Evidenced-Based Care of the Child with Traumatic Head Injury - PowerPoint PPT Presentation

Title: Evidenced-Based Care of the Child with Traumatic Head Injury


1
Evidenced-Based Care of the Child with Traumatic
Head Injury

• A. Student
• The Childrens 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/pubpgage
s/patres/anatofbrain.htmlmicro
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/englis
h/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

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

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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
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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 gt 10 cm H2O increases ICP

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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)

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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

• 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

Percent increase in ICP with suctioning
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 lt 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
Diuretic Therapy

• Osmotic Diuretic
• Mannitol (0.25-1 gm / kg)
• Increases osmolarity
• Vasoconstriction (adenosine) / less effect if
  autoregulation is impaired and if CPP is lt 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)

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

• Keep neck mid-line and elevate head of bed . To
  what degree?

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)
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
  lt 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 Shiverin
g 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 lt 10)
• Normoventilate
• Suction only as needed, limit passes,
  pre-oxygenate, /- pre-hyperventilate (not lt 30),
  use lidocaine when possible
• Maintain blood pressure and maintain CPP gt 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 gt 30
  degrees
• Treat pain and agitation - consider
  pre-medication for nursing activities
• Avoid hyperglycemia
• Allow family contact