Chapter 14 The Child with traumatic brain injury

Question 1

There are two types of injury to neural tissue: focal cerebral contusion/laceration and diffuse axonal injury.
How is the mechanism of injury different?

Answer 1

Focal cerebral contusion/laceration is due to direct impact or contrecoup impact

Diffuse axonal injury is from shearing injury

Question 2

Name the four types of intracranial haemorrage from damaged to intracranial blood vessels

Answer 2

Extradural
Subdural
Subarachnoid
Intracerebral

Question 3

What are the indications for intubation regarding a head injury?

Answer 3

Coma, GCS < 9
Loss of gag reflex
Ventilatory insufficiency: PaO2 < <9kPa (68mmHg)
hypercapnea > >6kPa (45mmHg)
Spontaneous hyperventilation causing PaCO2 < 3.5kPa (26mmHg)
Respiratory irregularity

Other:
Significantly deteriorating GCS
Unstable facial factures
Copious bleeding into mouth
Seizures

Question 4

Is papilloedema an acute or late sign in raised ICP

Answer 4

Late so may not be present on arrival to ED even with very high ICP

Question 5

When a child is pre-verbal or with intubated patients, how can you score “verbal” on a GCS scale?

Answer 5

Best Grimace Response:
5 = spontaneous normal facial/oromotor activity
4 = Less than usual spontaneous or only response to touch stimuli
3= Vigorous grimace to pain
2 = Mild grimace to pain
1 = No response to pain

Question 6

What is the arterial PCO2 target level with a head injury?

Answer 6

30 - 34 mmHg

Question 7

What is the blood pressure target in the setting of head injury

Answer 7

> 95th Centile for age to ensure adequate cerebral perfusion

Question 8

Is tranexamic acid useful in preventing intracerebral haematoma expansion

Answer 8

Some evidence for it but it is still being evaluated

Question 9

If pain is untreated with a head injury, how can this worsen the head injury?

Answer 9

Can raise the ICP
Child can be uncooperative and agitated

Question 10

In a paralysed child, what features suggest seizure?

Answer 10

Dilated pupils
Sudden increase in HR and BP

Despite paralysis seizure will raised ICP and increase cerebral metabolic demand.

Question 11

What are the complications of a phenytoin infusion?

Answer 11

Hypotension
Arrhythmias

Need to be on telemetry. Infuse of 20 minutes

Question 12

What are the management aims for an intubated child with a HI and raised ICP?

Answer 12

Temporary hyperventilation PaCO2 of 4-4.5kPa

Ensure treatment of hypotension

Hypertonic saline 2.7-3% at 3ml/kg

or

20% mannitol 0.25-0.5g/kg

ensure adequate analgesia and sedation

avoid hypoglycaemia with dextrose

prompt treatment of seizure activity with levetiracetam or phenytoin

Question 13

In a ventilated child with a HI what are your target blood gases?

Answer 13

PaO2 13kPa
PaCO2 4.5-5kPa

Question 14

what target CPP should there be for a ventilated child with a HI?

Answer 14

40-60mmHg

Question 15

what are the NICE agreed indications for neurosurgical referral?

Answer 15

GCS <9 after initial resus

Unexplained confusion lasting >4hrs

deteriorating conscious level

focal neurological signs

seizure without full recovery

definite or suspected penetrating brain injury

CSF fluid leak

Question 16

How would you modify your GCS to assess an infant?

Answer 16