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Establish airway, breathing, circulation

Specific therapies may be initiated as indicated to minimize and/or treat increased intracranial pressure (ICP). (See 'Pathophysiology' above.)

In many children with severe traumatic brain injury, life-saving supportive therapies are initiated by emergency clinicians. Whenever possible, these patients should then be managed by specialists with pediatric expertise, including neurosurgeons and intensivists.

Airway and breathing — General principles of airway management for children (including techniques for opening and maintaining an airway, bag-mask ventilation, and tracheal intubation) are reviewed elsewhere. (See "Basic airway management in children" and "Emergency endotracheal intubation in children".)

Specific considerations for the management of airway and breathing for children with severe TBI are discussed here.

The child who is lucid and has a normal blood pressure can be managed with supplemental oxygen alone. Advanced airway management, including tracheal intubation, may be required to maximize oxygenation and ventilation and protect against aspiration of gastric contents in the following situations:

●Decreasing level of consciousness (GCS <9)

●Marked respiratory distress

●Hemodynamic instability

Cervical spine immobilization must be maintained while airway procedures are being performed. (See "Pediatric cervical spine immobilization", section on 'Airway management'.)

Considerations for tracheal intubation for children with traumatic brain injury include the following:

●Nasotracheal intubation should not be performed in patients with midface trauma or signs of a basilar skull fracture (raccoon's eyes, mastoid hematoma, or CSF drainage from the nose or ear canals). Children with these injuries may have fractures of the cribriform plate.

●We generally use cuffed tracheal tubes for all major pediatric trauma to protect the airway from aspiration. (See "Emergency endotracheal intubation in children", section on 'Cuffed versus uncuffed'.)

Rapid sequence intubation — Unless consciousness is severely depressed, endotracheal intubation is accomplished by using a rapid-sequence technique with application of cricoid pressure and preoxygenation (table 3) (see "Rapid sequence intubation (RSI) in children") as follows:

●Pretreatment – Lidocaine may minimize any increase in intracranial pressure that can be associated with airway manipulation. (See "Rapid sequence intubation (RSI) in children", section on 'Lidocaine'.)

●Sedative agents – Etomidate and thiopental have neuroprotective properties. Thiopental causes vasodilatation and myocardial depression, resulting in a decrease in systolic blood pressure and should not be used in patients who are hemodynamically unstable. Etomidate is frequently used during RSI in children with severe traumatic brain injury; although etomidate can cause transient adrenal suppression, the benefits appear to outweigh the risks in most patients. (See "Rapid sequence intubation (RSI) in children", section on 'Sedative and induction agents'.)

●Paralytic agents – Although increased ICP with the use of succinylcholine has been reported in patients with brain tumors, there is no definitive evidence that succinylcholine causes a rise in ICP in humans with brain injury [38,39]. Factors that must be considered in choosing between succinylcholine and rocuronium include the risk of succinylcholine for children with undiagnosed neuromuscular conditions and the longer duration of paralysis with rocuronium for those who may have a difficult airway. (See "Rapid sequence intubation (RSI) in children", section on 'Paralysis'.)

Ventilation — Hyperventilation (PaCO2 <35 mmHg) may cause cerebral ischemia as the result of decreased cerebral blood flow [30,40]. Consequently, PaCO2 should be maintained between 35 and 38 mmHg unless there are signs of pending herniation [41]. (See 'Neurological assessment' above and 'Management' above.)

Fluid management — General principles of the management of hypovolemic and hemorrhagic shock in children, as well as techniques for vascular access, are discussed separately. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Hypovolemic shock in children: Initial evaluation and management", section on 'Fluid resuscitation'.)

In general, isotonic fluids are preferred to hypotonic fluids. Adult data suggest that albumin may be harmful after TBI [42].

Specific considerations for fluid management for children with severe TBI are discussed here.

Outcomes for children with severe TBI who are hypotensive at the initial evaluation are typically poor [10,12,14,20,43-45]. Volume should be restored. Isotonic solutions should be used for fluid resuscitation. Blood products should be administered as indicated. For example, in one observational study of 118 children with moderate to severe traumatic brain injury and documented hypotension, fluid therapy during early resuscitation was associated with significantly lower mortality (30 percent [17 of 57 patients] versus 56 percent [34 of 61 patients]) and significantly better functional neurologic outcome [43].

The target blood pressure required to maintain the minimum cerebral perfusion pressure necessary to meet cerebral metabolic demands in infants and children has not been established and may be an age dependent continuum. Systolic blood pressures should be maintained above the fifth percentile for age and gender at the very least [46]. However, improved outcomes have been reported for patients with substantially higher initial blood pressures [10,12].

Other initial management considerations — Interventions that are typically used to treat children with severe traumatic brain injury improve intermediate outcomes, such as intracranial pressure, cerebral oxygen consumption, and cerebral blood flow. Evidence that these treatments improve long-term clinical outcomes is therefore largely indirect.

Head positioning – The head should be maintained in a neutral position to avoid jugular venous obstruction. In prospective observational studies, elevating the head to 30 degrees appears to optimize cerebral perfusion pressure and decrease ICP for adult patients, provided that mean arterial pressure is maintained [47,48]. There are no data regarding the efficacy of this intervention for children.

Sedation and neuromuscular blockade – Adequate sedation and pharmacologic paralysis facilitate the safe transportation of intubated children with severe TBI. Oxygenation, ventilation, and blood pressure must be vigilantly monitored for patients who are sedated, with or without paralysis. Limited evidence suggests that cerebral oxygen consumption may be decreased in patients receiving neuromuscular blockade [49].

Antiseizure prophylaxis – Prophylactic treatment with anticonvulsants reduces the incidence of early posttraumatic seizures among children with severe TBI [50,51]. Seizures immediately following severe traumatic brain injury may increase brain metabolic demands and increase ICP, leading to secondary brain injury [41]. In addition, retrospective studies have demonstrated improved outcomes among children with TBI who were treated with anticonvulsants [52,53]. Experts suggest that children receive anticonvulsant therapy during the first week following severe TBI [54].

Hyperthermia – Hyperthermia should be aggressively prevented and treated [55].

Hyperosmolar therapy – Randomized trials, observational reports, and extensive clinical experience have demonstrated that hyperosmolar therapy effectively decreases increased intracranial pressure in children with TBI [56-62]. Options include hypertonic saline and mannitol:

Hypertonic saline – Evidence from small randomized trials and observational reports suggests that hypertonic saline, administered either as a bolus or a constant infusion, is effective for reducing intracranial pressure [58-62]. Adverse effects related to therapy with hypertonic saline include rebound intracranial hypertension, central pontine myelinolysis, and subarachnoid hemorrhage [63]. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Mannitol'.)

Mannitol – The effectiveness of mannitol for decreasing intracranial pressure among patients with traumatic brain injury has been demonstrated by extensive clinical experience and in several small series describing adult and pediatric patients [56,57]. Nephrotoxicity can occur with mannitol therapy, particularly if patients become hypovolemic [64].

Hyperventilation – Although hyperventilation reduces intracranial pressure, indirect evidence suggests that routine hyperventilation may be harmful for patients with TBI. Hyperventilation produces hypocapnia which causes vasoconstriction and decreased cerebral blood flow (CBF) [65,66]. Decreased CBF has been associated with poor outcomes among children with TBI [30], and severe hypocapnia (PaCO2 <30 mmHg) has been associated with increased mortality [67]. Patients should only receive temporary hyperventilation (to reduce PaCO2 to less than 35 mmHg) with signs and symptoms of impending herniation [41]. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Therapeutic hyperventilation'.)

Glucose – Hyperglycemia has been associated with poor outcomes for children and adults with TBI [11,15,68,69]. This may be because hyperglycemia (as the result of a stress response) is a marker for severity of injury and/or elevated blood sugar contributes to poor outcome by worsening brain tissue lactic acidosis [70-73]. In an observational study of 101 children under 14 years of age who underwent emergent craniotomy for TBI, perioperative hyperglycemia (serum glucose ≥200 mg/dL [11.1 mmol/L]) was found in 45 percent of children and was significantly associated with age <4 years, GCS ≤8, and the presence of multiple traumatic lesions, including subdural hematoma [74]. We typically maintain glucose levels ≤200 mg/dL for head injured children.

Corticosteroids – Limited evidence does not support a benefit for treatment with corticosteroids for head injured patients. In addition, a large, prospective, multicenter trial described increased mortality among patients with acute traumatic brain injury who received corticosteroids [75]. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Patients with vasogenic edema'.)

Hypothermia – Hypothermia for children with severe traumatic brain injury is not beneficial and may be harmful and should not be performed. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Temperature control'.)

Burr hole – Rarely, a patient with an epidural hematoma may require emergent drainage through a burr hole. This procedure should be done by a neurosurgeon whenever possible.

Monitoring — Initial monitoring of the child with severe TBI includes measurement of heart rate, blood pressure, and pulse oximetry. Capnography should be used (when available) to monitor end-tidal CO2 to avoid excessive hyperventilation for patients who require controlled ventilation. If end-tidal CO2 is to be used as the primary monitor for ventilation, an initial determination of arterial pCO2 should also be performed to ensure that end tidal and arterial CO2 are correlating well [76].

Intracranial pressure monitoring is generally recommended for children who have an abnormal initial head CT and an initial GCS score between 3 and 8 [77]. Interventions that have been effective for decreasing ICP (ie, hyperosmolar therapy, decompressive craniotomy, and hyperventilation) require accurate and continuous monitoring of intracranial pressure [61,78,79]. ICP monitoring is usually not initiated in the emergency department. However, children who may need ICP monitoring should be admitted to a pediatric intensive care unit at a trauma center.

Initial management decisions — The immediate management of a child with severe traumatic brain injury (GCS score ≤8) (table 1), or with moderate injury (GCS score between 9 and 12) (table 1) whose condition is deteriorating or has associated injuries should include the following :

●Focal injuries that may require neurosurgical intervention (ie, penetrating injuries, epidural hematomas, or subdural hematoma) must be quickly identified. (See 'Evaluation' above.)

●Immediate neurosurgical consultation should be requested for children with focal injuries who have signs of increased intracranial pressure on physical examination or imaging studies. (See 'Neurological assessment' above.)

●Children with GCS scores ≤8 or with GCS scores between 9 and 12 whose conditions are deteriorating should undergo endotracheal intubation. Intubation should also be considered for those with GCS scores between 9 and 12 who cannot protect their airways or are being transported out of the emergency department. (See 'Rapid sequence intubation' above.)

●Children with signs of herniation should be treated as follows (figure 1) (see 'Other initial management considerations' above):

•Assure adequate oxygenation, breathing, and blood pressure.

•Give hyperosmolar therapy.

•Provide mild hyperventilation (PaCO2 30 to 35 mmHg) for children who do not respond to hyperosmolar therapy.

•Request immediate neurosurgical evaluation.

Prehospital Care

Provide stabilization and rapid transport to a facility with experience in the management of brain injury. The most important prehospital interventions are airway and blood pressure management. If the patient needs prehospital intubation, avoid hyperventilation (which causes cerebral vasoconstriction and can negatively affect outcome), and use capnometry to keep PCO2 at 35 to 45 mm Hg. Treat hypotension aggressively. If transport times are short, do not give mannitol or hypertonic saline for elevated ICP.

Guidelines for prehospital care are available at http://www.braintrauma.org.

Immediate Management of Life-Threatening Problems

1. Prevent Cervical Cord Injury or further Injury to the Cervical Cord: Cervical Spine Immobilization

Cervical spine injury is associated with 5% of all blunt force injuries to the head; the greater the force, the greater the incidence of associated injury.

2. Airway, Breathing, Circulation

Nasal Oxygen

All patients with traumatic head injury should receive 100% oxygen by high-flow nonrebreathing mask as initial therapy.

CT Scan


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A 28-year-old woman has severe head trauma after a motor vehicle accident. One year after the accident, she is noted to have spontaneous eye opening and is able to track an object visually at times. She does not speak or follow any commands. She breathes independently but is fed through a gastrostomy tube. She can move all extremities spontaneously but without purposeful movement. What term best describes this patient's condition?

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The correct answer is D. You answered C.

Alterations in consciousness are among the most common reasons for admission to the hospital and occur frequently in seriously ill patients. When evaluating a patient with an alteration in consciousness, one must have a framework for understanding the spectrum of arousability one may encounter. Coma is a frequently misunderstood term that refers to a deep sleeplike state from which a patient cannot be aroused. A stuporous patient can be aroused briefly with noxious stimuli, and drowsiness refers to a patient who can be aroused easily with maintenance of attention for brief periods. Other conditions that alter the ability of a patient to respond appropriately to stimuli and are often confused with coma. A vegetative state is an awake but unresponsive condition that can occur in a patient who has emerged from a coma and is associated with extensive bilateral cerebral damage. A patient in a vegetative state can open the eyes spontaneously and often track objects. In addition, the patient has retention of respiratory and autonomic functions as well as spontaneous movement of extremities. However, meaningful responses to stimuli do not occur, and a vegetative state is sometimes referred to as an "awake coma." This patient would be characterized as being in a persistent vegetative state because the duration of the vegetative state has been 1 year. At this point, the likelihood of meaningful recovery of mental faculties is almost zero. A minimally conscious state is a less severe manifestation of bilateral cerebral injury. A patient in a minimally conscious state may have rudimentary vocal or motor behaviors and minimal responses to external stimuli. Other conditions that may be misinterpreted as a coma include akinetic mutism, catatonia, abulia, and locked-in syndrome.


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