Severe Head Injury Management

• Definition:
• 1 or more major criteria or
• 2 or more minor criteria

flowchart TD
 subgraph V["PbrO2 Pathway"]
        V2["Raised FiO2"]
        V1["Maintain PbrO2 >10mmHg"]
        V3["Vasopressor, Hyperventilate, optimize Hb"]
  end
 subgraph W["CPP Pathway"]
        W2["Confirm appropriate CVP (CVP 8-12 mmHg)"]
        W1["Maintain CPP >40mmHg"]
        W3["Bolus hypertonic saline"]
        W4["Vasopressor use"]
  end
 subgraph X["ICP Pathway"]
        X2["Bolus and/or infusion of hypertonic saline"]
        X1["CSF drainage if ventriculostomy present"]
        X3["Additional analgesia/sedation"]
        X4["Neuromuscular blockade"]
        X5["Additional hypertonic saline<br>/hyperosmolar therapy"]
  end
 subgraph Y["Herniation Pathway"]
        Y2["Emergency treatment:<br>Hyperventilation therapy to reverse pupillary dilation<br>FiO2=1.0<br>Bolus of IV hypertonic saline or mannitol<br>Open EVD to continuous drainage<br>Emergency CT"]
        Y1["If signs and symptoms of herniation:<br>Pupillary dilation<br>Hypertension/bradycardia<br>Extensor posturing"]
  end
    U1["TBI (GCS ≤ 8)"] --> U2["Cranial CT"]
    U2 --> U3["Insert ICP Monitor"] & U5["Surgery if target found"]
    U3 --> U4["Maintain appropriate analgesia/Sedation<br>Maintain Normothermia<br>Ensure appropriate intravscular volume (CVP)<br>Mainatain Hb&gt;7<br>Treat coagulopathy<br>Elevate head 30 deg<br>Consider antiepileptics (Keppra/Phenytoin)/EEG<br>Start nutrition as early as possible"]
    U4 --> V & W & X & Y
    V1 -- if PbrO2 still low --> V2
    V2 -- if PbrO2 still low --> V3
    W1 -- if CPP still low --> W2
    W2 -- if CPP still low --> W3
    W3 -- if CPP still low --> W4
    X1 -- "if ICP still raised (ICP &gt; 20-25 for &gt; 5 min;<br>major priority if ICP &gt; 25 mmHg)" --> X2
    X2 -- if ICP still raised --> X3
    X3 -- if ICP still raised --> X4
    X4 -- if ICP still raised --> X5
    Y1 --> Y2
    X5 --> Z["Second tier therapy"]
    Y2 --> Z
    V3 --> Z
    W4 --> Z
    Z --> A["↑ ICP Refractory to <br>first tier therapies"]
    A --> B["Repeat CT scan (if surgical <br>option is being considered)"]
    B --> C{"New or expanding<br>surgical lesion"}
    C -- YES --> D["Surgery as indicated"]
    C -- NO --> F["Barbiturate infusion²"] & G["Moderate hypothermia³<br>32-34°C"] & H["Hyperventilation⁴<br>28-34 mmHg"] & I["Higher levels of<br>osmolar therapy⁵"] & J["Consider additional advanced neuro-monitoring<br>EEG, TCD, PRx, CBF"]
    D --> E["Surgical intervention:<br>Remove mass lesion and/or<br>decompressive craniectomy¹"]

    style U4 fill:#000000
    style V fill:#AA00FF
    style W fill:#FF6D00
    style X fill:#FFD600
    style Y fill:#00C853



    

• Key
• The algorithm includes several components
Baseline Care (black)
• benzodiazepine-opiate (Midazolam-morphine/fentanyl) combination for initial sedative/analgesic therapy.
• Mechanical ventilation target
• PaO2: 90–100 mmHg. 12-13Kpa
• Minute ventilation target: PaCO2: 35-40mmHg 4.6-5.3Kpa
• Intravascular volume target
• Euvolemia: targeting normovolemia requires at least 75% maintenance fluids and that a neutral fluid balance should be achieved with a urine flow rate of greater than 1 mL/kg/hr
• Fluids: Normal saline in general
• Can use 5% dextrose + NS in younger children to prevent hypoglycemia
• Glucose target
• Normoglycaemia: 180 mg/dL (10mmol/L)
• Use insulin if glucose level is greater than 198 mg/dL (11mmol/L) on two consecutive measurements
• Na limits
• 135 mEq/L between 150 mEq/L
• With hyperosmolar therapy it can go higher than 150mEq/L
• Coagulopathy
• Treatment of abnormal coagulation variables is recommended prior to
• Keep INR < 1.6 with FFP before insertion of ICP or Pbro2 monitors
• Keep INR < 1.2 with FFP before decompressive craniectomy
• Caution: Overresuscitation with plasma to normalize INR after TBI in children may worsen coagulopathy, producing fibrinolysis shutdown, and that treatment of coagulopathy should address active bleeding and/or be titrated to thromboelastography
• Antiseizure
• EEG monitor esp when neuromuscular blockade
• Keppra prefered
• No consensus on who to start -- up to you
• ICP Pathway (yellow)
• Targets
• < 20 mm Hg as an initial ICP target in all age groups
• need for an intervention when ICP is > 20 mm Hg for at least 5 minutes.
• Herniation Pathway (green),
• Emergent tx in the herniation pathway
• manual hyperventilation with Fio2 of 1.0, titrated to reversal of pupillary dilation;
• administration of
• mannitol (0.5–1 g/kg) over 10 minutes, or
• Upper limit 320 mOsm/L
• hypertonic saline (3%; 1–3 mL/kg, up to a maximum dose of 250 mL, or 23.4%, 0.5 mL/kg, maximum dose of 30 mL) over 10mins;
• Upper limit 360 mOsm/L
• maintenance of hemodynamic stability
• Cerebral Perfusion Pressure (CPP) Pathway (orange),
• Target: >40mmHg
• Implicit in the CPP pathway is the practice of tolerating mild intracranial hypertension in the presence of adequate CPP (“permissive intracranial hypertension”) as an alternative to immediate initiation of second tier therapies.
• Brain Tissue Partial Pressure of Oxygen (Pbro 2) Pathway (Purple).
• Target >10mmHg
• Raise PbrO2 with
• hypoventilation
• Inc. FiO2
• The blue box indicates the need for second tier therapy
• Solid lines identify the ICP and CPP pathways, reflecting their primary role,
• Dashed line identifies the Pbro 2 pathway given the fact that it represents a monitoring and management option that is less commonly used and has less literature support.
• Dotted plus dashed line identifies the weaning or withdrawal of the various interventions.
• BUN = blood urea nitrogen, CVP = central venous pressure, EEG = electroencephalogram, EVD = external ventricular drain, GCS = Glasgow Coma Scale, Fio 2 = fraction of inspired oxygen, Hgb = hemoglobin, HOB = head of bed.

• Minimal Targets

CPP	40 mm Hg
PbrO2	10 mm Hg
Hb	7 g/dL
ICP	<20mmHg

• For treatment of refractory intracranial hypertension when tier 1 approaches are inadequate.

• CBF = cerebral blood flow, EEG = electroencephalogram, ICP = intracranial pressure, PRx = pressure reactivity index, TCD = transcranial Doppler ultrasonography.

• Barbiturate
• Pentobarbital
• Indicated
• osmotherapy and hyperventilation have failed to maintain ICP less than 25 mmHg
• If barbiturate infusion fails to control ICP, as defined by persistent ICP greater than 25 mm Hg, decompressive craniectomy, or one of the other second tier therapies, should be considered,
• If barbiturate infusion works (ICP maintained <20 mm Hg for 24 hours while receiving a stable pentobarbital infusion dose) the infusion can be decreased and then withdrawn over 24–96 hours.

• Hypothermia
• Early moderate hypothermia has been tested in clinical trials and is not recommended
• Hutchinson 2008 and Beca et al 2015
• Hypothermia has poorer outcome and mortality
• Late Hypothermia can be used (32-34 deg)
• Only used in some studies but not studied in RCT

• the interventions are withdrawn in the reverse order of their application.

• Need to show 24 hrs of stability before starting to wean

• Consider ICP monitoring in infants and children with severe TBI and treating when ICP exceeds 20-25 mmHg.

https://braintrauma.org/coma/guidelines/pediatric