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[Severe head injuries in the young child: early management]
F Trabold1, P Meyer, G Orliaguet
1Département d'anesthésie-réanimation chirurgicale, hôpital Necker-Enfants Malades, 149, rue de Sèvres 75743 Paris, France.
Insights
Effective initial management of severe head injuries in children prevents secondary brain damage. Prompt treatment of systemic insults and intracranial pressure is crucial for improved neurological outcomes.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma management
- Emergency medicine
Context:
- Severe head injuries in infants and children require immediate and specialized medical intervention.
- Secondary brain damage from systemic insults like hypoxemia and hypotension is a major concern.
- Glasgow Coma Scale (GCS) score is a key indicator for intubation decisions.
Purpose:
- To outline the critical initial management strategies for severely head-injured pediatric patients.
- To emphasize the prevention and treatment of secondary brain injury.
- To highlight the importance of a multimodal approach including airway management, ventilation, and hemodynamic support.
Summary:
- Initial management focuses on preventing secondary brain damage by addressing systemic insults (hypoxemia, hypotension) and maintaining adequate cerebral perfusion pressure.
- Orotracheal intubation is mandatory for patients with a GCS of 8 or less, followed by mechanical ventilation to maintain normoxia and normocarbia.
- Fluid resuscitation and vasopressors are used to manage hypotension, while mannitol is reserved for life-threatening intracranial hypertension.
- Cerebral tomodensitometry aids in diagnosing surgical lesions, but associated extra-cranial injuries must also be considered in pediatric head trauma patients.
Impact:
- Optimal initial management of severe pediatric head trauma can significantly improve neurological outcomes.
- Recognizing and treating associated extra-cranial injuries is vital to prevent avoidable deaths.
- Standardized protocols for pediatric head injury management can enhance patient care and reduce morbidity.
Abstract:
The initial management of severely head-injured patients, including infants and children, is aimed at preventing and treating secondary brain damage, which mainly result from systemic insults (hypoxaemia, hypercarbia, arterial hypotension). Orotracheal intubation, followed by continuous sedation-analgesia, is mandatory when the Glasgow Coma Scale score (GCS) is less than or equal to 8 (crush induction is recommended). The goal of mechanical ventilation is to maintain normoxaemia and normocarbia. Moreover, the maintenance of an optimal cerebral perfusion pressure, usually 50 mmHg in infants, requires volume loading (isotonic fluids and colloids), and catecholamines if arterial hypotension persists. Intravenous mannitol is used only in case of life threatening intracranial hypertension, keeping in mind the potential for aggravating an hypovolaemia. Cerebral tomodensitometry is the most relevant imaging procedure for diagnosing surgical brain lesion. However, it should be noted, that severe head trauma is frequently associated with extra-cranial traumatic injuries, which may be responsible for (avoidable) deaths if the diagnosis is not made or delayed. Therefore, infants and small children presenting with severe head trauma should be considered as multiple injured and treated accordingly. Adequate initial management of severely head-injured children may participate to improved neurological outcome.