Chapter 14 The Child with traumatic brain injury Flashcards
There are two types of injury to neural tissue: focal cerebral contusion/laceration and diffuse axonal injury.
How is the mechanism of injury different?
Focal cerebral contusion/laceration is due to direct impact or contrecoup impact
Diffuse axonal injury is from shearing injury
Name the four types of intracranial haemorrage from damaged to intracranial blood vessels
Extradural
Subdural
Subarachnoid
Intracerebral
What are the indications for intubation regarding a head injury?
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
Is papilloedema an acute or late sign in raised ICP
Late so may not be present on arrival to ED even with very high ICP
When a child is pre-verbal or with intubated patients, how can you score “verbal” on a GCS scale?
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
What is the arterial PCO2 target level with a head injury?
30 - 34 mmHg
What is the blood pressure target in the setting of head injury
> 95th Centile for age to ensure adequate cerebral perfusion
Is tranexamic acid useful in preventing intracerebral haematoma expansion
Some evidence for it but it is still being evaluated
If pain is untreated with a head injury, how can this worsen the head injury?
Can raise the ICP
Child can be uncooperative and agitated
In a paralysed child, what features suggest seizure?
Dilated pupils
Sudden increase in HR and BP
Despite paralysis seizure will raised ICP and increase cerebral metabolic demand.
What are the complications of a phenytoin infusion?
Hypotension
Arrhythmias
Need to be on telemetry. Infuse of 20 minutes
What are the management aims for an intubated child with a HI and raised ICP?
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
In a ventilated child with a HI what are your target blood gases?
PaO2 13kPa
PaCO2 4.5-5kPa
what target CPP should there be for a ventilated child with a HI?
40-60mmHg
what are the NICE agreed indications for neurosurgical referral?
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
How would you modify your GCS to assess an infant?
