David Bliss Chris Dael Tim Deakers Michael Levy Karl Maher Todd Maugans Gordon McComb Karen McVeigh Alan Nager Christopher Newth Carol Nicholson Niurka Rivero Randall Wetzel Children’s Hospital of Los Angeles 11.18.97 Management Management Guidelines for Guidelines for Head Trauma Head Trauma
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David Bliss Chris Dael Tim Deakers Michael Levy Karl Maher Todd Maugans Gordon McComb Karen McVeigh Alan Nager Christopher Newth Carol Nicholson Niurka.
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David BlissChris DaelTim DeakersMichael LevyKarl Maher Todd Maugans Gordon McComb Karen McVeighAlan Nager Christopher NewthCarol NicholsonNiurka Rivero Randall Wetzel
Children’s Hospital of Los Angeles
11.18.97
Management Management Guidelines for Guidelines for Head TraumaHead Trauma
Comments: R. Chestnut IComments: R. Chestnut I
“As a result of tumultuous growth and somewhat erratic emergence of neurotraumatology, there is little consensus at this time regarding pathophysiologic mechanisms and methods of management.”
Randall Chestnut. CCM 25:1275,1997.
Comments: R. Chestnut IIComments: R. Chestnut II
“It is generally accepted that an organised concatenation of individually unproven but collectively apparently successful therapies is associated with improved outcome from traumatic brain injury.”
Randall Chestnut. CCM 25:1275,1997.
Comments: R. Chestnut IIIComments: R. Chestnut III
“However, there appears to be significant controversy regarding most of the component treatment concepts when approached individually.”
Randall Chestnut. CCM 25:1275,1997.
Airway management: GCSAirway management: GCS
Patients with Glasgow coma scores of 8 or below require oral endotracheal
– succinylcholine : its rapid onset and rapid reversibility make it desirable in the trauma patient
– succinylcholine : can lead to increased ICP, cerebral blood flow and CO2 production
– these potential adverse effects can be minimized, making our first choice for neuromuscular blockade in the acute trauma setting succinylcholine (1-2 mg/kg IV)
In controlled circumstances, where large doses of non-polarizing neuromuscular blocking agents can be safely administered and sufficient personnel are available, an alternative (non-depolarizing) neuromuscular blocking agent might be used:
– rocuronium 1-1.5 mg/kg IV– vecuronium 0.2-0.4 mg/kg IV
Ventilation IVentilation I
– regional blood flow is decreased by hyperventilation in head injured children
– hyperaemia is less common than once thought
– CMRO2 is decreased more than perfusion
– outcomes are worse in the mild to moderate injury group.
J Neurosurg 75:731-739, 1991.Crit Care Med 25:1402-1409, 1997.
Ventilation IIVentilation II
There is nono indication for prophylactic hyperventilation.
Normocapnoea is good for you !Normocapnoea is good for you !
Ventilation IIIVentilation III
The recommended standard of care at CHLA is to monitor end tidal pCO2 following oral endotracheal intubation, during transport, during neuroradiologic procedures and in the intensive care unit.
Normocapnoea is the goal
3 y/o boy after MVA. Spontaneouly breathing
but nasal flaring present. Atlantoaxial distraction
with severed spinal cord
odontoidatlas
Intravascular volume IIntravascular volume I
The targeted ideal for volume resuscitation in head trauma is euvolemiaeuvolemia. This should be maintained with either normal saline or Lactated Ringer's.
•Intravascular volume should be maintained with solutions containing >133meq\L Na+ (isotonic).
•Hypertonic (3%) saline may be indicated (euvolaemic hypernatraemia).
Intravascular volume IIIntravascular volume II
• Hyperglycaemia and Hypoglycaemia must be avoided.
• Glucose (D5) not indicated for children over 6 months of age.
• monitor serum glucose.
Intravascular volume IIIIntravascular volume III
Sedation and pain management ISedation and pain management I
Children who are agitated or possibly in pain, requirerequire sedation and/or analgesia.
Sedation and pain management IISedation and pain management II
Midazolam and fentanyl are adequate, short acting drugs to be used in this setting. No other drugs are necessary routinely for sedation and analgesia in the first 12 hours.
fentanyl: 1-3 mcg/kg/min q 1 hr prn
midazolam: 0.05 to 0.1 mg/kg over 2 minutes
Propofol has been considered; however, it has a propensity for hypotension in the acute setting.
Positioning IPositioning I
• In-line traction for intubation– (all head injury is neck injury)
• Do Not occlude venous drainage– watch the neck collars– avoid Trendelenberg (central lines)
Positioning IIPositioning II
ICP monitoring IICP monitoring I
Indicated for children with head trauma with a Glasgow coma score of 7 or less or who are rapidly deteriorating.
ICP monitoring IIICP monitoring II
In children who require neuromuscular blockade or deep sedation or anesthesia, intracranial pressure monitoring may be indicated at a higher GCS.
Anaesthesia makes clinical monitoring of elevated intracranial pressure extremely difficult and thus, in selected cases ICP should be directly measured if surgery is necessary.
Cerebral perfusion pressure ICerebral perfusion pressure I
Inhalational anaesthesia IIIInhalational anaesthesia III
Temperature regulation ITemperature regulation I
Temperatures should, at all times, be maintained below 37.5.0 C (higher temperatures are associated with elevated ICP, increased CMRO2)
acetominophen, 15-20 mg/kg q 4-6 hours prn
body exposure direct cooling
Temperature regulation IITemperature regulation II
• mild hypothermia for patients with measured elevated intracranial pressure (>20 torr, 25 cm H2O) will be instituted.
• the goal is to maintain body temperatures between 33-35o C (less is not better).
NEJM 336:540,1997
Summary - TrendsSummary - Trends
• No prophylactic hyperventilation• Use of controlled hypothermia• Euvolemic resuscitation• Hypertonic fluids (3% saline)• No steroids• Propofol and Sevoflurane
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