Pediatric Head Trauma

The goals of therapy are:

1. limit the impact of  secondary brain injury

   1. physiologic and biochemical processes that occur as a result of the primary injury; swelling is an example

2. prevent second insults

   1. These are preventable conditions that occur following trauma that may complicate and exacerbate the original injury; an example is ischemia that occurs due to hypoxemia or hypotension

Initial treatment goals for pediatric head trauma

1. Maintain adequate perfusion
2. Maintain optimal oxygenation
3. Maintain optimal ventilation

What to do for the trauma patient:

1. Head of Bed elevated 30 degrees
2. Head in mid-line position
3. Use only isotonic fluid for resuscitation and maintenance
4. Intubate for GCS≤ 8
5. Provide adequate  sedation once intubated
6. Maintain PaCo2 / ETCO2 35 – 40
7. DO NOT HYPERVENTILATE

The signs of increase ICP and possible herniation:

1.  Changes in pupillary response

i. unequal and/or nonreactive pupils
ii. unilateral pupillary dilation, minimal changes in conscious and contralateral weakness are ominous signs suggestive of uncal herniation syndrome.

2.  changes in the level of consciousness
3. Flexor posturing
4. Cushings Triad:

i. Bradycardia
ii. Hypertension
iii. Central Hyperventilation

Treating herniation:

1. Ventilation

i. Intubation

1. Taking precautions to limit the effect on ICP

ii. Bag Valve Mask

2. Mild Hyperventilation (PaCO2 35 to 40)
3. Osmolar agents:

i. Mannitol IV bolus 0.25 – 0.5 mg/kg

1. if the patient’s perfusion and BP are adequate
2. Mannitol will rapidly lower blood pressure

ii. 3% Normal Saline

1. if the patient has some degree of hemodynamic compromise
2. 3% NS will maintain blood pressure and increase osmolarity     

Reference Article: “Critical care management of head trauma in children” Critical care Medicine 2002 Vol. 30, no. 11

The information provided is intended as a resource only not medical advice.