What is the immediate management for a child with central nervous system (CNS) trauma and suspected hemorrhage?

From the Guidelines

The immediate management for a child with CNS trauma and suspected hemorrhage requires rapid stabilization following the ABCDE approach, with a focus on securing the airway, ensuring adequate oxygenation, and maintaining cervical spine immobilization until injury is ruled out, as recommended by the most recent guidelines 1. The first step is to secure the airway and ensure adequate oxygenation, aiming for oxygen saturation above 95%.

• Maintain cervical spine immobilization until injury is ruled out, as the mechanism of injury may be compatible with spinal injury 1.
• Control any external bleeding with direct pressure.
• Establish two large-bore IV lines and begin isotonic crystalloid fluid resuscitation with normal saline or Ringer's lactate at 20 mL/kg boluses, reassessing after each bolus. For hypotension, target a systolic blood pressure appropriate for age, with mean arterial blood pressure targets provided in Table 5 of the guidelines 1. Perform a rapid neurological assessment including Glasgow Coma Scale, pupillary response, and motor function. Administer mannitol 0.5-1 g/kg IV or hypertonic saline 3% at 3-5 mL/kg over 10-20 minutes for signs of increased intracranial pressure, as recommended by the guidelines 1. Prevent secondary brain injury by maintaining normothermia, normoglycemia, and treating seizures promptly with benzodiazepines (lorazepam 0.1 mg/kg IV or midazolam 0.1 mg/kg IV). Urgent neuroimaging with CT scan should be obtained, and neurosurgical consultation initiated immediately, as recommended by the guidelines 1. This approach addresses both the primary trauma and prevents secondary injury from hypoxia, hypotension, and increased intracranial pressure, which can significantly worsen outcomes in pediatric CNS trauma. It is also important to consider the management of bleeding and coagulopathy following major trauma, as outlined in the guidelines 1. The management of severe traumatic brain injury in children should be done in a pediatric trauma centre or in an adult trauma centre with pediatric expertise, as recommended by the guidelines 1.

From the FDA Drug Label

Mannitol Injection is indicated for the following purposes in adults and pediatric patients. Therapeutic Use Reduction of intracranial pressure and brain mass.

Reduction of Intracranial Pressure and Brain Mass: Pediatric patients: 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes.

The immediate management for a child with central nervous system (CNS) trauma and suspected hemorrhage may include the administration of Mannitol (IV) to reduce intracranial pressure and brain mass. The recommended dosage for pediatric patients is 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes 2. However, it is crucial to carefully evaluate the patient's condition and monitor for potential adverse reactions, particularly Central Nervous System (CNS) Toxicity, as mannitol may worsen intracranial hypertension in children who develop generalized cerebral hyperemia during the first 24 to 48 hours post injury 2.

• Key considerations:
  • Monitor serum sodium and potassium levels during mannitol administration.
  • Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol.
  • Discontinue mannitol if renal, cardiac, or pulmonary status worsens, or CNS toxicity develops.
  • The patient's clinical status should be closely reviewed and mannitol infusion suspended if necessary. 2, 2

From the Research

Immediate Management for a Child with CNS Trauma and Suspected Hemorrhage

The immediate management of a child with central nervous system (CNS) trauma and suspected hemorrhage involves several key steps:

• Ensuring adequate airway, breathing, and circulation (ABCs) to prevent further brain injury due to hypoxia or hypotension 3
• Conducting a comprehensive neurological examination to assess the severity of the injury and guide further management
• Using hyperosmolar therapy, such as mannitol or hypertonic saline, to reduce intracranial pressure (ICP) and prevent further brain injury 3, 4, 5
• Considering the use of seizure prophylaxis, such as levetiracetam or phenytoin, to prevent post-traumatic seizures 6
• Obtaining repeat neuroimaging to monitor for radiologic progression of the hemorrhage and guide further management 7

Hyperosmolar Therapy

Hyperosmolar therapy is a crucial component of the management of CNS trauma and suspected hemorrhage:

• Mannitol and hypertonic saline are commonly used hyperosmolar agents to reduce ICP 3, 4, 5
• The choice of hyperosmolar agent may depend on the specific clinical scenario and the patient's individual needs
• Equiosmolar doses of mannitol and hypertonic saline have been shown to be equally effective in reducing ICP in children with severe traumatic brain injury 5

Seizure Prophylaxis

Seizure prophylaxis is an important consideration in the management of CNS trauma and suspected hemorrhage:

• Levetiracetam and phenytoin are commonly used antiepileptic medications for seizure prophylaxis 6
• Phenytoin has been shown to reach therapeutic levels in the cerebrospinal fluid (CSF) more quickly than levetiracetam 6
• The choice of antiepileptic medication may depend on the specific clinical scenario and the patient's individual needs

Monitoring and Further Management

Close monitoring and further management are critical in the care of a child with CNS trauma and suspected hemorrhage:

• Repeat neuroimaging should be obtained to monitor for radiologic progression of the hemorrhage 7
• The patient should be closely monitored for signs of clinical deterioration, such as worsening neurological examination or increasing ICP
• Further management may include surgical intervention, such as craniotomy or ventriculostomy, depending on the specific clinical scenario 7