PediaNotes

Approach to a Child with Traumatic Brain Injury (TBI)

4 min read

Alogrithm


graph TD

classDef start fill:#1b5e20,color:#ffffff,stroke:#66bb6a;
classDef step fill:#0d47a1,color:#ffffff,stroke:#42a5f5;
classDef decision fill:#4a148c,color:#ffffff,stroke:#ab47bc;
classDef alert fill:#b71c1c,color:#ffffff,stroke:#ef5350;

A(<b>Pediatric TBI Protocol</b><br>Initial Assessment):::start
B1[<b>Airway Management</b><br>Check GCS and reflexes]:::step
B2[<b>Breathing and Circulation</b><br>Normoventilation Isotonic Fluids]:::step
B3[<b>Neuro Assessment</b><br>NCCT Head and ICP Monitor]:::step
B4[<b>AVOID</b><br>Steroids Hypotonics]:::alert

A --> B1
A --> B2
A --> B3
A --> B4

C1{<b>GCS 8 or less</b>}:::decision
B1 --> C1
C1 -->|Yes| D1[<b>Intubate</b><br>Cerebroprotective meds]:::step
C1 -->|No| D2[<b>Maintain Airway</b><br>Strict C-Spine Control]:::step

C2{<b>Raised ICP Status</b>}:::decision
B3 --> C2

T0[<b>General Measures</b><br>Head 30 deg Sedation AEDs]:::step
T1[<b>Tier 1 Osmotherapy</b><br>Hypertonic Saline or Mannitol]:::step
T2[<b>Tier 2 Therapies</b><br>Barbiturate Coma]:::step
T3[<b>Tier 3 Surgical</b><br>Decompressive Craniectomy]:::step

C2 -->|Baseline| T0
C2 -->|Tier 1| T1
C2 -->|Tier 2| T2
C2 -->|Tier 3| T3

Initial Assessment And Stabilization

  • Immediate priority demands rapid assessment and stabilization of airway, breathing, and circulation.
  • Primary goal involves preventing secondary brain injury from hypoxia and ischemia.

Airway Management

  • Secure airway while strictly maintaining cervical spine stabilization.
  • Implement cerebroprotective drug-assisted intubation to prevent reflex spike in intracranial pressure.
  • Administer premedications including intravenous lidocaine, thiopental, and short-acting non-depolarizing neuromuscular blocking agents.

Indications For Endotracheal Intubation

  • Glasgow coma scale score of 8 or less.
  • Rapidly declining Glasgow coma scale with drop of 3 or more.
  • Absent protective airway reflexes.
  • Apnea.
  • Signs of impending brain herniation.

Breathing And Ventilation

  • Administer supplemental oxygen immediately to treat or prevent hypoxia.
  • Target oxygen saturation greater than 92% and PaO2 between 80-120 mmHg.
  • Maintain strict normoventilation targeting PaCO2 between 35-40 mmHg.
  • Avoid prophylactic hyperventilation.
  • Reserve hyperventilation strictly as temporary rescue measure for acute signs of impending herniation.

Circulation And Hemodynamics

  • Maintain euvolemia and normal mean arterial pressure to ensure adequate cerebral perfusion pressure.
  • Utilize isotonic crystalloids such as 0.9% normal saline as fluid of choice.
  • Administer fluid boluses of 20 ml/kg normal saline for circulatory failure or hypotension.
  • Initiate vasopressors if required to target mean arterial pressure greater than 50th percentile for age.

Neurological Evaluation And Monitoring

Clinical Examination

  • Perform thorough neurological examination to establish baseline and detect focal deficits.
  • Quantify coma depth objectively utilizing modified Glasgow coma scale.
  • Assess pupillary size, symmetry, and reactivity to light as critical surrogate markers for brainstem function.
  • Identify unilateral fixed and dilated pupil as sign of impending uncal herniation.

Hemodynamic Targets And Monitoring

  • Calculate cerebral perfusion pressure as mean arterial pressure minus intracranial pressure.
  • Target minimal acceptable cerebral perfusion pressure greater than 40-50 mmHg for infants and toddlers.
  • Target minimal acceptable cerebral perfusion pressure greater than 50-60 mmHg for older children.

Invasive Intracranial Pressure Monitoring Indications

  • Severe traumatic brain injury with Glasgow coma scale 3-8 after resuscitation plus abnormal admission head CT.
  • Severe traumatic brain injury with normal CT accompanied by motor posturing or hypotension.

Neuroimaging

  • Perform non-contrast computed tomography of head as primary rapid imaging modality.
  • Identify surgically correctable lesions in emergency setting.
  • Evaluate for epidural or subdural hematomas and intraparenchymal hemorrhage.
  • Assess for midline shift, effacement of basilar cisterns, and loss of grey-white matter differentiation indicative of diffuse cerebral edema.

Stepwise Management Of Raised Intracranial Pressure

  • Escalate medical management through specific therapeutic tiers based on clinical response and intracranial pressure monitoring.
Therapeutic TierInterventions And Clinical Targets
General MeasuresMaintain head in midline position with 30° elevation to facilitate venous drainage. Ensure cervical collar avoids obstructing venous return.
Metabolic ControlMaintain normothermia below 38°C. Treat fever aggressively with antipyretics. Maintain strict blood glucose between 80-120 mg/dL to prevent hyper- and hypoglycemic brain injury.
Sedation And AnalgesiaAdminister adequate sedation and analgesia to blunt noxious stimuli. Utilize endotracheal lidocaine prior to suctioning.
Seizure ProphylaxisAdminister prophylactic phenytoin or levetiracetam for 7 days. Indicated in severe traumatic brain injury, parenchymal injury, or depressed skull fractures.
Tier 1 OsmotherapyHypertonic Saline (3% NaCl): Preferred agent, particularly in hypovolemia. Administer 5 ml/kg bolus over 30 mins, followed by 0.5-1.5 ml/kg/hr infusion. Target serum sodium 155-160 mEq/L.
Mannitol (20%): Administer 0.5-1 g/kg bolus every 4-6 hours. Avoid continuous infusions. Contraindicated in hypotension or serum osmolality greater than 320 mOsm/kg.
Tier 2 TherapiesModerate Hyperventilation: Target PaCO2 28-34 mmHg. Reserve strictly for acute impending herniation or acute neurological deterioration.
Barbiturate Coma: Initiate thiopentone or pentobarbital infusion titrated to achieve burst suppression on EEG. Requires invasive hemodynamic monitoring due to profound myocardial depression.
Tier 3 SurgicalDecompressive Craniectomy: Indicated for medically refractory intracranial hypertension with diffuse swelling on CT, or for evacuation of mass lesions.

Therapies Strictly Contraindicated

  • Avoid corticosteroids completely.
  • Corticosteroids proven to worsen outcomes with no benefit for traumatic cytotoxic edema.
  • Avoid hypotonic fluids strictly.
  • Fluids such as 5% dextrose or 0.45% saline increase free water clearance into brain, exacerbating cerebral edema.
  • Avoid routine prophylactic hyperventilation.
  • Decreasing PaCO2 routinely without signs of herniation induces severe cerebral vasoconstriction, causing secondary ischemic infarction.

Backlinks

Graph View