Emergency Treatment Options for Pediatric Traumatic Brain Injury

J Exo; C Smith; R Smith; MJ Bell

Pediatr Health. 2009;3(6):533-541.

Conclusion & Future Perspective

In summary, children with TBI have significant chances of mortality and severe disability. Current neurocritical care therapies are directed toward normalizing physiological parameters in a step-wise manner, with maintenance of normal systemic function, treatment of mechanical disturbances, application of mild hyperventilation, administration of hyperosmolar therapies and induction of coma through use of barbiturates being the currently recognized agents. Experimental use of hypothermia has great promise for periods of intracranial hypertension and may be of utility as a neuroprotectant when applied early after injury. We believe that future research to improve neurological outcome will focus on optimal neurocritical care thresholds (interstitial brain oxygen concentrations, microdialysis measurements of stress metabolites or other parameters), improved nutritional support, an understanding of targeted therapies for intracranial hypertension and a greater understanding of the role of surgery for refractory medical cases. Development of novel therapies is urgently needed to provide further breakthroughs in treatment for these unfortunate children.

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Financial & competing interests disclosure
Supported in part by grants from NIH (T32HD40686 and NS052478). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Cite this: Emergency Treatment Options for Pediatric Traumatic Brain Injury - Medscape - Dec 01, 2009.

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Executive Summary

General care

Avoidance of hypoxia by maintaining partial pressure of oxygen in arterial blood above 60–65 mmHg, oxygen saturation (hemoglobin) above 90% and brain tissue oxygen tension above 25 mmHg prevents secondary hypoxic damage.
Maintaining optimal, age-based cerebral perfusion pressure (children > 60 mmHg & infants and toddlers > 45 mmHg) has been demonstrated to improve outcome.

Mechanical therapies

Elevation of the child's head by 30° to aid in draining venous blood and to minimize intracranial volumes and intracranial pressure (ICP).
Surgical evacuation of hematomas and other pathological masses allow expansion of the intracranial cavity volume.
Decompression surgery may offer benefit for recalcitrant elevations of ICP.

Cerebrospinal fluid drainage

Drainage of cerebrosprinal fluid (CSF) by externalized ventricular drain will decrease intracranial volumes and therefore decrease ICP.
Lumbar drainage of CSF can also be instituted, but this must be carried out with great care to prevent differential pressures within the cranial vault and potential uncal herniation.

Hyperventilation

Hyperventilation leads to decreased cerebral blood flow, which ultimately leads to decreased cerebral blood volume and decreased ICP.
Brief periods of hyperventilation can be used to treat acute neurologic deterioration, while longer periods of aggressive hyperventilation may be appropriate for refractory intracranial hypertension when cerebral blood flow is known to be increased or when all other therapies have failed.
Routine, severe hyperventilation appears to represent a significant risk for brain hypoxia.

Hyperosmolar therapies

Intravenous mannitol and hypertonic saline lead to an immediate decrease in blood viscosity with reflex cerebral vasoconstriction associated with no change in cerebral blood flow, thereby decreasing cerebral blood volume and exhibiting an immediate decreasein ICP.
Administration of hyperosmolar agents leads to an increase in serum osmolarity and a net fluid flux from the brain into the serum, leading to decreased edema, relative brain dehydration and decreased ICP.

Barbiturates & drug-induced coma

Pentobarbital therapy has been associated with improved ICP, improved brain oxygenation and decreased markers of excitotoxicity in CSF.
However, despite its widespread use, risks of hemodynamic instability and lack of improvements in long-term outcome studies lead to judicious use of this therapy.

Experimental therapy: hypothermia

Hypothermia is known to decrease ICP both early after traumatic brain injury as a neuroprotectant or in the delayed phase as a rescue therapy for recalcitrant intracranial hypertension.
Hypothermia has been trialled with both beneficial and detrimental effects in children, future research must be undertaken to determine efficacy.

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