Evidenced-Based Care of the Child with Traumatic Head Injury

1
Evidenced-Based Care of the Child with Traumatic
Head Injury

• Tara Trimarchi MSN, CRNP
• Pediatric Intensive Care Unit
• The Childrens Hospital of Philadelphia
• University of Pennsylvania
• School of Nursing

2
Objectives

• Discuss the scientific rationale for the
  therapeutic interventions used in the care of
  brain injured children
• Provide research based recommendations for the
  care of children with traumatic brain injury

3
Monroe- Kellie Principle
Copied from Rogers (1996) Textbook of Pediatric
Intensive Care p. 646
4
Traumatic Mass Occupying Lesions

• Epidural hematoma
• Subdural hematoma
• Subarachnoid hemorrhage
• Intra-paranchymal hemorrhage

5
Cerebral Spinal Fluid

• Produced by the choroid plexus
• Average volume 90 - 150 ml
• (0.35 ml / minute or 500 ml / day)
• Reabsorbed through the arachnoid villi
• Drainage may be blocked by inflammation of the
  arachnoid villi, diffuse cerebral edema, mass
  effect of hemorrhage or intraventricular
  hemorrhage

6
Cerebral Blood Flow
Regulation of Cerebral Vascular Resistance
CBF
Normal 50 - 100 ml / min
PaCo2 (mmHg)
MAP (mmHg)
Normal 30 - 50 mmHg
Normal 60 - 150 mmHg
Adapted from Rogers (1996) Textbook of
Pediatric Intensive Care pp. 648 - 651
7
Cerebral Edema

• Cellular response to injury
• Primary injury (mechanical trauma at time of
  event) and ...
• Secondary injury
• Hypoxic-ischemic injury
• Injured neurons have increased metabolic needs
• Concurrent hypotension and hypoxemia may be
  present
• Inflammatory response results

8
Diffuse Axonal Injury

• Shearing injury of axons
• Deep cerebral cortex, thalamus, basal ganglia
• Punctate hemorrhage and diffuse cerebral edema

Image from Neuroscience for Kids
www.faculty.washington.edu/chudler/cells/html
9
Neuronal Response to Injury
Primary mechanical injury secondary
hypoxic-ischemic injury
Inflammation Vasoreactivity Thrombosis
Neutrophils
Ca
ATP
Lactate Acidosis
Glucose
NMDA
.
O
Edema
Glutamate
Cyclooxygenase Lipoxygenase
Arachidonic Acid
Leukotriene Thromboxane Prostaglandin
Fluid
T.Trimarchi 2000
10
Is hyperglycemia detrimental?

• Hyperglycemia is associated with high brain
  lactate levels and possibly greater cerebral
  cellular injury, particularly in the early phases
  of brain injury (animal research / not conclusive
  / older studies)
• Recommendation Avoid hyperglycemia,
  particularly during the early stages of brain
  injury. Consider the use of intravenous
  solutions that do not contain dextrose for early
  fluid and electrolyte management
• Chopp et al., (1988). Stroke, 19.
• Lanier et al., (1987). Anesthesiology, 66.
• Ljunggren et al. (1974). Brain Research, 77.
• Myers et al., (1976). Journal of Neuropathology
  and Experiemental Neurology, 35.
• Smith et al. (1986). Journal of Cerebral Blood
  Flow and Metabolism, 6.
• Natale et al. (1990). Resuscitation, 19.

Source Rogers (1996) Textbook of Pediatric
Intensive Care pp.702-704
11
Monitoring Brain Metabolism

• Jugular Venous Catheter
• Jugular Venous Oxygen Saturation (SJVO2)
• Arteriojugular Venous Oxygen Difference (AJVO2)
• Cerebral Metabolic Rate For Oxygen (CMRO2)
• Possible better outcome when used (adult study)
• Cruz (1998) Critical Care Medicine, 26(2)
• Brain Sensors
• Brain tissue pH, PaO2, PcO2, lactate
• Kiening (1997) Neurology Research, 19(3)

12
Basic Monitoring
Ong et al. (1996) Pediatric Neurosurgery, 24(6)
GCS, hypoxemia and radiologic evidence of SAH,
cerebral edema and DAI are predictive of
morbidity GCS alone does not predict
morbidity Kokoska et al. (1998), Journal of
Pediatric Surgery, 33(2) Hypotension is
predictive of morbidity GCS and Pediatric Trauma
Score are not predictive of outcome

• Serial neurologic examinations
• Circulation / respiration
• Intracranial Pressure
• Cerebral Perfusion Pressure
• Radiologic Studies
• Laboratory Studies

Scherer Spangenberg, (1998) Critical Care
Medicine, 26(1) Fibrinogen and platelets are
significantly decreased in TBI patients
13
OverviewManagement of Traumatic Head Injury

• Maximize oxygenation and ventilation
• Support circulation / maximize cerebral perfusion
  pressure
• Decrease intracranial pressure
• Decrease cerebral metabolic rate

14
Respiratory Support Maximize Oxygenation

• Hypoxemia is predictive of morbidity
• Ong et al. (1996) Pediatric Neurosurgery, 24(6)
• Neurogenic pulmonary edema, concurrent lung
  injury, development of ARDS may be present
• Is use of Positive End Expiratory Pressure to
  maximize oxygenation a safe practice?
• May impair cerebral venous return
• Cooper et al. (1985) Journal of Neurosurgery, 63
• PEEP gt 10 cm H2O increases ICP
• Feldman et al. (1997) Journal of Neurosurgical
  Anesthesiology, 9(2)

15
Respiratory Support Normoventilation

• Hyperventilation Historical management more
  harm than good ???

CBF pre- hyperventilation CBF
post-hyperventilation
Originally adapted from research by Skippen et
al. (1997) Critical Care Medicine, 25
Image from ALL-NET Pediatric Critical Care
Textbook www.med.ub.es/All-Net/english/neuropage
/protect/vent-5htm
16
Research Supporting Normoventilation

• Forbes et al. (1998) Journal of Neurosurgery,
  88(3)
• Marion et al. (1995) New Horizons, 3(3)
• McLaughlin Marion (1996) Journal of
  Neurosurgery, 85(5)
• Muizelaar et al. (1991) Journal of Neurosurgery,
  75(5)
• Newell et al. (1996) Neurosurgery, 39(1)
• Skippen et al. (1997) Critical Care Medicine,
  25(8)
• Yundt Diringer (1997) Critical Care Clinics,
  13(1)

17
Use of Hyperventilation ...

• Transient management of very acute and serious
  elevation of intracranial pressure
• Possible role for occassional, preemptive use
  before activities known to seriously increase
  intracranial pressure
• No lower than 32-35 cmH20

--- Moderate and transient ---
18
Circulatory Support Maintain Cerebral
Perfusion Pressure
CPP MAP - ICP
Number of Hypotensive Episodes in the first 24
hours after TBI
Kokoska et al. (1998), Journal of Pediatric
Surgery, 33(2)
19
Circulatory Support Maintain Cerebral
Perfusion Pressure
CPP MAP - ICP

• Adelson et al. (1997) Pediatric Neurosurgery,
  26(4)
• Children (particularly lt 24 months old) are at
  increased risk of cerebral hypo-perfusion after
  TBI
• Low CBF is predictive of morbidity
• Rosner et al. (1995) Journal of Neurosurgery,
  83(6)
• Management aimed at maintaining CPP (70 mmHg)
  improves outcomes

20
Decreasing Intracranial Pressure
Brain
Blood
CSF
Mass

• Evacuate hematoma
• Drain CSF
• Intraventricular catheters use is limited by
  degree of edema and ventricular effacement
• Craniotomy
• Permanence, risk of infection, questionable
  benefit
• Reduce cerebral edema
• Promote venous return
• Reduce activity associated with elevated ICP
• Reduce cerebral metabolic rate

Bone
21
Hyperosmolar Therapy Increase Blood Osmolarity
Decreasing Intracranial Pressure
Brain cell
Blood vessel
Fluid
Movement of fluid out of cell reduces edema
Osmosis Fluid will move from area of lower
osmolarity to an area of higher osmolarity
T. Trimarchi, 2000
22
Diuretic Therapy
Decreasing Intracranial Pressure

• Loop Diuretic
• Furosemide
• Decreased CSF formation
• Decreased systemic and cerebral blood volume
  (impairs sodium and water movement across blood
  brain barrier)
• May have best affect in conjunction with mannitol
• Pollay et al. (1983) Journal of Neurosurgery, 59
  Wilkinson (1983) Neurosurgery,12(4)

• Osmotic Diuretic
• Mannitol (0.25-1 gm / kg)
• Increases serum osmolarity
• Vasoconstriction (adenosine) / less effect if
  autoregulation is impaired and if CPP is lt 70
• Initial increase in blood volume, BP and ICP
  followed by decrease
• Questionable mechanism of lowering ICP
• Rosner et al. (1987) Neurosurgery, 21(2)

23
Hypertonic Fluid Administration
Decreasing Intracranial Pressure

• Fisher et al. (1992) Journal of Neurosurgical
  Anesthesiology, 4
• Reduction in mean ICP in children 2 hours after
  bolus administration of 3 saline
• Taylor et al. (1996) Journal of Pediatric
  Surgery,31(1)
• ICP is lowered by resuscitation with hypertonic
  saline vs. lactated ringers solution in an animal
  model
• Qureshi et al. (1998) Critical Care Medicine,
  26(3)
• Reduction in mean ICP within 12 hours of
  continuous infusion of 3 sadium acetate solution
• Little continued benefit after 72 hours of
  treatment

24
Hyperosmolar Therapy
Goal Sodium 145-155 mmol/L

• Sodium square
• ICP circle

Copied from Qureshi et al. (1998) Critical
Care Medicine, 26(3)
25
Decrease Intracranial Pressure Promote Venous
Drainage

• Keep neck mid-line and elevate head of bed . To
  what degree?

Feldman et al. (1992) Journal of Neurosurgery,
76 March et al. (1990) Journal of Neuroscience
Nursing, 22(6) Parsons Wilson (1984) Nursing
Research, 33(2)
Image from Dicarlo in ALL-NET Pediatric
Critical Care Textbook www.med.ub.es/All-Net/eng
lish/neuropage/protect/icp-tx-3.htm
26
Management of Pain Agitation
Decrease Intracranial Pressure

• Problems
• Difficult to assess neurologic exam
• Risk of hypotension
• Use short acting agents

• Opiods
• Benzodiazepines

• Management of Movement
• Neuromuscular blockade may be required - use
  only when necessary

Do opiods increase CBF and ICP as well as lower
MAP and CPP? Increased ICP with concurrent
decreased MAP and CPP has been documented with
use of opiods. But, elevation in ICP is
transient and there is no resulting ischemia from
decreased MAP / CPP.
Albanese et al. (1999) Critical Care Medicine,
27(2)
27
Nursing Activities and ICP
ICP
Rising (1993) Journal of Neuroscience Nursing,
25(5)
28
Suctioning Practices

• Hyper-oxygenation
• Mild / moderate hyperventilation
• Brown Peeples (1992) Heart Lung, 21
• Parsons Shogan (1982) Heart Lung, 13
• Intratracheal / intravenous lidocaine
• Donegan Bedford (1980) Anesthesiology, 52
• Wainright Gould (1996) Intensive Critical
  Care Nursing, 12

53
Percent increase in ICP with suctioning using
preemptive hyperventilation, IV lidocaine and IT
lidocaine
0
Individualize suctioning practices according the
patients response
Wainright Gould (1996)
29
Family Contact and ICP

• Presence, touch and voice of family / significant
  others...
• Does not significantly increase ICP
• Has been demonstrated to decrease ICP

Bruya (1981) Journal of Neuroscience Nursing,
13 Hendrickson (1987) Journal of Neuroscience
Nursing, 19(1) Mitchell (1985) Nursing
Administration Quarterly, 9(4) Treolar (1991)
Journal of Neuroscience Nursing, 23(5)
Note Visitors require education and
preparation before spending time at bedside !
30
Reduction of Cerebral Metabolic Rate

• Goal Reduce cerebral oxygen requirement
• Anticonvulsants
• To prevent seizure activity
• Pentobarbital ??
• Adverse effects include hypotension and bone
  marrow dysfunction
• Used only after unsuccessful attempts to control
  ICP and maximize CPP with other therapies
• Improved outcome not fully supported by research

Traeger et al. (1983) Critical Care Medicine,
11 Ward et al. (1985) Journal of Neurosurgery,
62(3)
31
Reduction of Cerebral Metabolic Rate Hypothermia

• Metz et al. (1996) Journal of Neurosurgery,
  85(4)
• 32.5 C reduced cerebral metabolic rate for oxygen
  (CMRO2) by 45 without change in CBF
• intracranial pressure decreased significantly (p
  lt 0.01)
• Marion et al. (1997) New England Journal of
  Medicine, 336(8)
• At 12 months, 62 of patients (GCS of 5-7) cooled
  to 32-33 C have good outcomes vs. 38 of patients
  in control group

• Side-effects
• Potassium flux
• Coagulopathy
• Shivering
• Skin Breakdown

No pediatric studies!

• Requires
• Slow re-warming
• Close monitoring

32
Summary of Recommended Practices

• Serial neurologic assessments and physical
  examination
• Continuous cardio-respiratory, ICP, and CPP
  monitoring, /- cerebral metabolism monitoring
  adjuncts
• Maximize Oxygenation and Ventilation
• Maximize oxygenation (cautious use of PEEP /
  keep PEEP lt 10 to prevent inhibited venous return
  / individualize according to patient response)
• Normoventilate
• Support circulation / maximize cerebral perfusion
  pressure
• Maintain mean arterial blood pressure and
  maintain CPP (goal gt 60)

33
Summary of Recommended Practices

• Decrease intracranial pressure
• Evacuate mass occupying hemorrhages
• Consider draining CSF with ventriculostomy when
  possible
• Hyperosmolar therapy, /- diuresis (cautious use
  to avoid hypovolemia and decreased BP)
• Mid-line neck, elevated head of bead (some
  research supports elevation not gt 30 degrees)
• Treat pain and agitation - consider
  pre-medication for nursing activities, /-
  neuromuscular blockade (only when needed)
• Careful monitoring of ICP during nursing care,
  cluster nursing activities and limit handling
  when possible
• Suction only as needed, limit passes,
  pre-oxygenate / /- pre-hyperventilate (PaCo2
  not lt 30) / use lidocaine IV or IT when possible
• After careful preparation of visitors, allow calm
  contact

34
Summary of Recommended Practices

• Decrease Cerebral Metabolic Rate
• Prevent seizures
• Reserve pentobarbital for refractory conditions
• Avoid hyperthermia, /- hypothermia
• Avoid hyperglycemia (early)