Paeds · neurology-neurodisability-and-neuromuscular
Moderate and severe traumatic brain injury
Also known as Severe head injury · Severe TBI · Paediatric brain trauma · Intracranial hypertension after trauma · Diffuse axonal injury
Fellowship guide to moderate and severe traumatic brain injury in children. Covers the Glasgow Coma Scale severity bands of mild 13 to 15, moderate 9 to 12, and severe 3 to 8 with the paediatric verbal modification, the Monro-Kellie doctrine and the cerebral perfusion pressure equation, the primary versus secondary brain injury cascade from hypotension and hypoxia to herniation, the structured primary survey with cervical spine immobilisation and intubation for GCS 8 or less, computed tomography and intracranial pressure monitoring, the Brain Trauma Foundation pediatric guideline threshold of treating intracranial pressure over 20 mmHg while keeping cerebral perfusion pressure at least 40 mmHg, the stepwise ladder from head elevation and sedation through 3 percent saline and mannitol to barbiturate coma and decompressive craniectomy, the Hutchison hypothermia trial and the DECRA decompressive craniectomy trial, the recognition of Cushing triad and uncal herniation, and the neurorehabilitation and developmental follow-up.
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Red flags
- Any child with a Glasgow Coma Scale of 8 or less after head injury needs the airway secured by intubation
- A single episode of hypotension doubles mortality, so blood pressure must be maintained from the first contact
- A unilateral fixed dilated pupil with hypertension and bradycardia is uncal herniation and a neurosurgical emergency
- Cushing triad of hypertension, bradycardia, and irregular respiration is a late preterminal sign of critically raised intracranial pressure
- A lucid interval followed by rapid deterioration points to an extradural haematoma that needs urgent evacuation
- Do not use prophylactic hypothermia or prophylactic hyperventilation, because both can worsen outcome
- An infant with a subdural bleed and an inconsistent history raises non-accidental injury until excluded
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Clinical exam formats
Board mappings
- Classifies traumatic brain injury by the Glasgow Coma Scale into mild 13 to 15, moderate 9 to 12, and severe 3 to 8, and recognises severe injury as a child with a GCS of 8 or less
- States that airway, breathing, and circulation with cervical spine immobilisation come first and that a child with GCS 8 or less needs intubation
- Identifies hypotension, hypoxia, hypercapnia, hyperthermia, and seizures as secondary brain insults that worsen outcome and must be prevented
- Explains the Monro-Kellie doctrine, the cerebral perfusion pressure equation that CPP equals MAP minus ICP, and the cascade from raised intracranial pressure to herniation
- Applies the Brain Trauma Foundation pediatric guideline threshold of treating intracranial pressure over 20 mmHg while keeping cerebral perfusion pressure at least 40 mmHg
- Runs the stepwise intracranial pressure ladder from head elevation and sedation through hyperosmolar therapy to barbiturate coma and decompressive craniectomy, and appraises the hypothermia and DECRA trial evidence
- Glasgow Coma Scale severity bands and the indication to intubate any child with a GCS of 8 or less
- The intracranial pressure treatment threshold of 20 mmHg and the cerebral perfusion pressure floor of 40 mmHg
- The hyperosmolar doses of 3 percent saline 2 to 5 mL per kg and mannitol 0.25 to 1 g per kg, and the avoidance of prophylactic hypothermia and prophylactic hyperventilation
- Runs the immediate resuscitation of a severely head-injured child including airway protection, normoxia, normotension, and cervical spine immobilisation
- Escalates the intracranial pressure management ladder and recognises Cushing triad and pupillary asymmetry as signs of herniation
- Counsels the family on the intensive care course, the prognostic uncertainty, and the neurorehabilitation and developmental follow-up
- Level 1: Recognition that a GCS of 8 or less is severe traumatic brain injury needing airway protection, imaging, and intensive monitoring
- Level 2: Application of secondary brain injury prevention and the intracranial pressure management ladder with correct thresholds and doses
- Level 3: Coordination of refractory intracranial pressure management, neurosurgical decision-making, and the multidisciplinary neurorehabilitation plan
- Glasgow Coma Scale components and severity bands, including the paediatric verbal modification for preverbal children
- Pathophysiology of raised intracranial pressure, the cerebral perfusion pressure equation, and the secondary brain injury cascade
- Evidence from the Brain Trauma Foundation pediatric guidelines, the Hutchison hypothermia trial, and the DECRA decompressive craniectomy trial
- Structured assessment and GCS scoring of a head-injured child with cervical spine immobilisation and an airway decision
- Recognition of herniation signs and escalation of the intracranial pressure management ladder
- Communication with the family on prognosis, intensive care, and long-term neurodevelopmental outcome
- Severe traumatic brain injury as a GCS of 8 or less requiring airway protection, computed tomography, and intracranial pressure monitoring
- Secondary brain injury prevention and the stepwise intracranial pressure management ladder with correct doses and thresholds
- Outcomes and the multidisciplinary rehabilitation plan after severe paediatric traumatic brain injury
- Recognition of severe traumatic brain injury and the priority of airway, breathing, circulation, and cervical spine protection
- Prevention of secondary brain injury and escalation of intracranial pressure therapy using the guideline ladder
- Coordination of intensive care, neurosurgical consultation, and neurorehabilitation follow-up
- Canadian approach to severe paediatric traumatic brain injury with GCS-based severity and airway protection
- Intracranial pressure management ladder with the 20 mmHg treatment threshold and 40 mmHg cerebral perfusion pressure floor
- Appraisal of the hypothermia and decompressive craniectomy evidence and the neurorehabilitation plan
Overview & Definition
A child who does not open the eyes, speak, or obey commands after a head strike has a serious brain injury, and the job at that bedside is to protect the brain from the second, preventable wave of damage. Traumatic brain injury is brain damage caused by an external mechanical force, and in moderate and severe cases the threat is not only the bruise or the bleed that the impact caused, but the swelling, the hypoxia, and the falling blood pressure that follow it. The clinical question at the bedside is always the same: which child is in danger, and what must be done in the next few minutes to keep the brain perfused. [4]
The severity of the injury is graded by the Glasgow Coma Scale, the practical scoring system introduced by Teasdale and Jennett that turns a bedside observation into a number that drives every decision. The scale scores eye opening, verbal response, and motor response, and the total places the child on a spectrum from mild to severe. The line that matters most is at a score of eight. A child at or below eight cannot protect the airway and is at high risk of rising pressure inside the skull, which is why the airway, the breathing, and the circulation come before any scan. [1]
Three ideas make this topic central to the paediatric exam. The damage done at impact cannot be undone, but the damage that follows can be prevented, and so every minute of resuscitation is brain salvage. The Glasgow Coma Scale is the universal currency that decides who is intubated, who is scanned, and who is monitored. And the intracranial pressure ladder, built on the cerebral perfusion pressure equation, is the framework a fellow must run when the brain begins to swell. The Brain Trauma Foundation set these principles out for children in its guidelines, which remain the single most testable source on the topic. [5]
References12ShowHide
- [1]Teasdale G, Jennett B Assessment of coma and impaired consciousness. A practical scale. Lancet, 1974.PMID 4136544
- [2]Kirkham FJ, Newton CR, Whitehouse W Paediatric coma scales. Dev Med Child Neurol, 2008.PMID 18312424
- [3]Kuppermann N, Holmes JF, Dayan PS, et al Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet, 2009.PMID 19758692
- [4]Kochanek PM, Carney N, Adelson PD, et al Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med, 2012.PMID 22217782
- [5]Kochanek PM, Tasker RC, Carney N, et al Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery, 2019.PMID 30822776
- [6]Ducrocq SC, Meyer PG, Orliaguet GA, et al Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med, 2006.PMID 16885795
- [7]Hutchison JS, Ward RE, Lacroix J, et al Hypothermia therapy after traumatic brain injury in children. N Engl J Med, 2008.PMID 18525042
- [8]Cooper DJ, Rosenfeld JV, Murray L, et al Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med, 2011.PMID 21434843
- [9]Wu AG, Samadani U, Slusher TM, et al 23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis. Pediatr Crit Care Med, 2019.PMID 30664588
- [10]Stulce C, Reisner A, Kane JM, et al Fluid Overload in Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med, 2020.PMID 31568241
- [11]Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury N Engl J Med, 2011.PMID 21434843
- [12]Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children N Engl J Med, 2008.PMID 18525042