David Bliss
Chris Dael
Tim Deakers
Michael Levy
Karl Maher
Todd Maugans
Gordon McComb
Karen McVeigh
Alan Nager
Christopher Newth
Carol Nicholson
Niurka Rivero
Randall Wetzel Children’s Hospital of Los Angeles
11.18.97 Management Guidelines for Head Trauma
David Bliss
Chris Dael
Tim Deakers
Michael Levy
Karl Maher
Todd Maugans
Gordon McComb
Karen McVeigh
Alan Nager
Christopher Newth
Carol Nicholson
Niurka Rivero
Randall Wetzel Children’s Hospital of Los Angeles
11.18.97 Management Guidelines for Head Trauma
Comments: R. Chestnut I
“As a result of tumultuous growth and somewhat erratic emergence of neurotraumatology, there is little consensus at this time regarding pathophysiologic mechanisms and methods of management.”
Randall Chestnut. CCM 25:1275,1997.
Comments: R. Chestnut II
“It is generally accepted that an organised concatenation of individually unproven but collectively apparently successful therapies is associated with improved outcome from traumatic brain injury.”
Randall Chestnut. CCM 25:1275,1997.
Comments: R. Chestnut III
“However, there appears to be significant controversy regarding most of the component treatment concepts when approached individually.”
Randall Chestnut. CCM 25:1275,1997.
Airway management: GCS
Patients with Glasgow coma scores of 8 or below require oral endotracheal intubation.
succinylcholine : its rapid onset and rapid reversibility make it desirable in the trauma patient
succinylcholine : can lead to increased ICP, cerebral blood flow and CO2 production
these potential adverse effects can be minimized, making our first choice for neuromuscular blockade in the acute trauma setting succinylcholine (1-2 mg/kg IV)
Normalize the circulation and respiration. The decision to intubate and institute mechanical ventilation should center around the need for stabilization of the upper airway; are protective airway reflexes (i.e., cough and gag) intact? Can the child protect himself against aspiration? Respiratory drive may still be intact in a the stuporous person, but the gag reflex may be lacking, or upper airway muscle tone may be lax.
Airway management: succinylcholine
can elevate I.C.P. independent of laryngoscopy and intubation
related to increased muscle spindle activity
partially blocked by precurarisation
succinylcholine can be given to severely head injuried patients in the ICU without detrimental effects
Airway management: adjuncts I
2-5 minutes before the succinylcholine:
atropine (0.01mg/kg)
lidocaine (1.5-2.0 mg/kg)
defasciculation:
pancuronium (0.03 mg/kg)
vecuronium (0.03 mg/kg)
Airway management: adjuncts II
sedation:
midazolam (0.05 - 2.0 mg/kg)
sodium thiopentone (1 -4 mg/kg IV bolus)
[only if hemodynamics are stable]
analgesia:
fentanyl (1-5 mcg/kg)
Airway management: non-depolarizing agents
In controlled circumstances, where large doses of non-polarizing neuromuscular blocking agents can be safely administered and sufficient personnel are available, an alternative (non-depolarizing) neuromuscular blocking agent might be used:
rocuronium 1-1.5 mg/kg IV
vecuronium 0.2-0.4 mg/kg IV
Ventilation I
regional blood flow is decreased by hyperventilation in head injured children
hyperaemia is less common than once thought
CMRO2 is decreased more than perfusion
outcomes are worse in the mild to moderate injury group.
J Neurosurg 75:731-739, 1991.
Crit Care Med 25:1402-1409, 1997.
Ventilation II
There is
no indication
for
prophylactic
hyperventilation. Normocapnoea is good for you !
Ventilation III
The recommended standard of care at CHLA is to monitor end tidal pCO2 following oral endotracheal intubation, during transport, during neuroradiologic procedures and in the intensive care unit.
Normocapnoea is the goal
3 y/o boy after MVA. Spontaneouly breathing but nasal flaring present. Atlantoaxial distraction with
severed spinal cord odontoid atlas
Intravascular volume I
The targeted ideal for volume resuscitation in head trauma is euvolemia. This should be maintained with either normal saline or Lactated Ringer's.
Normalize the circulation and respiration. Circulation should be normalized, with the aim of optimizing perfusion to all tissues. In general a modest fluid restriction is beneficial, mainly to avoid fluid overload and attendant hypervolemia. One should not restrict, however, to the point of oliguria, as circulation may suffer and little real benefit has been demonstrated with fluid restriction. The urine output and serum sodium should be monitored, however, and fluid restriction tightened if there are signs of the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Intravascular volume II
Intravascular volume should be maintained with solutions containing >133meq\L Na+ (isotonic).
Hypertonic (3%) saline may be indicated (euvolaemic hypernatraemia).
Fluid management in the face of SIADH or diabetes insipidus (DI). Inappropriate secretion of antidiuretic hormone is a frequent accompaniment of central nervous system injury or infection, and it can occur with other types of brain disruption as well, and with pulmonary disease. The diagnosis of SIADH can be made tentatively by analyzing urine and serum osmolalities in the hyponatremic patient. Urine osmolality should be higher than expected, and is sometimes higher than the serum osmolality. The effects of SIADH can be lessened by fluid restriction; SIADH is almost always self-limited, although it may persist until mechanical ventilation ceases. Diabetes insipidus, on the other hand, often heralds a very poor outcome in the child with significant brain injury. A damaged pituitary or hypothalamus can induce unbridled urine output, dehydration and a rapidly rising serum sodium. The sodium can rise as much as 30 mEq/L in a few hours. Diabetes insipidus can be managed with vigorous intravenous fluid intake, but is better controlled with vasopressin or DDAVP.
Intravascular volume III
Hyperglycaemia and Hypoglycaemia must be avoided.
Glucose (D5) not indicated for children over 6 months of age.
monitor serum glucose.
Sedation and pain management I
Children who are agitated or possibly in pain, require sedation and/or analgesia.
Sedation and pain management II
Midazolam and fentanyl are adequate, short acting drugs to be used in this setting. No other drugs are necessary routinely for sedation and analgesia in the first 12 hours.
fentanyl: 1-3 mcg/kg/min q 1 hr prn
midazolam: 0.05 to 0.1 mg/kg over 2 minutes
Propofol has been considered; however, it has a propensity for hypotension in the acute setting.
Positioning I
In-line traction for intubation
(all head injury is neck injury)
Do Not occlude venous drainage
watch the neck collars
avoid Trendelenberg (central lines)
Comments