • first line treatment • guidelines • To improve the care of children with severetraumaticbraininjury Traumatic Brain Injury in Children

3. TBI • Epiduralhemorrhage • Subduralhemorrhage • Subarachnoidhemorrhage • Contusions • Cerebral edema • Ischemicinjury • Diffuse AxonalInjury • Abusive Head Trauma – Shaken Baby Syndrome Traumatic Brain Injury in Children

4. Head trauma - physiology Primarybraindamage • Direct following the trauma • Irreversibel– Diffuse AxonalInjury • Treatmentdoes not improveprognosis Secundarybraininjury • Proper resuscitationwillimproveprognosis and preventfurtherdamage • Hypoxemia • Convulsions • Hypotension • Hyperthermia • Raised ICP • Hypoglycemia Decreased cerebral perfussion Cerebral oxygen delivery Increased oxygen consumption Increasedischemia

5. Neuroprotective agents pH Electrolytes Glucose ROS Sedation Temperature ICP Cerebral perfusion Chalkias A in J of Neurological Sciences 2012

6. Cerebral edema • Intracellular – hypoxia • Cellular metabolism • Cellular retention of sodium and water • Apoptosis • Vasogenic • Rupture of BBB leads to leakage from capillaries Traumatic Brain Injury in Children

7. Paediatric trauma care Traumatic Brain Injury in Children

8. Hypotension is bad 131/299 = 44% had hypoxia Absense of BP monitoring => OR of death 4.5 118/299 = 39% had hypotension Traumatic Brain Injury in Children

9. Hypotension is bad Traumatic Brain Injury in Children

10. Guidelines • Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents Traumatic Brain Injury in Children

11. Treatment • Resuscitation A B C D Traumatic Brain Injury in Children

12. Treatment - Airway • Earlyintubation • Modified Rapid SequenzeInduction Traumatic Brain Injury in Children

13. Rapid SequenceInduction • Premedication with spontaneous ventilation • Preoxygenation • Induction • Propofol/Tiopental (Ketamin/Etomidat) • Rocuronium • Fentanyl (Rapifen) • Mask ventilation (10-12 cm H2O) • Intubation

14. Treatment - Breathing • Oxygen • Maintainoxygenationwithin normal range • PEEP mightincrease ICP Traumatic Brain Injury in Children

15. Hypoxia is worse OR 1,92 OR 1,25 Mortality risk lowest at O2 8 – 10 kPa (60 – 75 mmHg) Mortality risk increase with hypoxia and hyperoxia

16. Hyperventilation • Hyperventilation => hypocapnia => vasoconstriction => lower CBF and CBV => lower ICP • Vasoconstrictionworsen cerebral ischemia • Hyperventilationonlyafterneurosurgicalconsultation and ifherniation is impending Traumatic Brain Injury in Children

17. Circulation • Systolic BP > 70 + 2 x age • Haemorrhagecontrol • Fluid resuscitation • Krystalloid 20 ml/kg • SAGM 10-20 ml/kg • FFP 10-20 ml/kg • TC 5-10 ml/kg • Vasopressors? Traumatic Brain Injury in Children

18. Resuscitation - fluids • Albumin vssaline • Ringers Lactatevs Saline osmolality 270 vs 308 Sodium 130 vs 154 Traumatic Brain Injury in Children

19. Physiology – cerebral perfusion • Cerebral perfusion pressure (CPP) • Mean arterial pressure (MAP) • Intracerebral Pressure (ICP) CPP = MAP - ICP • Level 3 evidence • CPP > 40 mmHg • ICP < 20 mmHg Traumatic Brain Injury in Children

20. Disability - ICP monitoring • ICP < 20 mmHg • No evidencedirectly in favor of ICP monitoring – but: • Childrenwith severe TBI have high ICP • Pooroutcome with intracranialhypertension • Betteroutcome with protocols for treatmentof ICP • Betteroutcome with succesful ICP loweringtherapies Traumatic Brain Injury in Children

21. Anaesthesia • Ketamin • Propofol • Tiopental • Etomidat Increase HR Increase BP Bronchodilatation Decrease cerebral metabolism Cerebral vasoconstriction Inducesystemichypotension => lower CPP Traumatic Brain Injury in Children

22. Anaesthesia • Sevoflurane and Isoflurane • Nitrousoxide Decrease cerebral metabolism Vasodilatation => CBF and CBV Increase cerebral metabolism Increase CBF => ICP Shouldbeavoided Traumatic Brain Injury in Children

23. Neuromuscularblocking agents • Succinylcholine • Increase ICP • Provide rapid optimal conditions for intubation • Cardiacarrytmias • Rocuronium • Optimal drug for paediatricintubation • Reversal with Sugammadex • 0,6-1,0 mg/kg Traumatic Brain Injury in Children

24. Positioning • Improvevenousdrainage • Elevate head 15-30o • Avoidflexion or rotation Traumatic Brain Injury in Children

25. Mannitol • 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 Traumatic Brain Injury in Children

26. Hypertonic Saline 3 % • 5 ml/kg • 513 mmol/l Na+, • Osmolality 1027 mOsm/l • Osmotic action in the brain • Restoresintravascularvolume • Increasedinotopy • Increase MAP and CPP Traumatic Brain Injury in Children

27. Hyperosmolartherapy • 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. • Mannitolis commonly used but no RCI exists Traumatic Brain Injury in Children

28. Hypothermia • Level 2 • Moderate hypothermia (32-33C) beginning early after TBI for only 24 hrs’ duration shold be avoided Traumatic Brain Injury in Children

29. Hypothermia

30. Hypothermia – adverseeffects • Hypotension • Bradycardia • Arrhytmias • Sepsis • Coagulopathy Traumatic Brain Injury in Children

31. Treatment - Conclusion • Resuscitation • Triage – expeditious • Surgicaltreatment • ICP monitoring and control • Optimization of organ systems Traumatic Brain Injury in Children

32. Traumatic Brain Injury in Children

33. Traumatic Brain Injury in Children