Shantaveer
Gangu
MentorDr.Baldauf MD
Demographics
Account for 75% all pediatric trauma
hospitalizations
80% of trauma related deaths in children
Domestic falls, MVAs, recreational injuries
and child abuse account for majority of
them.
Gang and drug related assaults are on a rise.
Firearm injuries to brain account for 12%
pediatric deaths.
Pathophysiology of Brain
Injury
Cerebral
Contusion
Most common Focal
brain Injury
Sites Impact site/
under skull #
Anteroinferior frontal
Anterior Temporal
Occipital Regions
Petechial
hemorrahges
coalesce
Intracerebral
Hematomas later on.
DAI
Hallmark of severe
traumatic Brain Injury
Differential Movement
of Adjacent regions of
Brain during
acceleration and
Deceleration.
DAI is major cause of
prolonged COMA after
TBI, probably due to
disruption of
Ascending Reticular
connections to Cortex.
Angular forces >
Oblique/ Sagital Forces
Blood Flow
changes(Global/reg
ional)
Uncoupling of
Substrate delivery
and extraction
CBF
CMRoxy
External
Compression
Intraparenchymal
Extraxial
(subdural/epidural)
Pneumocephalus
Depressed skull
fracture
Initial Stabilization
Initial assessment and resuscitative
efforts proceed concurrently.
Few things to watch for,
1.Airway
2.Cervical spine injury
3.Hypotension
4.Hypothermia
5.Neurogenic Hypertension
Neurological Assessment
Rapid Trauma Neurological Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
Level Of Consciousness
Pupils
Eom
Fundi
Extremity Movement
Response To Pain
Deep Tendon Reflexes
Plantar Responses
Brainstem Reflexes
Level Of Consciousness
Glasgow Coma Scale
Eye Opening
Spontaneous
To Voice
3
To Pain
None
1
Best Verbal
4 Oriented
Best Motor
Obeys
Command
Localizes
Withdraws
Incomprehensible 2
Flexion
None
Extension
None
Confused
2 Inappropriate
Verbal response
Motor response
Smiles, orientated
to sounds, follows
objects, interacts.
5
Cries but
consolable,
inappropriate
interaction 4
Inconsistently
inconsolable,
moaning
3
Inconsolable,
agitated
2
No verbal response
1
Extension to pain
(decerebrate response) 2
No motor response
Pupillary
Exam
Pupillary size is
balance b/n
Sympath and
parasympatheti
c influences.
Size, shape and
reactivity to
light are tested
parameters.
Mydriasis
Miosis
3 Cr.N.
damageMydriasis
Carotid A.
injury in neck
or skull base
Unilateral
mydriasis
Transtentorial (
Uncal)
Herniation
Horners
syndromeMiosis with
Ipsilateral
ptosis and
anhydrosis.
Traumatic
iridoplegia
Hypothalamic,
cervicothoracic
or direct orbital
injury.
Seizure/
postictal state
Atropine /
Sympathomim
etics
Eye Movements
SO4,LR6, All3
Injury location
Abnormality
3 Cr.N
Hemianopsia + ipsilateral
conjugate gaze preference
Brainstem Reflexes
Facial palsy unilateral
Vestibuloocular function
Periodic( Cheyne-stokes)
b/l hemispheric/diencephalic
injury to as caudal as upper pons
Positive Babinski
Neurodiagnostic Evaluation
Skull Radiograph
CT
Contiguous slices from vertex to
foramen Magnum.
Extend to C3 if upper spine #
suspected
Brain, Blood and Bone windows
May miss # that run parallel to CT
slice and located at vertex.
MRI
Cerebral angiography
Carotid/vertebrobasilar
dissections/occlusions
Scalp Injuries
Skull Fractures
Depressed Skull Fractures
Basilar Skull Fractures
Vascular Injuries
Penetrating Head Injury
Intracranial Hemorrhage
Epidural Hematoma
Subdural Hematoma
Subarachnoid Hemorrhage
Intracerebral Hemorrhage
Scalp Injuries
Most are laceration
Simple Linear/ Stellate ED Rx
Extensive, Degloving/Avulsion Repair
GA
Overlying Depressed Skull#, Infections
Repair+ Elevation Of #
Hematomas
Subgaleal
Cephalohematomas
Galeal Apo & Periost
Limited By S.Lines
Skull Fractures
Thin skull #s common place.
Risk of # associated intracranial injuries?
CT to R/o
1. Open
2. Closed
3. Linear (3/4)
4. Comminuted ( multiple branches)
5. Diastatic ( edges split
apart)<3yrleptomeningeal cyst,
cephalomalacia,
6. Depressed
7. Basilar
Depressed Skull #
From focal blow
Closed 10% FND/15% seizures Rx,
for cosmetic reasons
< skull thickness- no elevation
Open/ frontal sinus intracranial wall
elevate and Sx + frontal sinus irrigation
Free floating remove/replace wrt size
and after soaking in abx
Basilar Skull #
Diagnosis
CT is diagnostic
Initial Ct Hyperdense Lentiform
collection beneath skull
Actively bleeding- Mixed densities
Severe anemia- isodense/hypodense
Untreated EDH imaging over days
Hyperdense Isodense Hypodense
w.r.t. brain
Treatment
Non surgical
Minimal / no symptoms
Should be located outside of
Temporal or Post fossae
Should be < 40 ml in volume
Should not be associated with
intradural lesions
Should be discovered 6 or more
hours after the injury
Surgical
Subdural Hematoma
Common in infants.
Cause high velocity impact/
assault/ child abuse/ fall from
significant height.
Associated with cerebral contusions
+ DAI
Adults
Source cortical bridging
Child/infantsveins/
Cerebral
convexities
over frontal/
Occipital + Parietal cortex
Dural
venous
sinuses.
temporal regions
Removed
SAH
Intracere
bral
Rare in Peds.
60%
from small
Bleed
contusions coalesce to
form larger hematoma.
Rarely , violent angular
acceleration bleed in
deep white matter, basal
ganglia, thalamus
Transtentorial Herniation
midbrain bleed ( Duret
hemorrhages)
Common sites
Ant Temporal and Inf
Frontal lobes { impact
against lateral sphenoid
bone/ floor of ant fossa}
CT- hyperdense/mixed
MRI- small petechial
bleed+ DAI
Rx- small- non
operative. Resolve in 23 weeks
Large- Sx drainage.
Repeat CT in small
bleeds after 12-24 hr is
warranted to r/o
coalescence to form
large hematoma.
Penetratin
Infantsg
andHead
children fall on sharp objects
with thin skull and open foraminae could
predispose
for these injuries.
Injury
Intracranial Hypertension
Pathophysiology
ICP monitoring and control are the
cornerstones of TBI management
Normal ICP
Adults <10mmhg
Children 3-7mmhg
Infants 1.5- 6mmhg
When to treat?
Adults > 20
Children >15
Infants >10 { Arbitrary numbers most
commonly used, pending outcome studies}
CBF Autoregulation
CPP = MAP- ICP { mmhg}
Normal Brain
CBF maintained within CPP
range of 50-150mmhg as
vessels can expand / constrict
accommodate p changes.
<50 CPP maximal Dilation
occurs CBF falls as CPP drops
>150CPP maximal
Constriction occurs CBF
raises with CPP
TBI
CBF falls b/n 50-80 mmhg of
CPP Range of Hypo perfusion
Auto regulation may be ,
1.Completely lost linear
relation B/n CBF & CPP
2.Incompletely lost Plateau
after CPP of 80 mmhg
Monro-Kellie doctrine
Vol of intracranial
compartment must
remain constant
because of
inelastance of skull
Normal State- ICV is a balance
b/n Blood, brain & CSF.
With ICSOL ICP remains
normal till compensation can
occur
At the Point of decompensation
The ICP starts to increase.
The brains compensatory
reserve is called Compliance
Measure of compliance
1.Volume pressure response
2.Pressure Volume Index
( PVI)
=
V/ LOG P1P2
Transient elevation
in ICP
Lundberg Waves
1. A wave
Duration = 2-15 min
Amplitude = 50-80mmhg
Results from
Transient occlusion of venous
outflow as bridging veins
occlude against
compressed dura. Or
transient vasodialtion and
hence increase CBF as a
response to ischemia
Sustained A waves may
indicate sustained
elevation in ICP and hence
low brain compliance
2. B waves changes in ICP
w.r.t. Ventilation
3. C waves short lived waves
w.r.t. arterial TraubeHerring waves
ICP measurement
Intraventricular Cath coupled
to ICP transducer is Gold
standard.
Which patients need ICP
monitoring??
1.TBI + abnormal CT scan who
are not following commands
( 50-63%)
2.Comatose + Normal CT had
lower risk ( 13%) unless
associated with
1. Older age
2. Systemic Hypotension ,
<90mmhg
3. Motor posturing, with
these risk is upto 60%
3.Most clinicians use abnormal
CT scan result + low GCS scores
( < 8) as candidates for ICP
monitoring
Device / method
Risk / benefit
1. Intraventricular catheter
Mangement of ICP
Goal to maintain CPP by
Reducing ICP, and/or
Increasing MAP { hyper/normo volumia preffered as
opposed old school Hypovol}
Brief periods of hypotension can double the mortality rates
CPP should be match with cerebral metabolic demand to
avoid hypoperfusion / hypeeperfusion.
Cerebral OEF is helpful as,
Decrease in CBF increase OEF increase AvDo2 fraction
AvDo2= diff b/n O2 content of Arterial jugular mixed
venous blood.
Considering Ao2 as constant, venous O2 alone can solely
be assessed.
Normal svJo2 is 65%, a drop to 50-55% global cerebral
ischemia
Hyperdynamic therapy
To maintain CPP of about >70, by increasing
MAP
{ CPP= MAP-ICP}
IVF- crystalloid/colloid
PRBC if low HCT(<30%)
Pressors as needed ( Dopa, Dobu,Phenylephri)
if autoregulation is intact? incres CPP
vasoconstriction constant CBFless
volume reduction in ICP.
Systemic Hypo ? Vice versa
Contin drainage
Rx + hypothermia.
Disadvantages
1.paco2 < 30 torr red CBF to
ischemic level
2.Regional variation in autoreg
hyperventilation induced reverse
vascular steal
Current recommendations
1. routine hypervent ( 35 ) not be
used in first 24 hrs
2.Chronic hypervent be avoided
in absence of documented ICP
rise
3.Reserved for deterioration not
responding to other measures.
4.When needed with caution,
PaCo2 never <30 torr.
5.svJo2 can be used as indicator
of extreme ischemia( CBF fall)
6.If used, withdrawn slowly to
avoid rebound rise
Diuretics
Mannitol works as osmotic
diuretic extract extra and
intra cellular edema fluid from
brain
3 dosing methods
intermittant boluses when ICP
15-20
Intermittant Q6 hrly
Continous infusion
Cons
ALGORITH for
treatment of
elevated ICP with
severe head injury.
( Brain trauma
Foundation,
American
Association of
neurological
Surgeons, Joint
section of
Neurotrauma and
critical care)
Bispectral Index
Bispectral index(BIS) is
one of several recently
developed technologies
which purport to monitor
depth of anesthesia.
Uses ,
1. Monitor depth of anesthesia
2. Reduce incidence of
intraoperative awareness
3. Monitor recovery from brain
injury
4. With ICP to monitor during
therapeutic burst
suppression.
5. 0-100 scale.
6. 40-60 good depth of
Anesthesia.
Seizure prophylaxis
Only during first week Or
till intracranial
hypertension phase is
passed.
Prolonged usage has
cognitive deficits on
long term follow ups.
Phenytoin commonly used
Thank You