Severe Pediatric Traumatic Brain Injury
Evidence-based guidelines for prehospital pediatric traumatic brain injury care
Traumatic brain injuries (TBI) affect 475,000 children under age 14 each year in the United States alone. Ninety percent of patients are treated in emergency departments and released; however, more than 47,000 hospitalizations per year are a direct result of these injuries. On average, 2,685 children die annually from traumatic brain injuries, and more than 30,000 children per year acquire lifelong disabilities. With proper prehospital care of these severely injured children, we can reduce secondary injury and maximize survival and good neurological outcomes.
EPIDEMIOLOGY
Children comprise two of three age groups most prone to traumatic brain injuries. In particular, children younger than five years and adolescents to young adults 15 to 24 years are most vulnerable, due to exploration and lack of coordination in young children and risk-taking behaviors in adolescents.
The most common causes of traumatic brain injuries in the United States, in order of prevalence, include falls, motor vehicle collisions and struck by/against events. TBIs occur in toddlers falling down stairs, as well as from non-accidental trauma such as shaken-baby syndrome. Adolescents and young adults sustain traumatic brain injuries from motor vehicle collisions; sports injuries like skiing/snowboarding, football, ATV/snowmobile riding and trampoline use; and other causes. Alcohol experimentation is involved in a number of incidents. This paper specifically addresses current recommendations for prehospital management of pediatric severe traumatic brain injury (GCS less than 9) in order to maximize outcomes.
BRAIN INJURIES
Traumatic brain injury is a spectrum of insults to the brain. Epidural hematoma occurs when damage to a meningeal or other artery causes bleeding between the skull and dura. These patients classically present with a lucid interval prior to becoming rapidly unresponsive. Subdural hematoma results from injury to the bridging vessels between the dura and brain. These bleeds may be self-limited or extensive, causing massive cerebral shifting. Intraparenchymal hemorrhage results from injury to the vessels within the brain itself, causing bleeding within one or multiple spots within the brain matter. Lastly, diffuse axonal injury (DAI) is microscopic damage to the axons of the brain nerves. This type of injury is most common in traumatic brain injuries, is not seen on CT-scanning and can result in devastating outcomes. All of these injuries can cause cerebral edema, further worsening patient outcome.
Numerous multidisciplinary teams have been formed to provide guidelines for management of both adult and pediatric severe TBI. Specific guidelines for management of pediatric TBI include Guidelines for the Acute Medical Management of Severe Traumatic Brain Injuries in Infants, Children, and Adolescents.1 More recent recommendations published in December 2007 include An Evidence-based Approach to Severe Traumatic Brain Injury in Children.2 Several other groups have also published guidelines that encompass pediatric care.3,4
AIRWAY MANAGEMENT
As with all trauma patients, cervical spine immobilization should be established immediately. This is especially true in pediatric trauma care, as the majority of spinal cord injuries in children are to the cervical spine. This is due to a relatively large head, weak neck musculature and ligaments, and incomplete ossification of the vertebrae.
Endotracheal intubation was once thought to be the mainstay of airway management for traumatic brain injuries. Several studies have brought this mind-set into question. One retrospective study of rural EMS endotracheal intubation attempts in 105 pediatric trauma patients found that only 9.3% of patients could not be ventilated or oxygenated by bag-valve mask (BVM) alone.5 Furthermore, multiple intubation attempts were associated with transport delays and lower discharge Glasgow Coma Scale (GCS) scores. Gausche, et al., in a prospective, randomized trial demonstrated no difference in outcomes in TBI patients, but fewer complications with BVM in general trauma. Current guidelines do not recommend endotracheal intubation over bag-valve mask ventilation in prehospital care. Some indicators suggesting a potential need for intubation include a GCS under 9 (severe TBI), hypoxemia, hypercarbia, aspiration or signs of elevated intracranial pressure.
