[size=5]A 5-year-old is an unrestrained passenger in an MVC. The patient was found outside of the vehicle with an obvious depressed skull fracture. EMS was unable to secure an airway in the field. On arrival to the trauma bay the patient is found to be hypoxic with hypertension and bradycardia. The patient has a GCS of 3 with a dilated right pupil. What is the best next step in the management of this patient?

 

a Transfuse whole blood

 

b Emergently intubate

 

c Bolus 3% Normal Saline

 

d Bolus Mannitol

 

e Decompressive craniotomy[/size]

B

B

B

B

B

[b]correct answer

b Emergently intubate[/b]

 

This patient presents with a severe traumatic brain injury with evidence of herniation and elevated intracranial pressure. Management of the intracranial pressure to relieve intracranial hypertension is paramount to improve and optimize cerebral perfusion pressure and prevent further injury.

 

The most recent evidence based guidelines for the management of pediatric severe traumatic brain injury were published in 2019. This third edition included 22 evidence-based recommendations with 3 level II and 19 level III guidelines—there is insufficient evidence to support any level I recommendations in the pediatric severe TBI literature. It is notable that of over 90 publications reviewed by the guidelines committee, 68 described a protocol used at the authors’ institution to manage pediatric TBI, verifying the heterogeneity of treatments and treatment thresholds in the published literature. Another recent study showed significant variability in the management of traumatic brain injury amongst Pediatric Intensive Care Units in the United Kingdom.

 

It is important to note that as a baseline, these algorithms all assume the patient has had their airway definitively secured. This is the initial management step in any patient that presents with a severe brain injury to prevent further injury due to hypoxemia. Additional initial steps include appropriate sedation and analgesia, prevention of hypovolemia, cross sectional imaging of the head and consideration of placement of an intracranial pressure monitor. These protocols also assume emergent neurosurgical consultation.

 

Baseline management of the patient with a severe TBI includes:

 

• Maintenance of appropriate analgesia
  
• Maintenance of adequate ventilation and oxygenation
  
• Normothermia
  
• Ensure appropriate intravascular volume along with a Hgb of greater than 7 g/dL
  
• Elevation of the head of bed greater than 30 degrees
  
• Phenytoin or levetiracetam to prevent seizures
  
• Early implementation of nutrition
  

In cases of continued elevated intracranial pressure, a stepwise strategy is employed. The consensus guidelines suggest the following algorithm in the setting of persistently elevated ICP

 

• CSF drainage if ventriculostomy present
  
• Bolus or infusion of hypertonic saline
  
• Additional analgesia/sedation
  
• Neuromuscular blockade
  
• Additional hypertonic saline or osmolar therapy