What are the Current Recommendations for Treatment of Acute Traumatic Head Injury?

Patient Presentation
A 12-year-old male was transported by ambulance to the emergency room after he was riding an all-terrain vehicle and hit a tree at an unknown speed.
He was wearing a helmet but there was significant trauma to the helmet.
He was initially agitated and somewhat conscious with a Glascow Coma Scale (GCS) of 13 but rapidly deteriorated in the emergency room to a GCS of 7.
He was sedated, paralyzed and intubated using rapid sequence intubation using atropine, lidocaine, and a defasciculating dose of vecuronium.
He was mildly hyperventilated with an arterial blood gas with pH = 7.43, pCO2 = 35, pO2 = 82, base excess = 23.
After initial stabilization, he was taken for a radiologic evaluation of his head by computed tomography which showed multiple facial fractures of the nose, sinuses, orbits and left temporal bone.
He also had a large frontal lobe contusion with associated edema.
In the pediatric intensive care unit, he was given mannitol and Dilantin.
The pertinent physical exam in the intensive care setting showed an intubated male with temperature = 36.6, heart rate = 115, respiratory rate =18 (with the ventilator), blood pressure = 109/69, and estimated weight = 45 kilograms.
He had a cervical spine collar in place along with peripheral IVs.
HEENT showed edema of entire face, with blackened eyes, and pupils 3-4 mm bilaterally, symmetrical and reactive to light.
Nose had epistaxis and he was orally intubated. There was a left hemotympanum.
His mandible was stable with teeth intact.
Neck had no obvious tenderness.
Lungs had normal breath sounds and chest wall movement was symmetrical.
Abdomen was normal and he had a Foley catheter in place.
Neurologically he was moving all extremities but not purposefully.
Extremity examination demonstrated some scrapes and bruises of the upper limbs.
The diagnosis of multiple trauma with head injury and facial fractures was made.
The patient’s clinical course was that on day 2 he had improving mental status but this waxed and waned. On day 3 he had consistently improving mental status and his mannitol was stopped and he was later extubated.
On day 6 he was taken to the operating room for definitive surgery performed by ophthalmology and otolaryngology. He was discharged at day 10 to home and at 3 weeks had a normal neurological examination except for a slight left eye droop with improved over the next 6 months.
Dilantin had been discontinued at 6 weeks post-op.


Figure 52 – Axial image of a CT scan of the brain performed without intravenous contrast in bone (left) and soft tissue (right) windows shows a frontal skull fracture and an associated large frontal lobe brain contusion with pneumocephaleus and edema as well as an associated frontal subgaleal hematoma. The patient also had extensive maxillofacial fractures and a left temporal bone fracture (not pictured).

Discussion
As part of Advanced Trauma Life Support® evaluations, assessment for neurological injury is performed early and is the paramount factor in determining treatment.
The Glasgow Coma Scale can be quickly used for multiple assessments over time and is an important tool for communicating the patient’s neurological status to other healthcare providers.
The GCS was originally developed for adults but has been modified for children and infants under two years of age mainly in the verbal response category.
The score ranges from 3 to 15 with a higher score being a better neurological status. GCS fall into general categories <8 = severe head injury, 9 – 12 = moderate head injury, 13 – 15 = mild head injury.

Score	Adult GCS			Pediatric GCS

Eye Opening Response
4	Spontaneous with blinking 	Spontaneous
	at baseline
3	To verbal stimuli 		To verbal stimuli
	(e.g. commands, speech)
2	To pain				To pain
1	None				None

Verbal Response
5	Oriented			Coos, babbles
4	Confused conversation,		Irritated cry
	but able to answer questions

3	Uses inappropriate words	Cries to pain
2	Incomprehensible speech		Moans to pain
1	No response			No response

Motor Response
6	Obeys commands for movement	Normal spontaneous
					movement
5	Purposeful movement to pain	Withdraws to touch
4	Withdraws to painful stimuli	Withdraws to painful stimuli
3	Flexion posturing in response  	Flexion posturing in response
	to pain (decorticate posturing)	to pain (decorticate posturing)
2	Extension posturing in response Extension posturing in response
	to pain (decerebrate posturing)	to pain (decerebrate posturing)
1	No response			No response

Children often hit their heads and luckily most injuries are insignificant. For those that are, many children will have some degree of personality change as they are initially recovering from the injury, especially disinhibition.
Diffuse axonal injury is still very difficult to diagnose on computed tomograph scans and therefore magnetic resonance imaging is may be used to help evaluate a child who seems to have minimal injuries but is not recovering at the expected pace.

Learning Point
Acute traumatic brain injury guidelines were published in 2003 which focused on severe traumatic brain injury in children < 18 years old and were for primary and secondary injury from traumatic causes including shaken baby syndrome. They were not for drowning or hypoxic injury.

  • Airway management and oxygenation- the guidelines recommend avoidance of hypoxia and administration of supplemental oxygen initially with 100% oxygen. This could be done by bag-valve-mask ventilation (particularly in the pre-hospital setting) or intubation.
    Airway should be controlled if GCS is < 8 to avoid hypoxemia, hypercarbia and aspiration. Adequate oxygenation is necessary for cell survival.

  • Hyperventilation - prophylactic hyperventilation with pCO2 &lt; 35 mg Hg is not recommended especially in the first 24 hours as it may increase cerebral ischemia. Mild hyperventilation with pCO2 30-35 mm Hg can be considered for longer periods if the patient has intracranial hypertension that is non responsive to sedation, analgesia, neuromuscular blockade, CSF drainage and hyperosmolar therapy. Aggressive hyperventilation with pCO2 < 30 mm Hg can be used in refractory intracranial hypertension.
    The cerebral edema that accompanies severe traumatic brain injury used to peak at 3 days. With the use of hyperosmolar therapy, some clinicians report a shift in that curve toward later peak swelling periods with an approximate range of 3-7 days.

  • Blood pressure - the guidelines recommend to identify and correct hypotension as rapidly as possible. Blood pressure should be maintained in normal range for age with fluid resuscitation. Sedation, analgesia and neuromuscular blockage may be useful to maintaining blood pressure.
    Adequate blood pressure is needed to perfuse the brain (see cerebral perfusion pressure below). Large swings in blood pressure should to be avoided (high or low) if possible, as both extremes are associated with poor outcomes.

  • Cerebral perfusion pressure - is the mean arterial pressure minus the intracranial pressure. Cerebral perfusion pressure must be maintained to allow appropriate perfusion of the brain to prevent cellular death.
    Active treatment at specific threshold values for cerebral perfusion pressure has not shown improvement in outcome. The guidelines recommend keeping the cerebral perfusion pressure between 40-65 mm Hg.
    The loss of cerebral autoregulation is the critical physiological problem associated with traumatic brain injury and correlates with the severity of the injury. The goal is to maintain perfusion pressure to the healthy brain, but not exacerbate cerebral edema. Consequently, the literature recommends being very cautious about hyperventilation therapy, because at very low pCO2s brain perfusion may become critically low as the cerebral vessels vasoconstrict.

  • Cerebral spinal fluid drainage - ventricular drainage (+/- lumbar drainage) is an option in patients with refractory intracranial hypertension.
  • Hyperosmolar therapy - with hypertonic saline or mannitol can be used to lower intracranial pressure. The choice is left to practitioners. Mannitol has long-standing clinical acceptance and safety but has not been studied as much. Hypertonic saline has more studies but has not been used therapeutically as long.
  • Barbiturates - high dose barbiturates may be considered in hemodynamically stable patients with salvageable severe and refractory intracranial hypertension. Barbiturates work by suppression of metabolism and also decreasing cerebral blood flow.
  • Corticosteroids - are not recommended as they do not improve long term outcomes.
  • Anti-seizure prophylaxis - phenytoin, carbamazepine or phenobarbital should be considered as treatment to prevent early post-traumatic seizures in infants and children. From adult studies these medications do not appear to affect late post-traumatic seizures or outcome.

Questions for Further Discussion
1. How are the mechanisms of brain injury different for hypoxia cases (such as drowning) versus traumatic brain injury?
2. What is the American Academy of Pediatrics recommendations for children using all-terrain vehicles?
3. What are some of the potential long-term sequelae for traumatic brain injury survivors?
4. What are the components of Cushing's triad?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Topic

Information prescriptions for patients can be found at MedlinePlus for these topics: Head and Brain Injuries, Facial Injuries and Disorders and Child Safety
and at Pediatric Common Questions, Quick Answers for this topic: Head Injuries

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MP, Selden NR, Warden CR, Wright DW; American Association for Surgery of Trauma; Child Neurology Society; International Society for Pediatric Neurosurgery; International Trauma Anesthesia and Critical Care Society; Society of Critical Care Medicine; World Federation of Pediatric Intensive and Critical Care Societies. Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children and Adolescents.
Pediatr Crit Care Med 2003:4(3); S2-75.

Centers for Disease Control. Glascow Coma Scale.
Available from the Internet at http://www.bt.cdc.gov/masscasualties/gscale.asp (rev. 6/23/2006, cited 9/24/07).

Emergency Medical Services Program, Marin County California. ALS Treatment Guidelines Pediatric.
Available from the Internet at http://www.co.marin.ca.us/depts/HH/main/ems/documents/Policies/8310PEDTXr.pdf (rev. 1/3/2005, cited 9/24/2007).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients' is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients' health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D'Alessandro, MD
    Professor of Pediatrics, University of Iowa Children's Hospital

    A. Paige Davis, MD
    Associate, University of Iowa Children's Hospital

    Date
    November 5, 2007