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Severe Pediatric Head Injury – tips and tricks

Severe Pediatric Head Injury – tips and tricks. Jonathan Duff MD Division of Pediatric Critical Care University of Alberta. Conflicts of Interest. Nothing to declare. “…children exhibit almost limitless creativity with regard to sustaining injury”. Kids aren’t little adults.

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Severe Pediatric Head Injury – tips and tricks

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  1. Severe Pediatric Head Injury – tips and tricks Jonathan Duff MD Division of Pediatric Critical Care University of Alberta

  2. Conflicts of Interest • Nothing to declare

  3. “…children exhibit almost limitless creativity with regard to sustaining injury”

  4. Kids aren’t little adults • Immature/pliable skull • Weak neck musculature • Large head:body ratio

  5. A four-year-old boy is involved in a MVC – car is T-boned at high speeds • On arrival of medics, child is found restrained in the car. Unresponsive, moaning and with stiffening movements • What’s his GCS? And why do we care?

  6. Severe TBI: GCS < 9 • Standard GCS for verbal patients • Non-verbal patients • 4 Coos/babbles • 3 Irritable/cries • 2 Cries to pain • 1 Moans to pain

  7. Motor testing • Most important prognostic factor – get a history!! • Assessment is key

  8. Arrival to ED • Child arrives in full spinal precautions • HR: 143; BP 74/33; Sats 99% on 15lpm; RR 8

  9. Prevention of secondary injury is the key • Hypoxia, hypotension, hypercarbia, hyperthermia

  10. Cerebral Autoregulation PaCO2 CPP Cerebral Blood Flow PaO2 50 180 Pressure (mmHg)

  11. Mono-Kellie Doctrine

  12. Intubation Considerations • C-spine precautions • Medications: • Usual recommendation: • Propofol vs. fentanyl/midazolam • Etomidate? • Ketamine?

  13. Intubation Considerations • How fast do we bag? • The role of hyperventilation pCO2 45 pCO230

  14. Back to the case • Child has been intubated and fluid resuscitated • Taken to CT scanner – reported as normal

  15. Management of high ICP • Remember – avoid secondary injury • CPP = MAP – ICP • Target CPP > 40 – 50 mmHg • Adult > 65-70 mmHg • Minimize cerebral metabolism

  16. 5 ways to decrease ICP • Increase venous drainage • Decrease cerebral metabolism • Hyperosmolar therapy • CSF drainage • Decompression

  17. 5 ways to decrease ICP • Increase venous drainage • Elevate the head of the bed (if you can) • Watch for a tight cervical collar

  18. 5 ways to decrease ICP • Decrease cerebral metabolism • Need to decrease cerebral oxygen requirements • Hypothermia • Seizure control

  19. 5 ways to decrease ICP • Hyperosmolar therapy • Mannitol • 3% Saline

  20. 5 ways to decrease ICP • CSF drainage • External ventricular drain • Allows measurement of ICP and treatment

  21. 5 ways to decrease ICP • Decompression

  22. Summary • Traumatic brain injury is an important cause of pediatric morbidity and mortality • If you can’t prevent it, the key is to prevent secondary injury

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