Traumatic Brain Injury in Kids: What’s New?Bedside Critical Care

Daydream IslandSeptember 2012

Dr Francis Lockie,

Paediatric Emergency Department,

Women’s and Children’s Hospital

MedSTAR Emergency Medical Retrieval

South Australia

Scope

• Case

• Recent guideline update

• Avoid Secondary Brain Injury – Pre-hospital– ED– Definitive care

18 month old boy

HPC

•Dropped 4 times by mum

•Cried after first fall, quiet after fourth

•Baby left on couch whilst ambulance called

•Bradycardia en route

In ED• A – maintained with jaw thrust• B – chest clear, rr 20, SaO2 100% in HF O2 via

NRB• C – hr 130, BP 67/55• D - GCS 15 initially, PERL but sluggish initially,

then blown on Rt– Obvious bilat parietal haematomas

• VBG: pH 7.17, pCO2 50.6, b/c 18, BE -10, Hb 75

Alternating hypotension / hypertension

• 2 x 10ml/kg 0.9% NaCl

• 150ml O neg blood

• Modified RSI: ketamine and sux

• Episode of bradycardia / hypertension– Given 3% saline– Briefly hyperventilated

• Taken to CT

Progress

• Taken to theatre from CT

• Multiple arrests on the table

• BP difficult to manage

PICU:

• Protracted course

• Eventually extubated: guarded prognosis

Definitive Care

Pediatric Critical Care Medicine. 13:S1-S82, January 2012

Guidelines for the acute medical management of severe traumatic brain

injury in infants, children and adolescents – second edition

Pediatrics 2009;124;56

Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury

• 299 kids with mod-severe TBI

• 39% became hypotensive– Of these only 48% were treated

• 44% became hypoxic– Of these 92% were treated

Pediatrics 2009;124;56

Prevent secondary injury

• Hypoxia• Hypotension

Emerg Med J 2007;24:139–141

164 out of theatre intubations83% had 6 mths anaesthetic experience41% consultant presentPropofol in 76%96% NMBD32% DID not use capnography87% had rescue device39% suffered at least one adverse event around time of intubation

Anaesthesia 2009, 64(5):532-9

MilitaryPre-hospital care servicesEmergency / ICU settingsControversial

• Prospective, controlled trial• 30 ventilated, sedated trauma patients• ICP >18mmHg• Single ketamine bolus

Results

• 82 events total (groups 1 &2

• ICP reduced by 30% within 2 minutes of Ketamine administration

• P<0.001

“..refutes the notion that ketamine increases ICP..”

• In ventilated, anaesthetised patients, with raised ICP, ketamine decreased ICP with no untoward effects on MAP or CPP

• Combined with a BDZ, ketamine may be preferred agent for raised ICP

Conclusions

• Physician led prehospital trauma teams decrease the length of ICU stay for patients with severe head injury

• Trial compromised by highly selective patient cross-over (careflight vs ASNSW)

Steroids?

Steroids?

Pediatric Critical Care Medicine. 13:S1-S82, January 2012

C-spine collars may be bad for you

C-spine collars may be bad for you

• Tapes• Head up 30 degrees• Judicious use of PEEP

More Issues for the Intensivist

• Indications for ICP monitoring• Threshold for treatment of intracranial

hypertension• CPP thresholds• Advanced neuromonitoring• Neuroimaging• CSF drainage• DC for treatment of intracranial hypertension

Pediatric Critical Care Medicine. 13:S1-S82, January 2012

High quality neuro-intensive care from scene to definitive treatment

• Rigorous attention to ABC

• Care with RSI, ? Ketamine for all

• Crystalloid

• Sedation: have a plan!

• Deteriorates: – brief hyperventilation– Hypertonic saline over mannitol

• Systems: where is definitive care?