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Severe traumatic brain injury TBI in children - Coggle Diagram
Severe traumatic brain injury TBI in children
UpToDate 2022 july
severity of TBI
mild: GCS 13-15
moderate: GCS 9-12
severe: GCS <9
types of injury
diffuse brain insury DBI
most common
impact, acceleration, decelartion forces
diffuse traumatic axonal injury DAI: severe form of DBI
(concussion is milder form of DBI - no structural changes on imaging)
focal brain injury
brain contusion: coup, contrecoup
intraparenchymal brain hemorrhage
subdural hematoma
between dura and arachnoid membranes
source: bridging blood vessels/cerebral cortical haemorrhage
common in severe TBI, abusive head trauma
epidural=extradural hematoma
between dura and calvarion
source: middle meningeal artery/middle meningeal vein/diploic veins/venous sinuses
subarachnoid hemorrhage
may be isolated
source: small vessels in the pia mater
associated injuries
multiple trauma 2/3
cervical spine injury CSI: must be always suspected! 1-2%
pathophysiology
primary injury: direct trauma
secondary injury
cerebral odema peaks 24-72 h
cerebral ischemia
primary survey
Advenced Trauma Life Support - rapid stabilization
emergency involvement of a neurosurgeon
cervical spine motion restriction should be maintained throughout the primary survey
initial evaluation
head CT
abnormality on the head
GCS</=12
signs of transtentorial herniation
hypertension with bradycardia/tachycardia
unequal/fixed and dilated pupils
abnormal breathing pattern (Cheyne-Stokes)
hemiparesis
decorticate, decerebrate or absent motor response to pain
RSI endotracheal intubation
GCS<9 or rapidly deteorating
pretreatment atropine
shock
<1 year
<5 year + succinylcholine
older children 2nd dose of succinylcholine
induction:
etomidate
, propofol, ketamine
paralytic agent: succinylcholine; rocuronium - antidote sugammadex
ventilation: end-tidal CO2: 35-40 Hgmm unless signs of pending herniation
circulation
fluid management
hypotonic solution D5W should be avoided
goal blood pressure: 75-90 th percentile for age, height and sex, (at least 5 th percentile)
cerebral perfusion pressure CPP
CPP=MABP-ICP
<5y: 40-50 Hgmm
5y-17y: 50-60 Hgmm
temperature management
secondary survey
head to toe assessment
history
focused neurological examinatiojn
level of conscioussness
pupillary examination
extraocular movements
fundoscopy
brainstem reflexes
deep tendon reflexes
response to pain
signs of herniation
uncal herniation: 3rd cranial nerve palsy, followed immediately by hemiplegia
progressive changes in respiratory pattern, pupil sizre, vestibuloocular reflexes, posture
Cushing's triad: hypertension, bradycardia, slow irregular respiration
abusive head trauma: retinal hemorrhages, fractures, unexplained bruises, apnea, seizures
lab: glucose, type and cross, blood gases, hemoglobin, hematocrit, CBC, electrolytes, serum osmolarity - mannitol, AST, ALT - intraabdominal injury, urinalysis - hematuria, PT, PTT, INR
imaging
spine: plain radiographs/CT/MRI
unenchanced CT, MRI
abdominal, pelvis CT
neurosurgical intervention: epidural, subdural hematomas - midline shift, penetrating brain injury
cardiopulmonar: avoid hypoxemia, normal ventilation, euvolemia, temperature, nutrition, normoglycaemia
intracranial hypertension management
sedation and analgesia
pediatric traume center: GCS<9, GCS<12+major injuries, deterioration