1. Management of Head Injury and Increased ICP
Nicole Baier, MD

2. Objectives Review the: Epidemiology of head injury
Various intracranial lesions
Pathophysiology of increased ICP
Management of head injury

3. Epidemiology 2 cases per 1000 children per year Mild TBI: 82%
Moderate to severe TBI: 14%
Fatal TBI: 5% (7000 deaths per year)

4. Etiology Motor vehicle accidents Falls Non-accidental trauma
Sports injuries

5. Mechanisms of injury Coup contusion Contrecoup contusion
Adjacent to the site of injury
Brain accelerates against the fixed skull
Injury to parenchyma and blood vessels
Contrecoup contusion
Deceleration and recoil of the brain
Contralateral lesions

6. Epidural Hematoma
Classic: arterial origin, blood collects between skull and dura

7. Subdural Hematoma
Due to tearing of bridging veins, blood collects between dura and cortex

8. Subarachnoid hemorrhage
Disruption of small vessels on the cortex, occur along the falx, tentorium, or outer cortical surface

9. Intraventricular Hemorrhage

10. Mechanisms of Injury Axonal injury: Areas affected:
Etiology: deceleration and shearing forces
Axonal swelling and degeneration
CT findings:
Normal initially
Delayed edema and petechial hemorrhages
Areas affected:
Basal ganglia
Thalamus
Deep hemispheric nuclei
Corpus callosum

11. Mechanisms of Injury

12. Diffuse Axonal Injury

13. Cerebral Edema Cytotoxic Edema Vasogenic Edema Interstitial Edema
Intracellular swelling
Due to cellular injury (DAI, hypoxia-ichemia)
Irreversible
Vasogenic Edema
Increased endothelial permeability
Therapy may prevent secondary injury
Seen with tumors, hematomas, infarcts, CNS infections
Interstitial Edema
Increased fluid in periventricular white matter
Etiology -  hydrostatic CSF pressure

14. Monro-Kellie Doctrine
Intracranial Volume = Brain + CSF + Blood
Normal:
Brain 80%
CSF 10%
Blood 10%

15. Monro-Kellie Doctrine

16. ICP and intracranial volume

17. Secondary injury Bleed/edema increases intracranial volume →
Compress intracranial vessels →
Impairs blood flow →
Ischemia

18. Cerebral perfusion pressure
CPP = MAP – ICP
> 70 in adults
Children ????

19. What is Cushing’s Triad?
Hypertension, tachycardia, and dilated pupils
Hypotension, bradycardia, and posturing
Hypertension, bradycardia, and dilated pupils
Hypertension, bradycardia, and irregular respirations
Hypotension, tachycardia, and posturing

20. Cushing’s Triad Hypertension Bradycardia Irregular respirations
Etiology:
When MAP < ICP, the hypothalamus stimulates sympathetic output
Increase in BP stimulates carotid baroreceptors and leads to a vagal response and bradycardia

21. A 2 year old boy is brought in by EMS
A 2 year old boy is brought in by EMS. He was playing outside at home when a van backed into the driveway and ran over him. He was minimally responsive at the scene required bag-mask ventilation on the way in. You cannot elicit any response from him with painful stimulation. What is his GCS? 2 3 4 5 6
GCS = 3

22. Glasgow Coma Score Eyes: Motor: Verbal: - 2 decerebrate
4 opens spontaneously follows commands
3 opens to verbal command - 5 localizes pain
2 opens to pain withdraws to pain
1 no response decorticate
Verbal: decerebrate
5 oriented no response
4 confused conversation
3 inappropriate words
2 incomprehensible sounds
1 no response

23. Head Injury - grading Mild: GCS ≥ 13 Moderate: 9-12 Severe: ≤8
Battle’s sign

24. You decide to intubate the child
You decide to intubate the child. Which of the following medications would be contraindicated in the given scenario?
Etomidate
Lidocaine
Fentanyl
Succinylcholine
Rocuronium
Given the crush injury, succinylcholine would be contraindicated in this scenario

25. Management - Airway Indications for intubation: GCS ≤ 8 Hypoxia
Loss of airway
protective reflexes
Hypoventilation

26. Management - Airway Rapid sequence intubation: C-spine stabilization
Preoxygenation
Cricoid pressure
Induction Meds:
Thiopental –  ICP ( cerebral metabolic rate) (may lower BP) or
Etomidate –  ICP or
Benzodiazepine (may lower BP) +
Opiate for analgesia for injuries/ laryngoscopy
+/- Lidocaine (may blunt  ICP assoc. with laryngoscopy)
Neuromuscular blockade

27. Insertion of an ICP monitor 3% normal saline bolus Mannitol
The child was successfully intubated after premedication with lidocaine, fentanyl, etomidate, and rocuronium. None of his labs are back yet. However, you decide to institute therapy for increased ICP. Which of the following therapies is indicated at this point?
Insertion of an ICP monitor
3% normal saline bolus
Mannitol
Hyperventilation to CO2 of 25-30
Therapeutic hypothermia
Mannitol is readily available in the ER and should be given. Another alternative is 3% NaCl bolus, although not as readily available and preferred route is via central line. Hyperventilation indicated only if signs of herniation (eg, pupil assymmetry).

28. Management - Breathing
Try to keep CO2 normal (35-40) in patients with  ICP
Risk of ischemia with hyperventilation
Hyperventilation used only for acute herniation

29. Management - Circulation
Maintain CPP to avoid secondary injury
Hypoxemia and hypotension each occur in 1/3 of patients
1 episode of hypotension  mortality 2x
Eval source of shock:
Internal bleeding?
Spinal cord injury?

30. Monitoring ICP Indications: Types: GCS ≤ 8
Neuro exam impossible (sedated, needs to go to OR for other injuries
Types:
Ventriculostomy most reliable, also therapeutic
Intraparenchymal – measurement drift
Subarachnoid, subdural, epidural – less reliable

31. Head positioning Head midline Head of bed to 30 degrees
Promote venous drainage

32. Sedation/ Analgesia Benefits:
Decrease cerebral metabolic demands associated with pain and stress
Prevent spikes in ICP that may occur with suctioning, etc.
Facilitate mechanical ventilation
Anticonvulsant and antiemetic actions
Prevent shivering

33. Neuromuscular blockade
Benefits:
 airway and intrathoracic pressure – facilitate cerebral venous outflow
Prevent shivering and posturing
Facilitate mechanical ventilation

34. Can only be given through a central venous line
Which of the following statements about the use of 3% normal saline is true?
Can only be given through a central venous line
Does not cause hypotension
Can only be used if serum osmolarity < 320
Dose is 10 mL/kg
Can only be used if serum sodium is < 160
Dose is 5-10 mL/kg bolus

35. Hyperosmolar Therapy 3% normal saline Creates osmotic gradient
Decreases ICP and increases CPP
Used as boluses and/or continuous infusion
Goal: serum sodium > 150
Max serum osm: 360 ??

36. Hyperosmolar Therapy Mannitol Mechanisms: 0.25-1 g/kg doses
 blood viscosity
creates osmotic gradient between plasma and brain
g/kg doses
May repeat every 6-8 hours
Max serum osm: 320
Adverse effects:
ATN
Hypovolemia

37. CSF Drainage
Ventriculostomy catheter

38. The hallmark of pentobarbital coma is burst suppression
Which of the following statements regarding the use of pentobarbital is false?
Continuous EEG monitoring should be present when a pentobarbital coma is induced
The hallmark of pentobarbital coma is burst suppression
Pentobarbital causes profound myocardial depression
Pentobarbital use requires the approval of a neurologist
Pentobarbital reduces cerebral blood flow #4

39. Barbiturate Coma Consider in: Mechanisms:
Patients with refractory intracranial hypertension
Mechanisms:
Lowers resting cerebral metabolic rate by 50%
Decreases cerebral blood flow and cerebral blood volume
Neuroprotective: inhibits free radical-mediated lipid peroxidation, stabilizes membranes

40. Barbiturate Coma Monitoring: Adverse effects: Burst suppression on EEG
Myocardial depression

41. Thermoregulation Avoid hyperthermia Increase cerebral metabolism
Inflammation
Lipid peroxidation
Excitotoxicity
Seizures

42. Surgical management Decompressive craniectomy
Favorable surgical outcomes:
Within 48hrs of injury
Secondary  GCS
Herniation
Unfavorable:
Unimproved GCS of 3
Extensive secondary
brain insults

43. Nutrition Begin by 72 hours Full replacement by 7 days
Patients with injury have increased resting metabolism expenditure
Increased mortality when head injured patients not fed within 1 week

44. Antiepileptic medications decrease the incidence of late seizures
Which of the following statements is true regarding the incidence of seizures in traumatic brain injury?
Antiepileptic medications decrease the incidence of late seizures
Children < 2yo have a lower risk of seizures
Most early seizures occur in the first 24 hours
Seizures do not affect the outcome of traumatic brain injury
All children with traumatic brain injury should be treated with antiepileptic medications until 1 week post-injury #3

45. Antiseizure prophylaxis
Posttraumatic seizures
Early: within 7 days
Late: after 7 days
Adverse effects:
Increase brain metabolic demands
Increase ICP
Lead to secondary brain injury

46. Antiseizure prophylaxis
Risk of seizures:
Early:
20-39% incidence in severe TBI
 risk if low GCS
< 2 yrs have 3x greater risk
Majority occur within first 24 hours

47. Antiseizure medications
Risk of seizures
Late:
7-12% incidence in severe TBI
Increased incidence in depressed skull fracture
Relation to early seizures?
Prophylactic anticonvulsants do not affect incidence