Professional Documents
Culture Documents
Sophia R. Smith, MD
WRAMC
November 2, 2005
Introduction
• Head injuries are one of the most common
causes of disability and death in children.
• The Centers for Disease Control and
Prevention (CDC) estimates that more
than 10,000 children become disabled
from a brain injury each year.
• Head injuries can be defined as mild as a
bump to severe in nature.
Prevalence of Pediatric Trauma
diffuse axonal
BBB inflammation injury
disruption apoptosis
necrosis
edema
formation
Brain trauma ischemia
energy failure
cytokines
Eicosanoids
Acetyl polyamines Calcium
endocannabinoids Choline ROS
Shohami, 2000
Green – pathophysiological processes; Yellow – various mediators
Anatomy of the cranium
• There are various brain contents that are
localized within a rigid structure.
– Cranium
• The cranial vault contents include:
– The brain
– The cerebral spinal fluid
– The cerebral blood
Cerebral Spinal Fluid
• CSF
– 150 cc in adults at all times
• Children slightly less
– Produced by choroid plexus – 20 cc/hr
– CSF is absorbed into venous system at
the subarachnoid villi
Cerebral blood and brain
• Cerebral blood
– Sum of blood in capillaries, veins, and arteries
• Brain
– 80% of the total intracranial volume
Eye Opening
Spontaneous 4
To Voice 3
To Pain 2
None 1
Best Verbal
Oriented 5
Confused 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
Best Motor
Obeys Commands 6
Localizes Pain 5
Withdraws to Pain 4
Flexion to Pain 3
Extension to Pain 2
None 1
Severe TBI
• Intubation.
– Pretreatment with lidocaine 1
mg/kg IV may prevent rise in
intracranial pressure (ICP).
Treatment
• Hyperventilation
– to maintain PO2 >90 torrs, PCO2 30 to 32 torrs.
– Hyperventilation may actually increase ischemia
in at risk brain tissue if PCO2 <25 torr by causing
excessive vasoconstriction and has fallen out of
favor. Prophylactic hyperventilation for those without
increased ICP is contraindicated and worsens
outcomes.
• PEEP relatively contraindicated because
reduces cerebral blood flow.
Maintain normal cardiac output.
• Mannitol
– dehydrate the brain, not the patient!
– monitor osmolality
• Hypertonic saline
• Decompressive craniectomy
ICP Monitoring
• ICU patients who have sustained head
trauma, brain hemorrhage, brain surgery,
or conditions in which the brain may swell
might require intracranial pressure
monitoring.
• Detect “events”
• Manage intracranial pressure
• Manage cerebral perfusion pressure
How?
• Ventriculostomy
• Intraparenchymal fiberoptic catheter
• Subarachnoid monitor
• Useful adjuncts:
– Arterial line
– Central venous line
– Foley catheter
Manipulation of ICP
CSF
• External drainage
– therapeutic as well as diagnostic
– technical issues
– infectious issues
What to do with the
information...
• CT Scan
• MRI
• PET Scan
• Jugular Venous Oxygen Saturation
Near-infrared Spectroscopy