[PS7-1C-K] Traumatic Brain Injury (TBI)
TBI is a relatively common and affects pediatric populations worldwide. The incidence varies greatly by country, with most reporting a range between 47 and 280 per 100,000 children. Mild TBI constitutes more than 80% of injuries; <10% need surgical intervention. The care of moderate-severe TBI is directed towards prevention and treatment of secondary insults such as hypoxia, hypotension, hyperthermia, raised intracranial pressure (ICP), and optimization of cerebral perfusion (CPP) using fluids and vasopressors such as norepinephrine. Monitoring of intracranial pressure, invasive arterial blood pressure (BP), metabolism, and seizures is needed. Hospitals that monitor ICP have shown better patient outcomes. Maintaining CPP >50 mm Hg in 6- to 17-year-olds and >40 mmHg in 0- to 5-year-olds and PbtO2 ≥ 10 mmHg are recommend. In suspected raised ICP in absence of ICP monitoring, mean arterial BP should be maintained at levels normal-for-age and systolic BP >75th percentile.
Recommended for treatment of raised ICP exceeding 20–25 mmHg is 3% saline as bolus and continuous infusion. Barbiturate therapy is recommended when maximal medical and surgical therapy has failed to control ICP. Decompressive craniectomy is an effective rescue intervention in patients with sustained ICP greater than 20 mmHg; it is associated with lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability. Early therapeutic hypothermia in severe TBI did not improve outcome; it may increase mortality. Hyperventilation may reduce cerebral blood flow (CBF) and may result in poor long-term outcomes. Corticosteroid administration is not associated with improved outcome and is not recommended. Prophylactic administration of phenytoin may reduce the incidence of posttraumatic seizures. There is insufficient evidence to recommend tight glycemic control despite pediatric studies suggesting that posttraumatic hyperglycemia is associated with poor outcome after severe TBI. Ongoing research suggests that several biomarkers may be useful in predicting the outcome. Research is also examining several pharmacologic neuroprotective agents such as glutamate antagonists, calcium channels blockers, scavenging oxygen radicals, flavenoids that may prevent secondary brain injury.
Recommended for treatment of raised ICP exceeding 20–25 mmHg is 3% saline as bolus and continuous infusion. Barbiturate therapy is recommended when maximal medical and surgical therapy has failed to control ICP. Decompressive craniectomy is an effective rescue intervention in patients with sustained ICP greater than 20 mmHg; it is associated with lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability. Early therapeutic hypothermia in severe TBI did not improve outcome; it may increase mortality. Hyperventilation may reduce cerebral blood flow (CBF) and may result in poor long-term outcomes. Corticosteroid administration is not associated with improved outcome and is not recommended. Prophylactic administration of phenytoin may reduce the incidence of posttraumatic seizures. There is insufficient evidence to recommend tight glycemic control despite pediatric studies suggesting that posttraumatic hyperglycemia is associated with poor outcome after severe TBI. Ongoing research suggests that several biomarkers may be useful in predicting the outcome. Research is also examining several pharmacologic neuroprotective agents such as glutamate antagonists, calcium channels blockers, scavenging oxygen radicals, flavenoids that may prevent secondary brain injury.