Evidenced-Based

Care of the Child

with Traumatic Head
Injury
Tara Trimarchi MSN, CRNP
Pediatric Intensive Care Unit
The Childrens Hospital of Philadelphia
University of Pennsylvania
School of Nursing
Objectives
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
Monroe- Kellie Principle
Copied from: Rogers (1996) Textbook of Pediatric Intensive Care
p. 646
Traumatic Mass Occupying Lesions
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intra-paranchymal hemorrhage
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
CBF
MAP
(mmHg)
Normal
50 - 100
ml / min
Normal 60 - 150 mmHg
Cerebral Blood Flow
Regulation of Cerebral Vascular Resistance
PaCo2
(mmHg)

Normal 30 - 50 mmHg
Adapted from: Rogers (1996) Textbook of Pediatric Intensive Care
pp. 648 - 651
Cerebral Edema
Cellular response to injury
Primary injury (mechanical trauma at time of event) and ...
Secondary injury
Hypoxic-ischemic injury
Injured neurons have increased metabolic needs
Concurrent hypotension and hypoxemia may be
present
Inflammatory response results

Shearing injury of axons
Deep cerebral cortex, thalamus, basal ganglia
Punctate hemorrhage and diffuse cerebral edema

Image from: Neuroscience for Kids
www.faculty.washington.edu/chudler/cells/html
Diffuse Axonal Injury
Primary mechanical injury & secondary hypoxic-ischemic injury
Neuronal Response to Injury
ATP
Glucose
Lactate
Acidosis
O
NMDA
Ca+
Glutamate
Fluid
Arachidonic Acid
Leukotriene
Thromboxane
Prostaglandin
Edema
Cyclooxygenase
Lipoxygenase
Inflammation:
Vasoreactivity
Thrombosis
Neutrophils
T.Trimarchi 2000
.
Is hyperglycemia detrimental?
Hyperglycemia is associated with high brain lactate levels and possibly
greater cerebral cellular injury, particularly in the early phases of brain
injury (animal research / not conclusive / older studies)
Recommendation: Avoid hyperglycemia, particularly during the
early stages of brain injury. Consider the use of intravenous
solutions that do not contain dextrose for early fluid and electrolyte
management
Chopp et al., (1988). Stroke, 19.
Lanier et al., (1987). Anesthesiology, 66.
Ljunggren et al. (1974). Brain Research, 77.
Myers et al., (1976). Journal of Neuropathology and Experiemental Neurology, 35.
Smith et al. (1986). Journal of Cerebral Blood Flow and Metabolism, 6.
Natale et al. (1990). Resuscitation, 19.



Source: Rogers (1996) Textbook of Pediatric Intensive Care pp.702-704
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 when used (adult study)
Cruz (1998) Critical Care Medicine, 26(2)
Brain Sensors
Brain tissue pH, PaO2, PcO2, lactate
Kiening (1997) Neurology Research, 19(3)
Basic Monitoring
Serial neurologic examinations
Circulation / respiration
Intracranial Pressure
Cerebral Perfusion Pressure
Radiologic Studies
Laboratory Studies

Ong et al. (1996) Pediatric
Neurosurgery, 24(6)
GCS, hypoxemia and
radiologic evidence of SAH,
cerebral edema and DAI are
predictive of morbidity
GCS alone does not predict
morbidity
Kokoska et al. (1998), Journal
of Pediatric Surgery, 33(2)
Hypotension is predictive of
morbidity
GCS and Pediatric Trauma
Score are not predictive of
outcome
Scherer & Spangenberg,
(1998) Critical Care
Medicine, 26(1)
Fibrinogen and
platelets are
significantly
decreased in TBI
patients

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

Respiratory Support: Maximize Oxygenation
Hypoxemia is predictive of morbidity
Ong et al. (1996) Pediatric Neurosurgery, 24(6)
Neurogenic pulmonary edema, concurrent lung injury, development
of ARDS may be present
Is use of Positive End Expiratory Pressure to maximize
oxygenation a safe practice?
May impair cerebral venous return
Cooper et al. (1985) Journal of Neurosurgery, 63
PEEP > 10 cm H2O increases ICP
Feldman et al. (1997) Journal of Neurosurgical
Anesthesiology, 9(2)
Respiratory Support: Normoventilation
Hyperventilation : Historical management more harm than good ???
Image from: ALL-NET Pediatric Critical Care Textbook
www.med.ub.es/All-Net/english/neuropage/protect/vent-5htm
Originally
adapted from
research by
Skippen et al.
(1997) Critical
Care Medicine,
25
CBF pre- hyperventilation CBF post-hyperventilation
Research 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)

Use of Hyperventilation ...
Transient management of very acute and serious elevation of
intracranial pressure
Possible role for occassional, preemptive use before activities
known to seriously increase intracranial pressure
No lower than 32-35 cmH20
--- Moderate and transient ---
Circulatory Support:
Maintain Cerebral Perfusion Pressure





0
1
2
3
4
5
6
Patient Outcome
Good
Moderate
Severe
Vegetative
Dead
Number of
Hypotensive
Episodes in
the first 24
hours after
TBI

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
CPP = MAP - ICP
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 hypo-perfusion 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
Decreasing Intracranial
Pressure
Evacuate hematoma
Drain CSF
Intraventricular catheters use is limited by degree of
edema and ventricular effacement
Craniotomy
Permanence, risk of infection, questionable benefit
Reduce cerebral edema
Promote venous return
Reduce activity associated with elevated ICP

Reduce cerebral metabolic rate

Brain Blood
CSF Mass
Bone
Hyperosmolar Therapy: Increase Blood Osmolarity
Fluid
Osmosis: Fluid will move from area of lower osmolarity to an
area of higher osmolarity
Movement of
fluid out of cell
reduces edema
Brain
cell
Blood
vessel
Decreasing Intracranial Pressure:
T. Trimarchi, 2000
Diuretic Therapy
Osmotic Diuretic
Mannitol (0.25-1 gm / kg)
Increases serum 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 of Neurosurgery,
59 ; Wilkinson (1983)
Neurosurgery,12(4)

Decreasing Intracranial Pressure:
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% sadium acetate solution
Little continued benefit after 72 hours of treatment

Decreasing Intracranial Pressure:
Copied from: Qureshi et al. (1998) Critical Care Medicine, 26(3)
Goal:
Sodium 145-155
mmol/L
Hyperosmolar Therapy
Sodium: square
ICP: circle
Decrease Intracranial Pressure: Promote Venous Drainage
Keep neck mid-line and elevate head of bed . To what degree?
Image from: Dicarlo in ALL-NET Pediatric Critical Care Textbook
www.med.ub.es/All-Net/english/neuropage/protect/icp-tx-3.htm
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)

Management of Pain & Agitation
Opiods
Benzodiazepines

Management of Movement
Neuromuscular blockade may be
required - use only when necessary
Problems:
Difficult to
assess neurologic
exam
Risk of
hypotension
Use short
acting agents
Decrease Intracranial Pressure:
Do opiods increase CBF and ICP as well as lower MAP and CPP?
Increased ICP with concurrent decreased MAP and CPP has been
documented with use of opiods. But, elevation in ICP is transient and
there is no resulting ischemia from decreased MAP / CPP.
Albanese et al. (1999) Critical Care Medicine, 27(2)
0
2
4
6
8
10
12
14
16
18
20
Before During After
Turning
Suctioning
Bathing
Nursing Activities and ICP
Rising (1993) Journal of Neuroscience Nursing, 25(5)
ICP
Suctioning Practices
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
Hypervent
IV lido
IT lido
53%
0%
Percent increase in
ICP with
suctioning using
preemptive
hyperventilation,
IV lidocaine and IT
lidocaine
Wainright & Gould (1996)
Individualize suctioning practices
according the patients response
Family Contact and 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)
Presence, touch and voice of family / significant others...
Does not significantly increase ICP
Has been demonstrated to decrease ICP
Note: Visitors require education and
preparation before spending time at bedside !
Reduction of Cerebral Metabolic Rate
Goal: Reduce cerebral oxygen requirement
Anticonvulsants
To 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)
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
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
Requires:
Slow re-warming
Close monitoring
No
pediatric
studies!
Summary of Recommended Practices
Serial neurologic assessments and physical examination
Continuous cardio-respiratory, ICP, and CPP monitoring, +/-
cerebral metabolism monitoring adjuncts
Maximize Oxygenation and Ventilation
Maximize oxygenation (cautious use of PEEP / keep PEEP < 10 to
prevent inhibited venous return / individualize according to patient
response)
Normoventilate
Support circulation / maximize cerebral perfusion pressure
Maintain mean arterial blood pressure and maintain CPP (goal > 60)



Summary of Recommended Practices
Decrease intracranial pressure
Evacuate mass occupying hemorrhages
Consider draining CSF with ventriculostomy when possible
Hyperosmolar therapy, +/- diuresis (cautious use to avoid
hypovolemia and decreased BP)
Mid-line neck, elevated head of bead (some research supports
elevation not > 30 degrees)
Treat pain and agitation - consider pre-medication for nursing
activities, +/- neuromuscular blockade (only when needed)
Careful monitoring of ICP during nursing care, cluster nursing
activities and limit handling when possible
Suction only as needed, limit passes, pre-oxygenate / +/- pre-
hyperventilate (PaCo2 not < 30) / use lidocaine IV or IT when
possible
After careful preparation of visitors, allow calm contact


Summary of Recommended Practices
Decrease Cerebral Metabolic Rate
Prevent seizures
Reserve pentobarbital for refractory conditions
Avoid hyperthermia, +/- hypothermia
Avoid hyperglycemia (early)