What are the management strategies for pediatric head trauma in a surgery casualty setting?

Pediatric Head Trauma Management in Surgery Casualty

Children with severe head trauma must be immediately transferred to a pediatric trauma center or an adult trauma center with pediatric expertise, as this approach significantly reduces morbidity and mortality. 1

Initial Assessment and Severity Classification

• Assess severity immediately using the Glasgow Coma Scale (GCS), focusing specifically on the motor response component, along with pupillary size and reactivity. 1, 2
• Classify severity as: Severe (GCS ≤8), Moderate (GCS 9-13), or Mild (GCS 14-15). 2
• Age, initial GCS score, and pupillary examination are the key prognostic factors that predict neurological outcome. 2

Immediate Resuscitation Priorities (The "ABCs" Reconsidered)

Airway Management

• Secure the airway in children with severe TBI (GCS ≤8) to prevent hypoxemia, which significantly increases mortality and worsens neurological outcomes. 2
• However, recognize that intubation in pediatric TBI patients with depressed mental status is associated with higher mortality rates, likely reflecting injury severity rather than the intervention itself. 3
• Ensure adequate oxygenation while avoiding unnecessary airway manipulation in stable patients. 2

Breathing and Ventilation

• Maintain normocapnia with PaCO₂ between 35-40 mmHg (or EtCO₂ 30-35 mmHg initially). 1, 2
• Never use prolonged hyperventilation, as it causes cerebral ischemia and worsens outcomes. 2, 4

Circulation and Hemorrhage Control

• Maintain adequate blood pressure to ensure cerebral perfusion—never allow hypotension in pediatric TBI patients, even when hemorrhagic shock is present elsewhere. 2, 4
• In polytrauma, tourniquets and hemostatic dressings for extremity hemorrhage control are highly effective and should be applied immediately. 3
• Avoid "permissive hypotension" strategies in children with TBI. 4, 5

Urgent Neuroimaging

• Obtain an urgent CT scan of the head and cervical spine without delay in all pediatric severe TBI patients. 1, 2
• Never delay neuroimaging in patients with a history of lucid interval, even if they currently appear stable—deterioration can be sudden. 2, 4
• The CT scan guides neurosurgical decision-making and identifies surgical lesions requiring immediate intervention. 1

Neurosurgical Consultation and Intervention

• Immediate neurosurgical consultation is necessary for: 2, 4
  • Depressed skull fractures
  • Open skull fractures with CSF leak or brain tissue exposure
  • Epidural hematoma with mass effect
  • Any expanding intracranial lesion causing midline shift or significant mass effect

Intracranial Pressure Monitoring and Management

ICP Monitoring Indications

• Implement ICP monitoring in severe TBI (GCS ≤8) with abnormal CT findings. 2
• ICP monitoring is less commonly performed in children <2 years old, but this population is at high risk for elevated ICP and poor outcomes—do not withhold monitoring based on age alone. 1
• The complication rates of ICP monitoring in infants do not differ from adults. 1

Age-Specific ICP and CPP Targets

• Target ICP <20 mmHg in children ≥6-8 years of age. 1
• Consider lower ICP thresholds (<20 mmHg) in younger children, as physiologic ICP values are age-dependent. 1

Age-specific Cerebral Perfusion Pressure (CPP) targets: 1

• Children 0-5 years: Maintain CPP >40 mmHg (CPP <30 mmHg associated with 8-fold increased risk of poor outcome)
• Children 6-11 years: Maintain CPP >50 mmHg (CPP <35 mmHg associated with 8-fold increased risk of poor outcome)
• Children 12-17 years: Maintain CPP >60 mmHg (CPP <50 mmHg associated with 2.35-fold increased risk of poor outcome)

Tiered Approach to Managing Elevated ICP

1. Elevate head of bed to 30 degrees to improve venous drainage. 2
2. Ensure adequate sedation and analgesia. 2
3. Maintain normothermia and treat seizures promptly. 2
4. Consider osmotic therapy with mannitol (0.25-2 g/kg) for clinical deterioration with elevated ICP. 2, 6
   • Mannitol dosing for pediatric patients: 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes. 6
   • Small or debilitated patients: 500 mg/kg. 6

Transcranial Doppler (TCD) Ultrasound

• TCD should be part of the initial assessment in the emergency room. 1
• In children, a diastolic blood flow velocity (Vd) <25 cm/s or a pulsatility index (PI) >1.3 is associated with poor outcome. 1
• If Vd <20 cm/s and PI >1.4, implement therapeutic measures immediately to improve brain perfusion. 1

Fluid Management

• Never use hypotonic fluids, as they worsen cerebral edema. 2, 4
• Use isotonic crystalloids to maintain adequate intravascular volume. 2

Special Considerations in Pediatric TBI

Children <2 Years Old

• Inflicted trauma (non-accidental trauma) is a prominent cause of TBI in this age group—maintain high index of suspicion. 1
• This population has high incidence of raised ICP despite less frequent monitoring. 1

Mannitol Use in Children

• Mannitol may worsen intracranial hypertension in children who develop generalized cerebral hyperemia during the first 24-48 hours post-injury. 6
• Monitor renal function closely, as children are at risk for osmotic nephrosis and renal failure with mannitol use. 6

Biomarkers

• Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) in clinical routine to assess initial severity—uncertainties remain regarding normal ranges and clinical utility. 1

Mild TBI (Concussion) Management

• Provide comprehensive discharge instructions including warning signs of deterioration, expected symptom course, and monitoring instructions. 2
• Recommend gradual return to activity with close monitoring of symptoms. 2
• Never prescribe complete rest beyond the first few days, as this may delay recovery. 2

Critical Pitfalls to Avoid

• Never assume stability in a child who appears well after initial injury—deterioration can be sudden, especially with lucid interval presentations. 2, 4
• Never delay transfer to a specialized center—management in pediatric trauma centers or adult centers with pediatric expertise significantly improves outcomes. 1
• Never allow hypoxemia or hypotension, as these are the most preventable causes of secondary brain injury and are independently associated with poor outcomes. 2, 7
• Never use prolonged hyperventilation as a routine measure. 2, 4