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Treatment of traumatic brain injury in pediatrics
Andranik Madikians1, Christopher C Giza
1Christopher C. Giza, MD Division of Pediatric Neurology, Department of Pediatrics and Department of Neurosurgery, UCLA Brain Injury Research Center, Room 18-218B, Semel Institute, 10833 Le Conte Boulevard, Mattel Children's Hospital-UCLA, Los Angeles, CA 90095, USA. cgiza@mednet.ucla.edu.
Insights
Preventing secondary brain injury in pediatric severe traumatic brain injury (TBI) is crucial. Intracranial pressure (ICP)-guided therapy, despite guideline variations, focuses on ICP control to improve cerebral perfusion pressure.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Neurosurgery
Background:
- Severe traumatic brain injury (TBI) in children poses significant management challenges.
- Variations in treatment protocols for pediatric TBI persist, particularly concerning intracranial pressure (ICP)-guided therapy.
- Heterogeneity in pediatric TBI and limited data hinder the establishment of standardized treatment approaches.
Purpose of the Study:
- To outline a management strategy for severe pediatric TBI focused on ICP control.
- To detail tiered therapeutic interventions for managing elevated ICP.
- To emphasize the importance of neuromonitoring in guiding treatment decisions.
Main Methods:
- Initial management involves ICP monitoring and medical interventions (head elevation, sedation, CSF drainage).
- First-tier therapies include hyperosmolar agents and controlled ventilation for refractory ICP elevation.
- Second-tier therapies encompass more aggressive measures like jugular catheterization, barbiturates, hypothermia, and decompressive craniectomy.
Main Results:
- ICP control is central to improving cerebral perfusion pressure in severe pediatric TBI.
- A stepwise approach, from basic maneuvers to advanced therapies, is necessary for managing elevated ICP.
- Comprehensive neuromonitoring, including ICP, blood pressure, and advanced modalities, is essential for effective treatment execution.
Conclusions:
- Effective management of severe pediatric TBI requires a systematic, ICP-guided approach.
- Tiered therapeutic interventions should be implemented based on ICP monitoring and patient response.
- Advanced neuromonitoring modalities enhance clinical decision-making and patient care in pediatric TBI.
Abstract:
The primary goal in treating any pediatric patient with severe traumatic brain injury (TBI) is the prevention of secondary insults such as hypotension, hypoxia, and cerebral edema. Despite the publication of guidelines, significant variations in the treatment of severe TBI continue to exist, especially in regards to intracranial pressure (ICP)-guided therapy. This variability in treatment results mainly from a paucity of data from which to create standards and from the heterogeneity inherent in pediatric TBI. The approach to management of severe TBI based on the published guidelines should be focused on ICP control, which should ultimately improve cerebral perfusion pressure. After identifying and surgically evacuating expanding hematomas, the first-tier treatment approach requires placing an ICP monitor. This is accompanied by medical management of elevated ICP, initially with simple maneuvers such as elevating the head of the bed to improve venous drainage, instituting sedation and analgesia to decrease metabolic demands of the brain, and draining cerebrospinal fluid. If these measures fail, then further first-tier interventions include hyperosmolar therapy to decrease cerebral edema and controlled ventilation to decrease cerebral blood volume. For elevations of ICP resistant to first-tier therapies, treatment escalates to second-tier therapy, which includes more aggressive measures such as placing jugular catheters to measure cerebral oxygenation with moderate hyperventilation, placing lumbar drains to remove more cerebrospinal fluid, administering high-dose barbiturates to suppress cerebral electrical activity, inducing hypothermia as a protective measure, and performing decompressive craniectomy to open the cranial vault. To properly execute these interventions, appropriate neuromonitoring is essential, starting from standard physiological parameters such as ICP, mean arterial blood pressure, and temperature. Additional modalities of neurologic monitoring are becoming more readily available and can provide additional clinically useful information about the pediatric patient with TBI; these include cerebral oxygenation, continuous electroencephalography, noninvasive blood flow monitoring, and advanced neuroimaging.
