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Evidenced-Based Care of the Child with Traumatic Head Injury

Evidenced-Based Care of the Child with Traumatic Head Injury. A. Student The Children’s Hospital of Philadelphia Dr. Abdul-Monim Batiha. Objectives. Describe the pathophysiology of traumatic brain injury

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Evidenced-Based Care of the Child with Traumatic Head Injury

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  1. Evidenced-Based Care of the Child with Traumatic Head Injury A. Student The Children’s Hospital of Philadelphia Dr. Abdul-Monim Batiha

  2. Objectives • Describe the pathophysiology of traumatic brain injury • Discuss the scientific rationale for the therapeutic interventions used in the care of brain injured children • Provide research based recommendations for the care of children with traumatic brain injury

  3. Rhoads & Pflanzer (1996) Human Physiology p. 211

  4. Traumatic Head Injury ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

  5. Layers of the Cranial Vault Anatomy of the Brain www.neurosurgery.org/pubpgages/patres/anatofbrain.html#micro

  6. Epidural and Subdural Hematoma ALL-NET Pediatric Critical Care Textbook - Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

  7. Subarachnoid Hemorrhage Rogers (1996) Textbook of Pediatric Intensive Care pp. 829

  8. Cerebral Spinal Fluid • Produced by the choroid plexus • Average volume 90 - 150 ml • (0.35 ml / minute or 500 ml / day) • Reabsorbed through the arachnoid villi • Drainage may be blocked by inflammation of the arachnoid villi, diffuse cerebral edema, mass effect of hemorrhage or intraventricular hemorrhage

  9. Brain Cells Concussion Contusion Intracerebral hemorrhage Rhoads & Pflanzer (1996) Human Physiology p. 213

  10. Neurons Neuroscience for Kids www.faculty.washington.edu/chudler/cells/html • Diffuse Axonal Injury • Shearing injury of axons • Deep cerebral cortex, thalamus, basal ganglia • Punctate hemorrhage and paranchymal edema

  11. Cerebral Blood Flow Regulation of Cerebral Vascular Resistance CBF Normal 50 - 100 ml / min PaCo2 (mmHg) MAP (mmHg) Normal 30 - 50 mmHg Normal 60 - 150 mmHg Rogers (1996) Textbook of Pediatric Intensive Care pp. 648 - 651

  12. Cerebral Edema • Cellular response to injury • Primary injury • Secondary injury • Hypoxic-ischemic injury • Injured neurons have increased metabolic needs • Concurrent hypotension and hypoxemia • Inflammatory response

  13. Neuronal Response to Injury Primary mechanical injury & secondary hypoxic-ischemic injury Inflammation: Vasoreactivity Thrombosis Neutrophils Ca+ ATP Lactate Acidosis Glucose NMDA O2 - Edema Glutamate Cyclooxygenase Lipoxygenase Arachidonic Acid Leukotriene Thromboxane Prostaglandin Fluid

  14. Monitoring Brain Metabolism Jugular Venous Catheter Jugular Venous Oxygen Saturation (SJVO2) Arteriojugular Venous Oxygen Difference (AJVO2) Cerebral Metabolic Rate For Oxygen (CMRO2) Possible better outcome in adults Cruz (1998) Critical Care Medicine, 26(2) Brain Sensors Brain tissue pH, PaO2, PcO2, lactate Kiening (1997) Neurology Research, 19(3)

  15. Cerebral Edema after Head Trauma ALL-NET Pediatric Critical Care Textbook Source: Research by Samuel Neff MD. www.med.ub.es/All-Net/english/neuropage/trauma/head-10htm

  16. Monroe- Kellie Principle Rogers (1996) Textbook of Pediatric Intensive Care p. 646

  17. Management of Traumatic Head Injury • Maximize oxygenation and ventilation • Support circulation / maximize cerebral perfusion pressure • Decrease intracranial pressure • Decrease cerebral metabolic rate

  18. Monitoring Ong et al. (1996) Pediatric Neurosurgery, 24(6) GCS, hypoxemia and radiologic evidence of SAH, edema and DAI predict morbidity GCS alone does not predict morbidity Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2) Hypotension is predictive of morbidity GCS and PTS are not predictive of outcome • Serial neurologic examinations • Circulation / Respiration • Intracranial Pressure • Radiologic Studies • Laboratory Studies Scherer & Spangenberg (1998) Critical Care Medicine, 26(1) Fibrinogen and platelets are significantly decreased in TBI patients

  19. Respiratory Support: Maximize Oxygenation • Hypoxemia is predictive of morbidity • Ong et al. (1996) Pediatric Neurosurgery, 24(6) • Neurogenic pulmonary edema / concurrent lung injury • Positive End Expiratory Pressure • May impair cerebral venous return • Cooper et al. (1985) Journal of Neurosurgery, 63 • Feldman et al. (1997) Journal of Neurosurgical Anesthesiology, 9(2) • PEEP > 10 cm H2O increases ICP

  20. Respiratory Support: Normoventilation Hyperventilation : Historical management more harm than good? Originally adapted from Skippen et al. (1997) Critical Care Medicine, 25 ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/vent-5htm

  21. Evidence Supporting Normoventilation • Forbes et al. (1998) Journal of Neurosurgery, 88(3) • Marion et al. (1995) New Horizons, 3(3) • McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5) • Muizelaar et al. (1991) Journal of Neurosurgery, 75(5) • Newell et al. (1996) Neurosurgery, 39(1) • Skippen et al. (1997) Critical Care Medicine, 25(8) • Yundt & Diringer (1997) Critical Care Clinics, 13(1)

  22. Use of Hyperventilation ... • Management of very acute elevation of intracranial pressure • Preemptive for activities known to increase intracranial pressure • No lower than 32-35 cmH20 --- Moderate and transient

  23. Suctioning 53% Percentincrease in ICP with suctioning • Hyper-oxygenation • Mild / moderate hyperventilation Brown & Peeples (1992) Heart & Lung, 21 Parsons & Shogan (1982) Heart & Lung, 13 • Intratracheal / intravenous lidocaine Donegan & Bedford (1980) Anesthesiology, 52 Wainright & Gould (1996) Intensive & Critical Care Nursing, 12 • As needed basis and individualize according to patient response 0% Wainright & Gould (1996)

  24. Circulatory Support: Maintain Cerebral Perfusion Pressure Number of Hypotensive Episodes Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

  25. Circulatory Support: Maintain Cerebral Perfusion Pressure • Adelson et al. (1997) Pediatric Neurosurgery, 26(4) • Children (particularly < 24 months old) are at increased risk of cerebral hypoperfusion after TBI • Low CBF is predictive of morbidity • Rosner et al. (1995) Journal of Neurosurgery, 83(6) • Management aimed at maintaining CPP (70 mmHg) improves outcomes CPP = MAP - ICP

  26. Lowering ICP Brain Blood CSF Mass • Evacuate hematoma • Drain CSF • Intraventricular catheters use is limited by degree of edema and ventricular effacement • Craniotomy • Permanence, risk of infection, questionable benefit • Reduce edema • Promote venous return • Reduce cerebral metabolic rate • Reduce activity associated with elevated ICP Bone

  27. Hyperosmolar Therapy: Increase Blood Osmolarity Brain cell Blood vessel Fluid Movement of fluid out of cell reduces edema Osmosis: Fluid will move from area of lower osmolarity to an area of higher osmolarity

  28. Osmotic Diuretic Mannitol (0.25-1 gm / kg) Increases osmolarity Vasoconstriction (adenosine) / less effect if autoregulation is impaired and if CPP is < 70 Initial increase in blood volume, BP and ICP followed by decrease Questionable mechanism of lowering ICP Rosner et al. (1987) Neurosurgery, 21(2) Loop Diuretic Furosemide Decreased CSF formation Decreased systemic and cerebral blood volume (impairs sodium and water movement across blood brain barrier) May have best affect in conjunction with mannitol Pollay et al. (1983) Journal ofNeurosurgery, 59 ; Wilkinson (1983) Neurosurgery,12(4) Diuretic Therapy

  29. Hypertonic Fluid Administration • Fisher et al. (1992) Journal of Neurosurgical Anesthesiology, 4 • Reduction in mean ICP in children 2 hours after bolus administration of 3% saline • Taylor et al. (1996) Journal of Pediatric Surgery,31(1) • ICP is lowered by resuscitation with hypertonic saline vs. lactated ringers solution in an animal model • Qureshi et al. (1998) Critical Care Medicine, 26(3) • Reduction in mean ICP within 12 hours of continuous infusion of 3% saline acetate solution • Little continued benefit after 72 hours of treatment

  30. Hyperosmolar Therapy Goal: Sodium 145-155 Sodium: square ICP: circle Qureshi et al. (1998) Critical Care Medicine, 26(3)

  31. Promote Venous Drainage Feldman et al. (1992) Journal of Neurosurgery, 76 March et al. (1990) Journal of Neuroscience Nursing, 22(6) Parsons & Wilson (1984) Nursing Research, 33(2) Keep neck mid-line and elevate head of bed …. To what degree? Dicarlo in ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/icp-tx-3.htm

  32. Reduction of Cerebral Metabolic Rate • Reduction in cerebral oxygen requirement • Anticonvulsants - Prevent seizure activity • Pentobarbital • Adverse effects include hypotension and bone marrow dysfunction • Used only after unsuccessful attempts to control ICP and maximize CPP with other therapies • Improved outcome not fully supported by research Traeger et al. (1983) Critical Care Medicine, 11 Ward et al. (1985) Journal of Neurosurgery, 62(3)

  33. Reduction of Cerebral Metabolic Rate: Hypothermia • Metz et al. (1996) Journal of Neurosurgery, 85(4) • 32.5 C reduced cerebral metabolic rate for oxygen (CMRO2) by 45% without change in CBF, and intracranial pressure decreased significantly (p < 0.01) • Marion et al. (1997) New England Journal of Medicine, 336(8) • At 12 months, 62% of patients (GCS of 5-7) cooled to 32-33 C have good outcomes vs. 38% of patients in control group Side-effects: Potassium flux Coagulopathy Shivering Skin Breakdown No pediatric studies! Slow re-warming Close monitoring

  34. Management of Pain & Agitation ICP management continued... Difficult to assess neurologic exam Monitor for hypotension Short acting agents beneficial • Opiods • Benzodiazepines • Management of Movement • Neuromuscular blockade Do opiods increase CBF? Increased ICP with concurrent decreased MAP and CPP has been documented. Elevation in ICP is transient and there is no resulting ischemia from decreased MAP / CPP. Albanese et al. (1999) Critical Care Medicine, 27(2)

  35. Nursing Activities and ICP ICP Rising (1993) Journal of Neuroscience Nursing, 25(5)

  36. Nursing Activities and ICP ICP Bathing Rising (1993) Journal of Neuroscience Nursing, 25(5)

  37. Family Contact and ICP • Presence, touch and voice of family / significant others... • Does not significantly increase ICP • Has been demonstrated to decrease ICP Bruya (1981) Journal of Neuroscience Nursing, 13 Hendrickson (1987) Journal of Neuroscience Nursing, 19(1) Mitchell (1985) Nursing Administration Quarterly, 9(4) Treolar (1991) Journal of Neuroscience Nursing, 23(5)

  38. Summary of Recommended Practices • Maximize oxygenation (PEEP < 10) • Normoventilate • Suction only as needed, limit passes, pre-oxygenate, +/- pre-hyperventilate (not < 30), use lidocaine when possible • Maintain blood pressure and maintain CPP > 60 • Evacuate intracranial blood • Drain CSF with ventriculostomy when possible

  39. Summary of Recommended Practices • Hyperosmolar therapy • Avoid hyperthermia, +/- hypothermia • Prevent seizures • Reserve pentobarbital for refractory conditions • Mid-line neck, elevated head of bead, ? not > 30 degrees • Treat pain and agitation - consider pre-medication for nursing activities • Avoid hyperglycemia • Allow family contact

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