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.

high10 referencesUpdated 16 July 202628 min readVerification in progress

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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 intubationA single episode of hypotension doubles mortality, so blood pressure must be maintained from the first contactA unilateral fixed dilated pupil with hypertension and bradycardia is uncal herniation and a neurosurgical emergencyCushing triad of hypertension, bradycardia, and irregular respiration is a late preterminal sign of critically raised intracranial pressureA lucid interval followed by rapid deterioration points to an extradural haematoma that needs urgent evacuationDo not use prophylactic hypothermia or prophylactic hyperventilation, because both can worsen outcomeAn infant with a subdural bleed and an inconsistent history raises non-accidental injury until excluded

Life stages

infanttoddlerpreschoolschool-ageadolescent

Care settings

ed-acutewardpicuretrieval

Clinical exam formats

written-onlyracp-dce-long-caseracp-dce-short-casemrcpch-history-managementmrcpch-communicationrcpsc-structured-oral

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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 lessStates that airway, breathing, and circulation with cervical spine immobilisation come first and that a child with GCS 8 or less needs intubationIdentifies hypotension, hypoxia, hypercapnia, hyperthermia, and seizures as secondary brain insults that worsen outcome and must be preventedExplains the Monro-Kellie doctrine, the cerebral perfusion pressure equation that CPP equals MAP minus ICP, and the cascade from raised intracranial pressure to herniationApplies the Brain Trauma Foundation pediatric guideline threshold of treating intracranial pressure over 20 mmHg while keeping cerebral perfusion pressure at least 40 mmHgRuns 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 evidenceGlasgow Coma Scale severity bands and the indication to intubate any child with a GCS of 8 or lessThe intracranial pressure treatment threshold of 20 mmHg and the cerebral perfusion pressure floor of 40 mmHgThe 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 hyperventilationRuns the immediate resuscitation of a severely head-injured child including airway protection, normoxia, normotension, and cervical spine immobilisationEscalates the intracranial pressure management ladder and recognises Cushing triad and pupillary asymmetry as signs of herniationCounsels the family on the intensive care course, the prognostic uncertainty, and the neurorehabilitation and developmental follow-upLevel 1: Recognition that a GCS of 8 or less is severe traumatic brain injury needing airway protection, imaging, and intensive monitoringLevel 2: Application of secondary brain injury prevention and the intracranial pressure management ladder with correct thresholds and dosesLevel 3: Coordination of refractory intracranial pressure management, neurosurgical decision-making, and the multidisciplinary neurorehabilitation planGlasgow Coma Scale components and severity bands, including the paediatric verbal modification for preverbal childrenPathophysiology of raised intracranial pressure, the cerebral perfusion pressure equation, and the secondary brain injury cascadeEvidence from the Brain Trauma Foundation pediatric guidelines, the Hutchison hypothermia trial, and the DECRA decompressive craniectomy trialStructured assessment and GCS scoring of a head-injured child with cervical spine immobilisation and an airway decisionRecognition of herniation signs and escalation of the intracranial pressure management ladderCommunication with the family on prognosis, intensive care, and long-term neurodevelopmental outcomeSevere traumatic brain injury as a GCS of 8 or less requiring airway protection, computed tomography, and intracranial pressure monitoringSecondary brain injury prevention and the stepwise intracranial pressure management ladder with correct doses and thresholdsOutcomes and the multidisciplinary rehabilitation plan after severe paediatric traumatic brain injuryRecognition of severe traumatic brain injury and the priority of airway, breathing, circulation, and cervical spine protectionPrevention of secondary brain injury and escalation of intracranial pressure therapy using the guideline ladderCoordination of intensive care, neurosurgical consultation, and neurorehabilitation follow-upCanadian approach to severe paediatric traumatic brain injury with GCS-based severity and airway protectionIntracranial pressure management ladder with the 20 mmHg treatment threshold and 40 mmHg cerebral perfusion pressure floorAppraisal of the hypothermia and decompressive craniectomy evidence and the neurorehabilitation plan

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Target exams

RACP DWERACP DCEMRCPCH TheoryMRCPCH ClinicalABP General Pediatrics

Red flags

Life stages

infanttoddlerpreschoolschool-ageadolescent

Care settings

ed-acutewardpicuretrieval

Clinical exam formats

written-onlyracp-dce-long-caseracp-dce-short-casemrcpch-history-managementmrcpch-communicationrcpsc-structured-oral

Board mappings

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]

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References10Show ledger

[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

Moderate and severe traumatic brain injury

Also known as Severe head injury · Severe TBI · Paediatric brain trauma · Intracranial hypertension after trauma · Diffuse axonal injury

high10 referencesUpdated 16 July 202628 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References10Show ledger

[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