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Resources for Management of Severe Pediatric Traumatic Brain Injury

Resources for Management of Severe Pediatric Traumatic Brain Injury - Clinical Hub, References, Emergency Department Resources, Emergency Department Pediatric Resources


Initial Stabilization and Transport

  1. After initial referral call from outside ED for pediatric patient with severe TBI:
    1. Access center coordinates conference call between the UW Attending Pediatric Trauma Surgeon, Neurosurgeon, Intensivist, and ED physician
    2. Return-call made to referring MD with recommendations for initial management. Initial efforts should focus on ensuring adequate perfusion, oxygenation, ventilation:
      • Continuously monitor oxygen saturation and provide 100% O2 throughout initial stabilization and transport.
      • Secure airway if:
        • GCS ≤ 8
        • Apnea, hypoventilation, or PaCO2 >45
        • Cyanosis, PaO2 < 65 mmHg, or O2 sat < 92%.
      • In intubated patients:
        • Continuously monitor ETCO2.
        • Titrate ventilatory rate to maintain ETCO2 33-35.
      • Hypotension should be identified and corrected rapidly with NS fluid resuscitation.
        • Target SBP ≥ 25th percentile for age
        • Maintenance fluids should be D5NS.
      • Suspected intracranial hypertension:
        • Mannitol 0.5 g/kg
        • Avoid hyperventilation unless active herniation syndrome is suspected
  2. On arrival to UW ED:
    1. Immediate neurosurgical evaluation
    2. Expedited transfer to PICU or OR after evaluation in ED (straight to PICU/OR from CT)
    3. ICP monitor or EVD placement if GCS ≤ 8
    4. In a patient intubated at scene:
      • Consider use of low dose propofol infusion in patient that is combative or not cooperating with mechanical ventilation in order to perform initial evaluation/imaging.
      • To assess GCS / need for EVD, may consider brief observation period off sedation if no significant intracranial injury on CT.

Management for severe TBI (GCS ≤ 8) 

  1. Standard Management
    1. Institute a daily goals sheet
    2. Head of bed at 30 degrees
    3. Maintain adequate sedation by titration of midazolam and fentanyl infusions
    4. Minimize stimulation
    5. Maintain PaCO2 38-40 mmHg and ETCO2 33-35
    6. Respiratory Therapy Ventilator Associated Pneumonia (VAP) prevention bundle
    7. Maintain normothermia:
      • Scheduled Tylenol
      • If T > 38.0 start cooling blanket set to 37.0
    8. Avoid hyponatremia - goal serum NA 145-150.
      • Titrate NS and hypertonic saline
  2. Management of Intracranial Hypertension (ICP ≥ 20)
    • See Flow Chart
    • ICP monitoring in patients with GCS ≤ 8
    • Consider EVD if ICP ≥ 20
  3. Hemodynamic Guidelines
    • See Flow Chart
    • Initial resuscitation to SBP ≥ 25th percentile for age
    • Maintain age-based MAP and CPP targets
  4. Seizure Prophylaxis (Based on age and injury severity)
    1. Neurology consult
    2. Age < 24 months with moderate or severe TBI (GCS ≤12)
      • Keppra load: 30mg/kg over 15 minutes, then 15mg/kg q12h x 7days
      • EEG monitoring: continuous EEG x 72hrs
    3. Age > 24 months with severe TBI (GCS ≤ 8)
      • Keppra load: 30mg/kg over 15 minutes, then 15mg/kg q12h x 7days
      • EEG monitoring: consider continuous EEG if requires neuromuscular blockade or for clinical suspicion of seizure.
    4. EEG will be reviewed twice daily by attending pediatric neurologist, and as needed by on-call neurologist for concern of subclinical seizures.
  5. Glycemic control and Nutrition:
    1. Feeding
      • Nutrition consult on admission
      • Start TPN within 24-48 hrs.
      • Transition to enteral feeds when no longer requires active titration of hyperosmolar therapy or vasopressors.
      • Calories to meet 1.2 REE with full protein
    2. Maintain blood glucose 140-180
      • For blood sugar persistently > 180, start insulin infusion 0.03 u/kg/h and titrate, monitoring blood glucose hourly.
  6. Multidisciplinary Team
    • On admission: consult PT/OT/Rehab, Palliative Care, and Health Psychology
    • Begin active physical therapy when tapering ICP management
    • Swallow Study when extubated prior to initiating PO feeds.

Subacute Management

  1. Taper of ICP management therapies
    1. When ICP/CPP stable x 24-48 hours
      • Discontinue neuromuscular blockade over 24 hrs.
      • Titrate down on hypertonic saline over 24 hrs to goal Na 145-150.
      • Wean sedation and assess for extubation readiness
      • Discontinue ICP monitoring after extubation
    2. Assess for extubation readiness by post-injury day 10 and consider tracheostomy and G-Tube GCS ≤ 8 or inadequate airway reflexes.
    3. For symptoms of sympathetic storming such as unexplained tachycardia, hypertension, fever:
      • Clonidine
      • Propranolol
  2. Referral to Brain Care Clinic for neurocognitive screening 1 month after discharge.
    • Age < 4 years: Neurodevelopmental assessment by Anna Dusick
    • Age > 4 years: Neuropsychological evaluation by Alanna Kessler
    • Other services available at clinic: Pediatric Neurology, PT/OT, Psychology, and social work Pediatric TBI Guidelines

Management of Intracranial Hypertension: ICP ≥ 20

Pediatric TBI Hemodynamic Guidelines

These guidelines were developed based on literature review and consensus opinion of a multidisciplinary committe with representation from Critical Care, Neurosurgery, Trauma Surgery, Neurology and Emergency Medicine. They are intended as guidelines only - it is recognized that these patients are highly complex and require individualized care that may on occasion fall outside the scope if these recommendations.