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APLS > The Child With Traumatic Brain Injury > Flashcards

The Child With Traumatic Brain Injury Flashcards

1
Q

Head injury is the most common cause of death from trauma in which age group?

A

1-15 years old

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2
Q

What are the most common causes of HI in children?

A

CAUSES OF HI

  1. RTA (most common in children)
    • pedestrians (most vulnerable) –>
    • cyclists – >
    • car passengers
  2. Falls (2nd most common in children)
  3. Child abuse (most common in infants)
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3
Q

Describe the pathophysiology of traumatic brain injury.

A

TRAUMATIC BRAIN INJURY

PATHOPHYSIOLOGY

  • PRIMARY DAMAGE
  • SECONDARY DAMAGE

PRIMARY DAMAGE

  • = damage as a direct consequence of impact
  • Disruption + often irreversible cell damage of
    • Neural tissue
      • neurones– focal cerebral contusions and lacerations (direct impact and contrecoup)
      • axonal sheaths – diffuse axonal injury (shearing injury)
    • Intracranial blood vessels
      • Haematoma - require surgical Rx
        • extradural ( esp. middle meningeal artery)
        • subdural (esp dural bridging veins)
        • intracerebral
      • Haemorrhage - subarachnoid

SECONDARY DAMAGE

  • = damage to CNS from 2ndary insults
  • can occur mins/ hrs/ days after initial injury
  • HI management aims to prevent/ reduce this
  • Insults:
    • HYPO-G/ HYPER-G
    • HYPOXIA
      • ​airway obstruction
      • inadequate respiration (loss of drive or mechanical disruption - chest wall or diaphragm)
      • shunt from pulmonary contusion
      • resp failure
    • SEIZURES
    • FEVER
    • INFECTION
      • ​open skull fractures
      • breach in the skull (vault/ base) or dural membrane
      • brain tissue comes into contact with external env.
    • ISCHAEMIA due to
      • HYPOTENSION (+/- ANAEMIA) e.g.
        • ​haemorrhage with hypovolaemia + dilutional anaemia
        • spinal cord injury
        • drug induced vasodilation
        • sepsis
      • RAISED ICP - ​Causes poor cerebral perfusion e.g.
        • expanding intracranial haematoma (made worse by coagulopathy)
        • cerebral oedema/ swelling = most common cause following HI
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4
Q

Describe the pathophysiology of raised ICP.

A
  • Young children = cranial sutures not yet closed
  • Sutures close at 12-18 months of age
  • Cranial cavity becomes fixed volume

PATHOPHYSIOLOGY OF RAISED ICP

  • Brain tissue swelling/ expanding Haematoma/ CSF blockage
  • Intracranial volume expansion
  • Young children/ SLOW –> HYDROCEPHALUS
  • Older Children (fixed cranium) / FAST
    • –> raised ICP
    • –> compensating mechanism - reduces volume of CSF + venous blood in the cranium
    • –> fails
    • –> ICP continues to rise
    • –> CPP falls (CPP = MAP - mean ICP)
    • –> CBF (cerebral blood flow falls)
  • CBF should be = 50 ml/ 100g brain tissue/ min
  • CBF < 20 ml/ 100 g brain tissue/ min
    • –> brain ischaemia
    • –> cerebral oedema increases
    • –> ICP increases more
    • –> CBF < 10 ml/ 100 g brain tissue/ min
    • –> electrical dysfunction of neurones + loss of intracellular homeostasis
  • Rise in ICP in the supratentorial compartment
    • –> Brain tissue pushed against more rigid intracranial structures
    • –> UNCAL (transtentorial) herniation
    • if unilateral pressure e.g. haematoma (subdural/ extradural) –> focal neuro signs e.g.
      • –> PUPIL = ipsilateral dilated (3rd nerve compression - nipped against the free border of the tentorium, loss of parasympathetic constrictor tone to ciliary muscles of eye on the same side)
      • –> EYE MOVEMENT = cannot move laterally (external oculomotor palsy)
      • –> BODY = hemiplegia
    • –> CENTRAL (transforaminal) herniation = central syndrome/ CONING
    • –> whole brain pressed down
    • –> cerebellar tonsils herniate through foramen magnum
      • –> TACHYCARDIA (initially)
      • –> BRADYCARDIA + high BP
      • –> IRREGULAR BREATHING
      • –> APNOEA
      • –> DEATH
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5
Q

How does the differing anatomy of infants affect their presentation with HI?

A

INFANTS WITH HI

  • unfused sutures (< 12- 18 months)
    • cranial volume can expand initially (not fixed)
    • large extradural/ subdural bleeds may occur BEFORE neurological signs/ Sx
  • Infants’ scalp very vascular => bleeds profusely
  • May present with
    • v. low Hb
    • SHOCK
  • Less likely in children > 1 year - if presenting w/ shock, seek extracranial injury
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6
Q

What factors indicate a potentially serious HI?

A

FACTORS INDICATING POTENTIALLY SERIOUS HI

  • History
    • substantial trauma e.g. RTA, fall from height
    • LOC
  • Examination
    • not fully conscious/ responsive
    • neuro signs & symptoms e.g.
      • headache
      • limb weakness
      • convulsions
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7
Q

Describe the primary survey and resuscitation of children with traumatic brain injury.

A

PRIMARY SURVEY + RESUSCITATION

TRAUMATIC BRAIN INJURY

  • <<c>> ABCDEFG
    <ul>
    <li>control of the above prevetns 2ndary cerebral damage from hypoxia/ shock </li>
    </ul></c>
  • Teams/ Referral
    • Low threshold for calling trauma team
    • Consider need to:
      • refer to neurosurgeons
      • transfer to neurosurgical centre (within first hour of attendance)
  • B
    • Indications for immediate I+V = GEE, VENTILATION CAN REALLY HELP!!!
      • Gag reflexes - loss of protective laryngeal
      • Ventilatory insufficiency (on blood gas)
        • Hypoxaemia - PaO2
          • < 9 on air
          • < 13 with added O2
        • Hypercarbia - PaCO2 > 6
      • Coma - GCS < 8
        • E: not eye opening
        • M: not obeying commands
        • V: not speaking
      • Respiratory irregularity
      • Hyperventilation (spontaneous)
        • –> PaCO2 < 3.5
    • Other indications = BREATHING CAN STILL FAIL
      • B​leeding (into mouth, copious)
      • Conscious level deteriorating sig.
      • Seizure
      • Facial fractures - unstable
  • D
    • stabilise C-spine
    • Pupil reactivity
    • AVPU
    • +/- GCS (not in time critical situations)
      • but note type of reaction to pain AND
      • EMV responses
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8
Q

Describe the secondary survey of children with traumatic brain injury.

A

SECONDARY SURVEY

TRAUMATIC BRAIN INJURY

  • History (from LAS, bystanders, carers) - AMPLE
    • Allergies
    • Medication
    • PMH
    • Last meal
    • Environment and events - mechanism of injury
  • Examination
    • GCS
      • Modified scale for < 4 years
      • standard scale 4-15 yo
      • snapshot of degree of brain dysfunction
      • repeat frequently - every 5 mins if fluctuating
      • Verbal
        • d/w carers re: best usual response
        • if pre-verbal or intubated then best GRIMACE RESPONSE
          • 5 = spontaneous normal facial/ oromotor activity
          • 4 = less than usual spontaneous ability / only response to TOUCH stimuli
          • 3 = VIGOROUS grimace to PAIN
          • 2 = MILD grimace to PAIN
          • 1 = NO RESPONSE to PAIN
    • HEAD
      • LOOK
        • bruises
        • lacerations
        • BASAL SKULL FRACTURE
          1. Blood/ CSF from nose/ ear
          2. Haemotympanum
          3. Panda Eyes
          4. Battle’s sign (bruising behind ear over mastoid process)
      • FEEL
        • depressed skull fracture
    • PUPILS
      • size & reactivity
      • dilated non-reactive pupil = 3rd nerve palsy due to IPSILATERAL INTRACRANIAL HAEMATOMA - until proven otherwise
    • FUNDI - opthlamoscopy
      • retinal haemorrhage = NAI
      • papilloedema - NB NOT seen in acute raised ICP
    • MOTOR FUNCTION = LEFT
      • Limbs
      • Eye movements (extraocular muscles)
      • Facial movements
      • Tone / power / reflexes - ? focal/ lateralising signs
  • Ix
    • Bloods - B, C, C, G, G
      • Baseline - FBC, U+E, LFTs
      • Clotting
      • Cross match
      • GLUCOSE
      • GAS (careful control of PaCO2 and PaO2 + monitor ETCO2)
    • Imaging
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9
Q

Describe the GCS and Children’s GCS.

A

not the DMV - the EMV!

(Eyes/ Motor/ Verbal – 4/6/5)

Lowest score in any is 1.

GCS (4-15 YEARS) & [[Children’s (<4 yo)]]

  • E
    • 4 - eyes open spontaneously
    • 3 - to speech
    • 2 - to pain
    • 1 - no response
  • M
    • 6 - obeys commands [/spontaneous]
    • 5 - localises to PAIN [/withdraws to TOUCH]
    • 4 - withdraws from PAIN
    • 3 - Abnormal FLEXION to PAIN (decOrticate) – F before E,
    • 2 - abnormal EXTENSION to PAIN (decErebrate) Extension is DecErebrate
    • 1 - no response (to pain)
  • V
    • 5 - ORIENTED & converses [ABC - Alert/ Babbles/ Coos as normal)
    • 4 - DISORIENTED & converses [< usual words, irritable CRY)
    • 3 - Inaprropriate WORDS [CRIES only to pain]
    • 2 - Incomprehensible SOUNDS [MOANS to pain]
    • 1 - No response (to pain)
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10
Q

Name the indications in suspected traumatic brain injury for performing an emergency head CT scan within 1 hour.

A

INDICATIONS

CHILDREN WITH HI

EMERGENCY HEAD CT WITHIN 1 HOUR OF IDENTIFYING THE RISK FACTOR

  • Any ONE of these: NATASHA FELL FROM NEW GREEN SWING
    • NAI suspected
    • > FIVE cm bruise/ swelling/ laceration on head if < 1yo
    • Fracture/ Fontanelle
      • Fracture- open skull/ base of skull suspected
      • Fontanelle tense
    • Neurological deficit - focal
    • GCS
      • < 14 on initial assessment (or < 15 if < 1yo)
      • < 15 - 2 hrs post injury
    • Seizures - post traumatic, but no h/o epilepsy
  • MORE THAN 1 of these: ACCIDENTS MAKE DEATH VERY LIKELY
    • Amnesia - antegrade or retrograde, lasting > 5 mins
    • Mechanism of injury - dangerous
    • Drowsiness - abnormal
    • Vomiting - 3 or more discrete episodes
    • LOC lasting > 5 mins
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11
Q

Describe the emergency management of traumatic brain injury.

A

TRAUMATIC BRAIN INJURY

EMERGENCY Mx

Aims

  • prevent secondary brain damage by maintaining
    • oxygenation
    • ventilation
    • circulation
  • avoid rises in ICP using neuro-protective measures

<<c>>ABCDEFG</c>

  • A
    • secure airway
  • B
    • GCS < 8 + agitative / combative –> I+V ASAP
    • Induction agents = ketamine + rocuronium
      • neuro-protection
      • less risk of sudden hypotension
    • Capnography (ETCO2)
      • confirms ETT placement
      • disconnection monitor
      • guide to maintain normocapnia/ mild hypocapnia if raised ICP
      • NB – NOT THE SAME AS PaO2 on gas, esp if shocked
    • Aim
      • O2 sats > 98%
      • PaO2 > 13
      • PCO2 4 - 4.5 (in raised ICP)
        • NB lower - risks adverse effects on cerebral perfusion in areas of the brain still responsive to changes in PCO2
  • C
    • Rx hypotension vigorously
    • avoid hypoperfusion of the brain (maintain adequate CPP)
    • Fluids / blood products
    • inotropic support
    • Tranexamic acid to prevent progressive intracranial haemorrhage (some evidence)
    • AIM SBP > 95th centile for age
      • <1 year: >80
      • 1-5 years: >90
      • 5-14 years: >100
      • > 14 years: >110
  • D:
    • NEURO-PROTECTIVE MEASURES - to avoid further increase in ICP
      • Positioning
        • 30 degree elevation of head of bed
        • head and neck in midline position
      • Medication
        • 3% hypertonic saline 3ml/kg (aim Na >135)
        • 20% mannitol 0.25 - 0.5 g/ kg
        • Consider loading dose phenytoin to avoid risk of convulsions
      • Transfer to neurosurgical unit
    • ANALGESIA
      • witholding will cause a rise in ICP and further deterioration + makes child agitated and uncooperative
      • Medication
        • Opioids e.g. morphine, fentanyl
        • Femoral nerve block
      • Opioids Beware:
        • head injured children more sensitive
        • reduced conscious level
        • resp depression
      • Careful titration of IV morphine
        • Normal GCS
          • 100 - 200 mcg / kg
          • < 1 year = 80 mcg/ kg
          • administer in increments
        • Obtunded/ GCS < 8
          • I+V 1st
        • Intermediate
          • Use half standard dose
        • NB can be reversed with IV naloxone
  • E
    • maintain normothermia
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12
Q

Describe the emergency management of deteriorating conscious level in the head injured child.

A

DETERIORATING CONSCIOUS LEVEL

EMERGENCY Mx

  • ABCDEFG
  • If
    • ABC stable
    • No hypoglycaemia
    • –> Assume due to raised ICP e.g. intracranial haematoma, cerebral oedema
  1. CT scan
  2. Urgent neurosurgical referral
  3. TEMPORISING MANOEUVRES - measures to temporarily increase cerebral perfusion = HIV 30
    • Hypotension - avoid: fluids/ blood prodcucts/ inotropes
    • Infusion: 3% saline or 20% mannitol
    • Ventilation - aim PaCO2 4 - 4.5
    • 30 degrees head up position + head in midline (improves venous drainage)
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13
Q

Describe the emergency management of sign of uncal or central herniation in the head injured child.

A

SIGNS OF UNCAL OR CENTRAL HERNIATION

EMERGENCY Mx

  • TEMPORISING MANOEUVRES - measures to temporarily increase cerebral perfusion = HIV 30
    • Hypotension - avoid: fluids/ blood prodcucts/ inotropes
    • Infusion: 3% saline or 20% mannitol
    • Ventilation - aim PaCO2 4 - 4.5
    • 30 degrees head up position + head in midline (improves venous drainage)
  • Refer to neurosurgeons
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14
Q

Describe the emergency management of convulsions in traumatic brain injury.

A

CONVULSIONS IN TRAUMATIC BRAIN INJURY

EMERGENCY Mx

  • FOCAL seizure = concerning
  • GENERALISED seizure - less prognostic significance
  • Physiological effects of seizure in both paralysed and non-paralysed pts:
    • raised ICP
    • acidosis
    • increased cerebral metabolic demand
  • Presentation
    • harder to detect if paralysed as no limb or facial movement
    • Consider if:
      • sharp rise in HR/ BP
      • dilated pupils
  • Mx
    • exclude HypoG - esp small children, adolescents drinking alcohol
    • PHENYTOIN IV 20 mg/ kg over 20 mins
    • monitor for dysrhythmias and hypotension
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15
Q

Name the indications for neurosurgical referral.

A

INDICATIONS FOR NEUROSURGICAL REFERRAL

TRAUMATIC BRAIN INJURY

Please Call Good Neurosurgeons Soon - C! C! (si si)

  • Penetrating injury - definite or suspected
  • Confusion - unexplained, lasting > 4 hrs
  • GCS < 8 - persisting coma after initial resus
  • Neurological signs - focal
  • Seizure without full recovery
  • CSF leak
  • Conscious level deteriorating (esp motor response changes)

Consider discussion:

  • depressed or basal skull fracture
  • initial GCS 8-12
  • all children with new, surgically significant abnormalities on imaging
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16
Q

Discuss the detailed review and continuing stabilisation of children with traumatic brain injury.

A

DETAILED REVIEW AND CONTINUING STABILISATION

TRAUMATIC BRAIN INJURY

  • Review <<c>> ABCDEFG
    <ul>
    <li>anatomical injuries - easy to miss if altered GCS, consider mechanism of injury </li>
    <li>physiological system control - essential to prevent secondary brain damage </li>
    <li>investigations incl. radiology</li>
    </ul></c>
  • A + B
    • check position of ETT
    • adjust and secure
    • re- check ABG
    • ventilator settings review
  • C
    • SBP > 95th centile for age
    • to ensure adequate CPP
    • prevent hypotension from sedation and paralysis
    • ensure morphine + midazolam infusion running (immediately after intubation)
    • bleeding controlled, volume restored
  • D
    • analgesia (morphine)
    • re-check GCS
  • E
    • Normal or slightly reduced temp
  • G
    • normoglycaemia
17
Q

Give examples of neurological deterioration which would prompt urgent reappraisal in the head injured child.

A

NEUROLOGICAL DETERIORATION

URGENT REAPPRAISAL

GEORGE HAS VERY BAD NEUROLOGY

  • GCS
    • sustained drop ( > 30 mins) of 1 point esp. in motor score
    • any drop of 2 points
  • Headache - severe or increasing
  • Vomiting - “
  • Behaviour - agitated or abnormal
  • Neurological signs - New

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