Pre-hospital Airway Management

? Effect of various
airway maneuvers in pre-
hospital care of
children after TBI
Hypoxemia leads to
poorer neurological
outcome
less success in pre-
hospital intubation
No change in outcome
from pre-hospital
intubation
Class 2

MANAGEMENTUL PACIENTULUI
CU TCC

CURS

 Pre-hospital Airway Management

Standard: Insufficient data to

support treatment
Guidelines: Avoid & correct
hypoxemia
Pre-hosp. BVM vs. ETI: No
advantage
Options: Pre-hospital
endotracheal intubation
ETI: Training in intubation &
EtCO2 monitoring

 BP, paO2, Pre-hosp. Brain-Specific Therapy

Presence of hypoxia had

no effect on mortality
(Class 3)
?Resistance to hypoxia
?Efficient pre-hosp care
BP Poorer Outcome
(Class 3)
BP Better outcome
(Class 2)

BP, paO2, Pre-hosp. Brain-Specific Therapy

Pre-hosp. brain
specific Rx: (NMBA,
sedation, mannitol,
hyperventilation):
No scientific literature
Battles Sign: posterior fossa basal skull fracture
Tailor to patients
needs
Mannitol for brain
herniation without
hypovolemia

 BP, paO2, Pre-hosp. Brain-Specific Therapy

Standard: None
Guidelines: Identify & correct BP
Options: GCS <8 - control airway
(pulse oximetry, EtCO2)
Correct: paO2, hypotension
Sedation, NMBA: Useful in
transport
Mannitol: Not recommended
Mild hyperventilation: Not
recommended

 ICP Monitoring in TBI

Standard: None
Guidelines: None
Options: ICP
monitoring is appropriate in
infants & children with
severe TBI & GCS<8
Class 3 recommendation
except for decompressive
craniotomy Class 2

 Threshold for Treatment of ICP

ICP > 20 mm Hg
ICP elevation > 20
should be corroborated
by frequent clinical
exam, physiologic
variables eg. CPP,
cranial imaging

 Threshold for Treatment of ICP

Standard:
Insufficient data to
support
Guidelines:
Insufficient data to
support
Options: Treatment
for ICP elevation
> 20 mm Hg
Class 3
recommendation

 Temperature control in TBI
Standard: None
Guidelines: None
Options:
1. Extrapolation from
adult data: Avoid
Hyperthermia
(>38.50C)
2. Hypothermia (<350C)
may be considered
for refractory ICP
(Class 3) Burst Suppression EEG Pattern

 Temperature control in TBI

Mechanism:
Reductions in:
Cerebral metabolism
Inflammation,
Lipid peroxidation,
Seizures,
Excitotoxicity

 Surgical Treatment of ICP

Standard: None
Guidelines: None
Options: Consider
decompressive
craniectomy in TBI
(includes abuse TBI),
diffuse brain swelling,
refractory ICP despite
adequate medical
therapy (Class 3)
Extradural hematoma

 Surgical Treatment of ICP

Favorable group:
1. Secondary
deterioration of GCS
2. Evolving cerebral
herniation within the
first 48 hours after injury
Unfavorable
group:
Unimproved GCS 3

Monitors: ICP, Oxygen, &

temperature

 GCS<8

Insert ICP Monitor

Maintain CPP
(Age Appropriate)

NO ICP Consider CT
Carefully withdraw
ICP treatment Sedation & Analgesia
HOB@300

NO ICP
Drain CSF if Ventriculostomy
May continue if is present May continue if S. Osm<360
S. Osm<320
NO ICP
Neuromuscular Blockade

Mannitol PRN ICP HTS 3%

Second Tier
Mild Hyperventilation
PaCO2 30-35 mm
Hg ICP Therapy
 Second Tier Therapy

ICP despite first tier Rx

Working Ventriculostomy Active EEG?

No contraindication to
Consider lumbar drain Barb

Consider high dose Barb

Salvageable patient

Consider decompressive
Evidence of Hyperemia ? craniectomy Evidence of Ischemia?
No Evidence of Ischemia No evidence of
contraindication
to Hypothermia?
Consider Hyperventilation
To PaCO2 < 30 mm Hg Consider moderate
Consider monitoringCBF, hypothermia
SjO2, AFDO2
 Background
Traumatic brain injury
Blunt
MVC
Falls
Abuse

 Anatomy
Brain cross section
Potential spaces

 Anatomy
Intracranial
compartments
Dural structures
Tentorium cerebelli
Falx cerebri

 Anatomy
Pediatric
Larger head in
proportion to BSA
Stability dependent on
ligamentous structures
Higher water content
88% vs 77%
Prone to acceleration-
deceleration injury
Unmyelinated

Open sutures

 Pathophysiology
Primary injury
Secondary injury

 Pathophysiology
Primary injury
Scalp injury
Skull fracture
Basilar skull fracture
Concussion
Contusion
Hematoma

Epidural

Subdural
Hemorrhage

Intraventricular

Subarachnoid

Diffuse axonal injury
Pathophysiology

 Pathophysiology
Secondary injury
Intracranial events
Inflammatory changes
Microciruculatory
disruption
Neuronal disintegration
Pathophysiologic
events
Cerebral edema
Traumatic axonal injury
Ischemia

 Monro-Kellie doctrine
V (I/c) = V (brain) + V(CSF) + V (blood)

 Prehospital
Initial stabilization
Assessment
Blood pressure
GCS
Pupils
SaO2

 History
Injury mechanism
Loss of
consciousness
Amnesia
Intoxication
Bleeding diathesis

 Military Context

 Blast Wave Physics

Courtesy of Keith Prusaczyk, Ph.D.
 Exam
ATLS protocol
Remember cervical spine
Remember tetanus

 Exam

 Exam
HEENT/face
Soft tissue injury
Basilar skull injury
Pupil exam
Facial injury
Lefort
Dental exam

 Exam
Neck
Cervical spine
stabilization
Palpation

NEXUS, CCR

 Classification
Closed head injury
Mild
Moderate
Severe

 Mild TBI
Most common
LOC <20 minutes (30 minutes)
Brief retrograde amnesia (24 hours)
GCS 13-15
Change in mental status
No focal neurological deficit
No intracranial complications
Normal CT findings

 ACEP definition
Blunt head trauma within 24 hours
Post traumatic LOC or amnesia
GCS 15 on presentation
Age >15

 Mild TBI
Low risk for
intracranial injury
No LOC
No amnesia
Not predictive
Headache
Dizziness
Scalp hematoma
Laceration, abrasion

 Mild TBI
Moderate/high risk
Progressive/severe HA
Age <2 yo
Post traumatic seizure
Focal neuro deficit

Skull fracture
Multi trauma
Blood dyscrasia

 Mild TBI
Infants <2
Difficult to assess
Absence of symptoms
Low threshold for
scan
Consider abuse

 Moderate/Severe TBI
GCS 8-12
GCS <8

 Treatment
Airway management
RSI

Medications
Ventilator management

Eucapnia

Prevent hypoxia
Post intubation care

Sedation
Paralysis

Analgesia

 Treatment
Cardiovascular
management
Euvolemia
MAP > 90
Pressors
CPP 70-80 mm Hg
CPP = MAP - ICP


 Treatment
ICP management
Elevate head of bed
Sedation/paralysis
Diuresis
Osmotic
Loop
Hyperventilation
Barbiturate

 Treatment
Hyperosmolar therapy
Mannitol
320 mOsm
Hypertonic saline
360 mOsm

 Treatment
Barbiturates
Pentobarbital
Thiopental
Goals
ICP <20 mm Hg
Burst suppression on
EEG monitor

 Treatment
Intracranial pressure
monitoring
Intraparenchymal
Intraventricular
Direct CSF drainage
Epidural