Current Guidelines for the Diagnosis and Treatment of Traumatic Brain Injury in Children
The article presents the basic diagnostic and therapeutic measures in traumatic brain injury in children, presented in the second edition of «Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents», published in Pediatric Critical Care Medicine (2012, Vol. 13, № 1).
These guidelines include a number of sections: indications for intracranial pressure monitoring, intracranial pressure values, requiring treatment of intracranial hypertension, the magnitude of the perfusion pressure of the brain, the use of extended neuromonitoring, brain scans, hyperosmolar therapy, body temperature regulation, cerebrospinal fluid drainage, use of barbiturates, decompression craniectomy for treatment of intracranial hypertension, hyperventilation, use of corticosteroids, analgesics, sedatives and neuromuscular blockade, glucose and nutrition, prevention of seizures.
The guidelines include literary sources of II and III levels of evidence on basic issues of intensive care for traumatic brain injury in children. All this allowed us to select main points of diagnosis and intensive care of pediatric traumatic brain injury and formulate their features.
It is widely accepted that there are additional difficulties in assessing the severity of head injuries only on the basis of clinical manifestations in children as compared to adults. Moreover, the younger the child, the more difficulties usually exist in diagnosis. So, atypical course of intracranial injuries is distinctive for children. This can be manifested, on the one hand, by a long asymptomatic course in life-threatening injuries in a child, and on the other hand — by severe clinical manifestations even with minimal brain injury. This peculiarity of the course of head injuries in children can be explained by age anatomical and physiological characteristics.
The following guidelines must be included in the treatment algorithm of traumatic brain injuries in children of all pediatric intensive care units of Ukraine regardless of their level of accreditation, as this will allow to change and to improve qualitatively early used treatment measures, to reduce mortality in this group of children and to reduce significantly subsequent neurological deficit in them.
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Kochanek P.M., Carney N., Adelson P.D., Ashwal S., Bell M.J., Bratton S., Carson S., Chesnut R.M., Ghajar J., Goldstein B., Grant G.A., Kissoon N., Peterson K., Selden N.R., Tasker R.C., Tong K.A., Vavilala M.S., Wainwright M.S., Warden C.R.; American Academy of Pediatrics-Section on Neurological Surgery; American Association of Neurological Surgeons/Congress of Neurological Surgeons; Child Neurology Society; European Society. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents — second edition // Pediatr. Crit. Care Med. 2012 Jan;13 Suppl. 1: S1-82. doi: 10.1097/PCC.0b013e31823f435c.
Adelson P.D., Bratton S.L., Carney N.A. et al. Guidelines for the acute medical manage ment of severe traumatic brain injury in infants, children and adolescents // Pediatr. Crit. Care Med. 2003; 4: S1-S75.
Hutchison J.S., Ward R.E., Lacroix J. et al. Hypothermia Pediatric Head Injury Trial Investigators and the Canadian Critical Care Trials Group. Hypothermia therapy after traumatic brain injury in children // N. Engl. J. Med. 2008; 358: 2447-2456.
Adelson P.D., Ragheb J., Kanev P. et al.: Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children // Neurosurgery. 2005; 56: 740-754.
Curry R., Hollingworth W., Ellenbogen R.G. et al. Incidence of hypo- and hypercarbia in severe traumatic brain injury before and after 2003 pediatric guidelines // Pediatr. Crit. Care Med. 2008; 9: 141-146.
Morris K.P., Forsyth R.J., Parslow R.C. et al. Intracranial pressure complicating severe traumatic brain injury in children: monitoring and management // Intensive Care Med. 2006; 32: 1606-1612.
Carter B.G., Butt W., Taylor A. ICP and CPP: Excellent predictors of long term outcome in severely brain injured children // Childs Nerv. Syst. 2008; 24: 245-251.
Wahlstrom M.R., Olivecrona M., Koskinen L-OD et al. Severe traumatic brain injury in pediatric patients. Treatment and outcome using an intracranial pressure targeted therapy — The Lund concept // Intensive Care Med. 2005; 31: 832-839.
Catala-Temprano A., Claret Teruel G., Cambra Lasaosa F.J. et al: Intracranial pressure and cerebral perfusion pressure as risk factors in children with traumatic brain injuries // J. Neurosurg. 2007; 106: 463-466.
Figaji A.A., Zwane E., Thompson C. et al. Brain tissue oxygen tension monitoring in pediat-ric severe traumatic brain injury. Part 1: Relationship with outcome // Childs Nerv. Syst. 2009; 25: 1325-1333.
Shore P.M., Thomas N.J., Clark R.S. et al. Continuous versus intermittent cerebrospinal fluid drainage after severe traumatic brain injury in children: Effect on biochemical markers // J. Neurotrauma. 2004; 21: 1113-1122.
Briassoulis G., Filippou O., Kanariou M. et al. Temporal nutritional and inflammatory changes in children with severe head injury fed a regular or an immune-enhancing diet: A randomized, controlled trial // Pediatr. Crit. Care Med. 2006; 7: 56-62.
Jagannathan J., Okonkwo D.O., Yeoh H.K. et al. Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intra-cranial pressure // J. Neurosurg Pediatr. 2008; 2: 240-249.
Bar-Joseph G., Guilburd Y., Tamir A. et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension // J. Neurosurg Pediatr. 2009; 4: 40-46.
Miller J.D. et al. Further experience in the management of severe head injury // J. Neurosurg. 1981. Vol. 54. Р. 289-299.
Barzilay Z., Augarten A., Sagy M. et al. Variables affecting outcome from severe brain injury in children // Intensive Care Med. 1988; 14: 417-421.
Bruce D.A., Raphaely R.C., Goldberg A.I. et al. Pathophysiology, treatment and outcome following severe head injury in children // Childs Brain. 1979; 5: 174-191.
Esparza J., Portillo J.M., Sarabia M. et al. Outcome in children with severe head injuries // Childs Nerv. Syst. 1985; 1:109-114.
Kasoff S.S., Lansen T.A., Holder D. et al. Aggressive physiologic monitoring of pediatric head trauma patients with elevated intracranial pressure // Pediatr. Neurosci. 1988; 14: 241-249.
Shapiro K., Marmarou A. Clinical applications of the pressure-volume index in treatment of pediatric head injuries // J. Neurosurg. 1982; 56: 819-825.
Pfenninger J., Santi A. Severe traumatic brain injury in children — Are the results improving? // Swiss Med. Wkly. 2002; 132: 116-120.
White J.R., Farukhi Z., Bull C. et al. Predictors of outcome in severely head-injured children // Crit. Care Med. 2001; 29: 534-540.
Alberico A.M., Ward J.D., Choi S.C. et al. Outcome after severe head injury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients // J. Neurosurg. 1987; 67: 648-656.
Chambers I.R., Treadwell L., Mendelow A.D. Determination of threshold levels of cerebral perfusion pressure and intracranial pressure in severe head injury by using receiver-operating characteristic curves: An observational study in 291 patients // J. Neurosurg. 2001; 94: 412-416.
Keenan H.T., Nocera M., Bratton S.L. Frequency of intracranial pressure monitoring in infants and young toddlers with traumatic brain injury // Pediatr. Crit. Care Med. 2005; 6: 537-541.
McLaughlin M.R., Marion D.W. Cerebral blood flow and vasoresponsivity within and around cerebral contusions // Neurosurg. 1996; 85: 871-876.
Vavilala M.S., Lee L.A., Lam A.M. The lower limit of cerebral autoregulation in children during sevoflurane anesthesia // Neurosurg. Anesthesiol. 2003; 15: 307-312.
Pfenninger J., Kaiser G., Lutschg J. et al. Treatment and outcome of the severely head injured child // Intensive Care Med. 1983; 9: 13-16.
Downard C., Hulka F., Mullins R.J. et al. Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients // J. Trauma. 2000; 49: 654-658; discussion 658-659.
Cruz J., Nakayama P., Imamura J.H. et al. Cerebral extraction of oxygen and intracranial hypertension in severe, acute, pediatric brain trauma: Preliminary novel management strategies // Neurosurgery. 2002; 50: 774-779; discussion 779-780.
Grinkeviciute D.E., Kevalas R., Matukevicius A. et al. Significance of intracranial pressure and cerebral perfusion pressure in severe pediatric traumatic brain injury // Medicina (Kaunas, Lithuania). 2008; 44: 119-125.
Chaiwat O., Sharma D., Udomphorn Y. et al. Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric traumatic brain injury // J. Neurotrauma. 2009; 26: 657-663.
Kapapa T., Konig K., Pfister U. et al. Head trauma in children, part 2: Course and discharge with outcome // J. Child Neurol. 2010; 25: 274-283.
Vavilala M.S., Tontisirin N., Udomphorn Y. et al. Hemispheric differences in cerebral autoregulation in children with moderate and severe traumatic brain injury // Neurocrit. Care. 2008; 9: 45-54.
Vavilala M.S., Muangman S., Waitayawinyu P. et al. Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: A preliminary report // J. Neurotrauma. 2007; 24: 87-96.
Tong K., Oyoyo U., Holshouser B. et al. Chapter 7: Evidence-based neuroimaging for traumatic brain injury in children // Evidence-Based Imaging in Pediatrics / Medina L., Applegate K., Blackmore C. (eds). — New York, NY: Springer, 2010. — Р. 85-102.
Hollingworth W., Vavilala M.S., Jarvik J.G. et al. The use of repeated head computed tomography in pediatric blunt head trauma: factors predicting new and worsening brain injury // Pediatr. Crit. Care Med. 2007; 8: 348-356.
Fisher B., Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma // J. Neurosurg Anesthesiol. 1992; 4: 4-10.
Peterson B , Khanna S , Fisher B. et al. Prolonged hypernatremia controls elevated in-tracranial pressure in head-injured pediatric patients // Crit. Care Med. 2000; 28: 1136-1143.
Khanna S., Davis D., Peterson B. et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury // Crit. Care Med. 2000. 28: 1144-1151.
Simma B., Burger R., Falk M. et al. A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringer’s solution versus hypertonic saline // Crit. Care Med. 1998; 26: 1265-1270.
Shiozaki T., Sugimoto H., Taneda M. et al. Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury // J. Neurosurg. 1993; 79: 363-368.
Biswas A.K., Bruce D.A., Sklar F.H. et al. Treatment of acute traumatic brain injury in children with moderate hypothermia improves intracranial hypertension // Crit. Care Med. 2002; 30: 2742-2751.
Heindl U.T., Laub M.C. Outcome of persistent vegetative state following hypoxic or traumatic brain injury in children and adolescents // Neuropediatrics. 1996; 27: 94-100.
Baldwin H.Z., Rekate H.L. Preliminary experience with controlled external lumbar drainage in diffuse pediatric head injury // Pediatr. Neurosurg. 1991; 17: 115-120.
Levy D.I., Rekate H.L., Cherny W.B. et al. Controlled lumbar drainage in pediatric head injury // J. Neurosurg. 1995; 83: 453-460
Ghajar J.B.G., Hariri R.J., Patterson R.H. Improved outcome from traumatic coma using only ventricular cerebrospinal fluid drainage for intracranial pressure control // Adv. Neurosurg. 1993; 21: 173-177.
Fortune J.B., Feustel P.J., Graca L. et al. Effect of hyperventilation, mannitol and ventriculostomy drainage on cerebral blood flow after head injury // J. Trauma. 1995; 39: 1091-1097; discussion 1097-1099.
Bratton S.L., Chestnut R.M., Ghajar J. et al. Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives // J. Neurotrauma. 2007; 24 (Suppl. 1). S71-S76
Demopoulos H.B., Flamm E.S., Pietronigro D.D. et al. The free radical pathology and the microcirculation in the major central nervous system disorders // Acta Physiol. Scand. Suppl. 1980; 492: 91-119.
Kassell N.F., Hitchon P.W., Gerk M.K. et al. Alterations in cerebral blood flow, oxygen metabolism, and electrical activity produced by high dose sodium thiopental // Neurosurgery. 1980; 7: 598-603.
Piatt J.H. Jr., Schiff S.J. High dose barbiturate therapy in neurosurgery and intensive care // Neurosurgery. 1984; 15: 427-444.
Chen H.I., Malhotra N.R., Oddo M. et al. Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation // Neurosurgery. 2008; 63: 880-886; discussion 886-887.
Goodman J.C., Valadka A.B., Gopinath S.P. et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients // J. Neurotrauma. 1996; 13: 549-556.
Cho D.Y., Wang Y.C., Chi C.S. Decompressive craniotomy for acute shaken/impact baby syndrome // Pediatr. Neurosurg. 1995; 23: 192-198.
Figaji A.A., Fieggen A.G., Peter J.C. Early decompressive craniotomy in children with severe traumatic brain injury // Childs. Nerv. Syst. 2003; 19: 666-673.
Hejazi N., Witzmann A., Fae P. Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature // Eur. J. Pediatr. 2002; 161: 99-104.
Muizelaar J.P., Marmarou A., Ward J.D. et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: A randomized clinical trial // J. Neurosurg. 1991; 75: 731-739.
Stringer W.A., Hasso A.N., Thompson J.R. et al. Hyperventilation-induced cerebral ischemia in patients with acute brain lesions: Demonstration by Xenon-enhanced CT // AJNR. 1993; 14: 475-484.
Skippen P., Seear M., Poskitt K. et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children // Crit. Care Med. 1997; 25: 1402-1409.
Schneider G.H., von Helden A., Lanksch W.R. et al.: Continuous monitoring of jugular bulb oxygen saturation in comatose patients Therapeutic implications // Acta Neurochir. (Wien). 1995; 134: 71-75.
Fanconi S., Kloti J., Meuli M. et al. Dexameth-asone therapy and endogenous cortisol production in severe pediatric head injury // Intensive Care Med. 1988; 14: 163-166.
Kloti J., Fanconi S., Zachmann M. et al Dexamethasone therapy and cortisol excretion in severe pediatric head injury // Childs Nerv. Syst. 1987; 3: 103-105.
Nilsson B., Rehncrona S., Siesjo B.K. Coupling of cerebral metabolism and blood flow in epileptic seizures, hypoxia and hypoglycaemia // Ciba Found Symp. 1978; 56: 199-218.
Rehncrona S., Siesjo B.K. Metabolic and physiologic changes in acute brain failure // Brain Failure and Resuscitation / Grenvik A., Safar P. (eds.). New York, NY, Churchill Livingstone, 1981. Р. 11-33.
Fortune J.B., Feustel P.J., Weigle C.G. et al. Continuous measurement of jugular venous oxygen saturation in response to transient elevations of blood pressure in head-injured patients // J. Neurosurg. 1994; 80: 461-468.
Kerr M.E., Weber B.B., Sereika S.M. et al. Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients // Crit. Care Med. 1999; 27: 2776-2781.
Raju T.N., Vidyasagar D., Torres C. et al. Intracranial pressure during intubation and anesthesia in infants // J. Pediatr. 1980; 96: 860-862.
White P.F., Schlobohm R.M., Pitts L.H. et al. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning // Anesthesiology. 1982; 57: 242-244.
Todres I.D. Post anesthesia recovery in the pediatric intensive care unit // Pediatric. Critical Care. — St. Louis, MO: Mosby, 1998. —Р. 1391-1398.
Prielipp R.C., Coursin D.B. Sedative and neuromuscular blocking drug use in critically ill patients with head injuries // New Horiz. 1995; 3: 456-468.
Hsiang J.K., Chesnut R.M., Crisp C.B. et al. Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary? // Crit. Care Med. 1994; 22: 1471-1476.
Cochran A., Scaife E.R., Hansen K.W. et al. Hyperglycemia and outcomes from pediatric traumatic brain injury // J. Trauma. 2003; 55: 1035-1038.
Chiaretti A., Piastra M., Pulitano S. et al. Prognostic factors and outcome of children with severe head injury: An 8-year experience // Childs Nerv. Syst. 2002; 18: 129-136.
Lewis R.J., Yee L., Inkelis S.H. et al. Clinical predictors of post-traumatic seizures in children with head trauma // Ann. Emerg. Med. 1993; 22: 1114-1118.
Bratton S.L., Chestnut R.M., Ghajar J. et al. Guidelines for the management of severe traumatic brain injury. XIII. Antiseizure prophylaxis // J. Neurotrauma. 2007; 24 (Suppl. 1): S83-S86.
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