HEAD INJURIES

Question 1

Approacgh to the Critically Ill Major Head Trauma

Answer 1

Monitor
Oxygen
Vitals
IV Access
Equipement (Airway)

GOALS: Prevent secondary brain insult

AIRWAY / BREATHING

Primary Goal: Prevent hypoxemia

Sp02 > 92%

ETT + Ventilation for GCS < 8

ETT Size Formula:
4 + age in years/4 for uncuffed tubes
Use 0.5 smaller size for cuffed tubes

Induction:
Ketamine 1-2 mg/kg IV

Neuromuscular Blockade:
Rocuronium 0.6-1.2 mg/kg

Consider Atropine for bradycardia: 0.02 mg / kg IV push

Succinylcholine c/i if muscular dystrophy or myopathies

Target PC02 35-45 mm Hg; end-tidal PC02 (ETC02) 30-40 mm Hg

Do NOT perform prophylactic hyperventilation

CIRCULATION

Primary Goal: Prevent Hypovolemia

20 ml/kg sodium chloride 0.9% bolus(es).

10 ml/kg pRBC for Hgb <7 g/dL

Norepinephrine (0.05-0.3 µg/kg/min)

Avoid HoTN:

0-28 days old:
(SBP) <60 mm Hg in term

1-12 months old:
SBP <70 mm Hg in infants

Children 1 - 10:
SBP > 90 + (age in years x 2) * 50th %*

Children >10: SBP > 90

DISABILITY

Primary Goal: Prevent increased ICP / Herniation

C-Spine immobilization

Head of bed elevated at 30 degrees

hypertonic sodium chloride 3% IV at 2.5-5 mL/kg over 15 min
OR
mannitol 0.5-1 g/kg IV over 20-30 min

Get stat POC Glucose, maintain normal blood glucose

Get temp: Maintain normothermia

Seizure PPX:
Levetiracetam (Keppra) 20-40 mg/kg (max 2500 mg) IV loading dose followed by total loading dose amount given in divided doses q12h for maintenance

EXPOSURE
Look for other injuries

Early neurosurgical consultation

Question 2

Traumatic Brain Injury: Classification

Answer 2

MILD: GCS 13-15
MODERATE: GCS 9 - 12
SEVERE: GCS 3-8

Question 3

History & Physical < 2

Answer 3

Ask about:

Time of incident

Area of injury

Mechanism: Fall greater than 3 ft, high impact mechanism, pedestrian / cyclist without helmet struck by vehicle, motor vehicle collision with death of passenger, rollover, patient ejection)

LOC (>/ 5 sec)

Not acting Normal

Look for:
GCS <14
AMS
Palpable Skull Fracture
Scalp hematoma (occipital, temporal, parietal)

Question 4

History & Physical >/ 2

Answer 4

Ask about:

Time of incident

Area of injury

Mechanism:
Fall greater than 5 ft, high impact mechanism, pedestrian / cyclist without helmet struck by vehicle, motor vehicle collision with death of passenger, rollover, patient ejection

LOC
Vomiting
Severe Headache

Look for:
GCS <14
AMS
Basilar Skull Fracture: racoon eyes, battle’s sign, rhinorrhea, otorrhea
Blown Pupil
FND

Question 5

Risk factors for highest morbidity and mortality

Answer 5

Hypotension
Low GCS on initial presentation
Coagulopathy
Hyperglycemia

Question 6

risk of TBI on cranial CT for children with GCS <14.

Answer 6

> 20%

Question 7

Red Flags for Abusive Head Trauma

Answer 7

Non traumatic complaint with:
Apnea
Difficulty Breathing
Vomiting
Seizures
Difficulty waking child from sleep

Question 8

Management / Disposition: Minor Head Trauma for patients who do NOT meet all very low risk PERCARN criteria

Answer 8

Observe in the ED for 2-4 h from the time of injury or perform CT imaging, depending on:

Provider experience

The number of criteria present

Worsening of symptoms in the ED

Age <3 mo

Parental preference

Question 9

Management / Disposition: moderate-severe TBI

Answer 9

PICU

Neurosurgery Consult

Question 10

Management / Disposition: mild TBI / non depressed skull fracture

Answer 10

Observation at home

Follow up with pediatrician in 24-48 hrs

Concussion management