Medical Management of Pediatric TBI

Original Date: 06/2017 | Supersedes: 06/2017, 09/2021 | Last Review Date: 02/2024 (Reviewed with no changes)
Purpose: To provide a guideline for medical management of pediatric patients with severe TBI (GCS < 8 without sedating medications and with evidence of TBI on CT).

  1. Airway:
    1. Intubate all unconscious patients with RSI (GCS < 9) to secure airway.
    2. Maintain cervical spine immobilization in all unconscious or symptomatic (neck pain or tenderness) patients.
  2. Breathing: Oxygenation and ventilation.
    1. Administer high flow oxygen to all patients with suspected head injury.
    2. Monitor oxygen saturation.
      1. Avoid hypoxia (SaO2 ≤ 90% or PaO2 ≤ 60 mmHg.)
    3.  Ventilation.
      1. Avoid hyperventilation unless signs of herniation are present
      2. Maintain PaCO2 35-40 mmHg.
      3. Monitor ETCO2 (check ABG if acute change >20%)
  3. Circulation:
      1. Resuscitate to goal mean arterial pressure (MAP) to maintain a presumptive cerebral perfusion pressure (CPP). Consider inotropic use if blood pressure is refractory to fluid resuscitation. If after 2-3 boluses blood pressure remains marginal start norepinephrine to maintain CPP
        • Infants/Toddlers >40 mmHg.
        • Children >50 mmHg,
        • Adults >60 mmHg
      2. Fluids and blood products as needed to correct coagulopathy and base deficit. Avoid crystalloids and albumin for boluses. No dextrose in maintenance fluids.

    Indications for Pediatric MTP include, but are not limited to:

      • Massive bleeding/ trauma patient
      • Massive blood loss with profound hemorrhagic hypovolemic shock
      • >50% of total blood volume loss in 3 hours with continuous bleeding
  1. Seizure prophylaxis:
    • Initiated at the recommendation of Neurosurgery team on a case-by-case basis.
    • Alternative antiepileptic agents may be considered for use, however the Brain Trauma Foundation (BTF) states, “There is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy in preventing early post traumatic seizures and toxicity.15”
    • All patient with intracranial blood should receive either Levetiracetam (20-40mg/kg) IV once for loading dose then scheduled maintenance per weight based dosing or fosphenytoin (20mg/kg) IV once for loading dose then scheduled weight bases maintenance.
  1. Temperature:
    • Aggressively treat hyperthermia >100.4 with antipyretics, Extended/active cooling may promote shivering and require a neuromuscular blockade. Avoid hypothermia unless ICP is refractory after optimizing other therapies
  1. Positioning
    • HOB 30°, reverse Trendelenburg for those in Cspine precautions
    • Ensure no venous obstruction to neck i.e. ill-fitting collar, head tilted to side, tracheostomy ties too tight
  1. If patient requiring intensive management of ICP:
    • Obtain q6 BMP and serum osmolality, urine osmolality; consider adding ABG, CBC, and/or TEG if  clinically indicated
    • Consider a CVL to monitor CVP, avoid placing Internal Jugular lines when possible
    • Place an arterial line for blood pressure measurement and frequent labs

Goals of Care

Neuro ICP <20 mmHg
CPP Infant/toddler >40mmHg
Children >50 mmHg,
Adults >60 mmHg
Seizure Prophylaxis Levetiracetam/fosphenytoin
Head of bed >30 degrees
CV MAP Minimum required to maintain CPP
CVP >5mmHg
Pulm SpO2 >93%
PaO2 >60mmHg
PaCO2 35-42mmHg
Heme Hgb ≥7 g/dL
TEG r-value <8min
Rapid TEG ACT <128 sec
TEG/rapid TEG k-time <2.5min
TEG/rapid TEC alpha angle >60 degrees
TEG/rapid TEG lysis <3%
DVT prophylaxis ≥14years TED/SCD: LMWH 24h after stable head CT and NSY clearance
Endo Glucose 80-110mg/dL
Renal Serum osmolality 280-320
Serum Na 145-165
GI Stress ulcer ppx Famotidine/ranitidine/Protonix
Nutrition Early enteral feeding

 

No Data Normal Abnormal Primary Treatment Secondary Treatment
ACT 86-118 118-150 FFP (10ml/kg)
150-170 FFP (15ml/kg) rFVIIa (30 μg/kg)
>170 FFP (20ml/kg) rFVIIa (60 μg/kg)
a-angle 64-80 <60 Cryoprecipitate (10 ml/kg) FFP (10-15 ml/kg), rFVIIa (30 μg/kg)
MA 52-71 46-52 DDAVP (0.3 units/kg) or Apheresis platelets (10 ml/kg)
40-46 Apheresis platelets (10 ml/kg) Cryoprecipitate (10 ml/kg)
<40 Apheresis platelets (10-15 ml/kg) Cryoprecipitate (10 ml /kg)
LY30 0-7% >7% Consider Amicar 200 mg/kg or Tranexamic Acid 10 mg/kg IV
TXA only if in first 2-3 hours post injury

rTEG normal values from MHH CARE4
Based on Spinella PC and Holcomb JB. Hemostatic Resuscitation: The Transfusion Approach to Hemorrhagic Shock. Current Concepts in Pediatric Critical Care. 2011.

Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring.

  1. Indications for ICP/CPP monitoring:General indications:
    1. Severe head injury (GCS 3-8) + abnormal CT scan.
    2. Severe head injury + normal CT scan and at least 2 of the following 3:
      1. Unilateral or bilateral posturing.
      2. SBP<90 mmHg.
    3. Inability to monitor neuro exam: prolonged sedation or anesthesia.
  2. Technique:
    1. ICP: Parenchymal ICP monitoring catheter or ventricular Catheter.
    2. CPP: Arterial line needed for continuous monitoring
      1. CPP = mean arterial pressure (MAP) – ICP
  3. Ensure that coagulation parameters are normalized in a timely fashion prior to ICP monitor placement
    INR ≤1.4 PLT count ≥ 100,000, Correct TEG to normal

Contraindications and Exclusions:

  1. Severe coagulopathy
  2. Unsalvageable

ICP/CPP treatment

Treatment is for ICP elevated >20mmHg for > 5 min. in which the patient is not agitated or under sedated. Should not be initiated without monitor placement or plans for placement, as there will not be a way to monitor efficacy

Parameters:

  1. Normal ICP:
    Term Infants 5-6 mmHg
    Young Children 3-7 mmHg
    Adults/Older Children 10-15mmHg,
  2. Goal CPP
    Infants/Toddlers >40 mmHg.
    Children >50 mmHg,
    Adults >60 mmHg

First Tier Therapies

  • HOB ≥30°
  • Maintain normothermia (36.5-38C/100.4 F)
  • CSF drainage via ventriculostomy, ensure patency and function
    • EVD drainage point is set at the prescribed level (as per Neurosurgeon documentation in postoperative orders)
    • EVD transducer is leveled to the patient’s external auditory meatus (Tragus) and re-leveled with repositioning
    • ICP waveform is pulsatile on monitor
    • Observe and record volume level of CSF in burette hourly
    • Report any signs of changes in patient’s neurological condition to medical staff.
    • Only Neurosurgery team may access EVD circuit i.e. flushing or obtaining specimen
  • Head/neck neutral position, no external compression

 Sedation and Analgesia:

  • Ensure adequate pain control with continuous infusion of Fentanyl (1mcg/kg/hr) and Midazolam (0.1mg/kg/hr) continuous drip for sedation. Provide bolus doses as needed prior to noxious stimuli (suctioning and repositioning).
  • If three or more prn doses are required in a 1 hour period and all care is optimized increase the basal rate on the gtts or consider alternative prn.

Hypertonic Saline Treatment:

Initiate HTS if ICP remains elevated after sedation/pain control optimized

  1. 3% or 7.3% hypertonic saline may be used as either bolus or continuous infusion, which are titrated to maintain an optimal serum sodium level and lower ICP.
  2. 3% HTS 2ml/kg bolus as need to increase serum Na to 150s
  3. 3% HTS 1-2ml/kg gtt for maintenance, may utilize 7.3% (1ml/kg/h) for maintenance if fluid restricting or difficulty achieving goal NA
    Hold HTS for NA >165 or serum >300All patients receiving HTS for treatment of intracranial hypertension must have the following:

    1. Central venous pressure monitoring
    2. Intracranial pressure monitoring
    3. Serum Na Q6H or more frequent if needed

Mannitol:

  • Initial evaluation: Use mannitol without ICP monitoring only if signs of Herniation or progressive neurologic deterioration, not attributable to Extracranial causes, are present.
  • For treatment of intracranial hypertension:
    • Effective doses range from 0.25-1 gram/kg, given by intermittent bolus Infusion Q 4-6 hrs.
    • Maintain euvolemia. Foley mandatory. CVP monitor recommended.
    • Monitor serum osmolality. Do not exceed 320 mOsm/kg.

Second Tier Therapies

  • Paralysis: Give one Rocuronium dose (1mg/kg) then observe response, if ICP improves begin drip. Prior to Rocuronium drip initiation, obtain a baseline train of four (TOF). Monitor TOF q6h and prn
  • Continuous or spot check EEG monitoring recommended

If ICP refractory to initial treatment notify Neurosurgery. Consider repeat CT (portable)

  • Barbiturates- Barbiturate coma with continuous EEG monitoring
    • High dose barbiturates may be considered for hemodynamically stable, Salvageable, severe head injury patients with intracranial hypertension
    • Refractory to maximal medical and surgical therapy. Load: 10-mg/kg pentobarbital IV over 30 minutes, then 5-mg/kg q1h x 3 doses Maintenance: 1 –mg/kg/hr, PICU attending must discuss with neurosurgery and trauma attending before instituting barbiturate therapy
  • Decompressive hemicraniectomy at the judgment of the attending neurosurgeon
  • Steroids should not be used in patients with severe head injury.

 Recognize and treat brain herniation syndromes.

  1. Signs:
    1. Pupils: Anisocoria (asymmetric,) irregular, or sluggish reaction, Progressing to fixed, dilated, and nonreactive.
    2. Motor: hemiparesis, decerebrate posturing, Babinski reflex.
    3. Progressive neurologic deterioration, not attributable to extracranial causes.
  2. Emergency treatment of herniation:
    1. Hyperventilation.
    2. Mannitol, if not hypotensive.
  3. In the absence of a herniation syndrome, do not initiate treatment for Intracranial hypertension, until CT scan is done or ICP monitor inserted.

References

1Narayan RK, Kishore PR, Becker DP, Ward JD, Enas GG, Greenberg RP, Domingues Da Silva A, Lipper MH, Choi SC, Mayhall CG, Lutz HA, Young HF. Intracranial Pressure: To Monitor or Not to Monitor? A Review of Our Experience with Severe Head Injury. J Neurosurg. May 1982;56(5):650-59.

2 Miller MT, Pasquale M, Kurek S, White J, Martin P, Bannon K, Wasser T, Li M. Initial Head Computed Tomographic Scan Characteristics Have a Linear Relationship with Initial Intracranial Pressure after Trauma. J Trauma. May 2004;56(5):967-72.

3 Eisenberg HM, Frankowski RF, Contant C, Marshall LM, Walker MD. High-Dose Barbiturate Control of Elevated Intracranial Pressure in Patients with Severe Head Injury. J Neurosurg. Jul 1988;69(1):15-23.

4Robertson CS, Valadka AB, Hannay HJ, Contant CF, Gopinath SP, Cormino M, Uzura M, Grossman RG. Prevention of Secondary Ischemic Insults after Severe Head Injury. Crit Care Med. Oct 1999;27(10):2086-95.

5 Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial Hypertension and Cerebral Perfusion Pressure: Influence on Neurological Deterioration and Outcome in Severe Head Injury. J Neurosurg. Jan 2000;92(1):1-6.

6Temkin NR, Dikmen SS, Anderson GD, Wilensky AJ, Holmes MD, Cohen W, Newell DW, Nelson P, Awan A, Winn HR. Valproate Therapy for Prevention of Posttraumatic Seizures: a Randomized Control. J Neurosurg. Oct 1999;91(4):593-600.

7Chestnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. The Role of Secondary Brain Injury in Determining Outcome from Severe Head Injury. J Trauma. Feb 1993;34(2):216-22.

8 Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF, Eisenberg HM, Foulkes MA, Marshall LF, Jane JA. Impact of ICP Instability and Hypotension on Outcome in Patients with Severe Head Trauma. J Neurosurg. Nov 1991;75(1S):S59-66.

9 Jones PA, Andrews PJ, Midgley SI, Piper IR, Tocher JL, Housley AM, Corrie JA, Slattery J, Dearden NM. Measuring the Burden of Secondary Insults in Head-Injured Patients during Intensive Care. J Neurosurg Anesthesiol. Jan 1994;6(1):4-14.

10 Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF. Adverse Effects of Prolonged Hyperventilation in Patients with Severe Head Injury: a Randomized Clinical Trial. J Neurosurg. Nov 1991; 75(5):731-9.

11Chiang YH, Chao DP, Chu SF, Lin HW, Huang SY, Yeh YS, Lui TN, Binns CW, Chiu WT. Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage: a Multi-Center Cohort Study. J Neurotrauma. Jan 2012; 29(1):75-80.

12 Eisenberg HM, Frankowski RF, Contant CF et al. Randomized controlled trial of high-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 1988; 69:15-23.

13 Memorial Hermann Hospital-TMC and UTHealth Texas Trauma Institute Trauma Guidelines. (2014 October).Emergency release of blood from the blood bank/Adult massive bleeding guideline. 

14 Memorial Hermann Hospital-TMC and UTHealth Texas Trauma Institute Trauma Guidelines. (2014 January). Management of severe traumatic brain injury. 

15 Guidelines for the Management of Severe Traumatic Brain injury 4th edition. Brain Trauma Foundation