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[Traumatic head injury in children: physiopathology and clinical management]
1Divisions of Neurosurgical Anaesthesia and Cardiovascular Anaesthesia Research, Department of Anaesthesia, Hospital for Sick Children, Toronto, Ontario, Canada, M5G 1X8. bruno@anaes.sickkids.on.ca
Insights
Traumatic brain injury (TBI) in children is a significant health issue. Early management focusing on oxygenation, airway control, and blood pressure is crucial to prevent secondary brain injury and improve outcomes.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Anesthesiology
Context:
- Traumatic brain injury (TBI) is a leading cause of death and disability in children.
- Daily admissions for head trauma occur in busy emergency departments.
- Anesthesiologists require deep understanding of TBI pathophysiology and initial management.
Purpose:
- To highlight the critical role of anesthesiologists in managing pediatric TBI.
- To emphasize the mechanisms and consequences of secondary brain injury.
- To outline the principles of initial management for pediatric head trauma.
Summary:
- TBI causes intracranial and systemic effects, leading to global cerebral ischemia.
- Secondary brain injury, driven by inflammatory cascades, significantly worsens outcomes.
- Over 91% of severe TBI deaths show evidence of secondary ischemic damage, explaining the 'child who talks and dies' phenomenon.
Impact:
- Active treatment and prevention of secondary injury are vital for "cerebral protection".
- Initial care must prioritize oxygenation, airway control, and management of arterial hypotension.
- Effective management can mitigate the severe morbidity and mortality associated with pediatric TBI.
Abstract:
Traumatic brain injury (TBI) constitutes a major health and economic problem for developed countries, being one of the main causes of mortality and morbidity in children. In a busy traumatology center, a child will be admitted daily in the emergency department with head trauma injury. The anaesthesiologist must have a complete understanding of the pathophysiology and develop a practical knowledge of initial management of such patients. Traumatic brain injury may have intracranial and systemic effects that combine to give global cerebral ischaemia. Injury to the nervous system, irrespective of the primary injury, initiates a multitude of inflammatory cascades resulting in secondary brain injury. The consequence of these secondary brain injuries is most often as important, if not, more important than the primary injury. This period of brain inflammation can last up to three weeks and renders the brain more susceptible to the effects of systemic insults such as hypotension, hypoxia and or pyrexia. It has been shown in post-mortem examination of patients dying from severe traumatic brain injury that more than 91% had evidence of secondary ischaemic damage. These secondary injuries may be responsible for the clinical presentation of the "child who talk and die". The concept of "cerebral protection" has been extended to encompass the active treatment of secondary injury and the prevention of cerebral ischaemia. Initial care focuses on achieving oxygenation, airway control and treatment of arterial hypotension.