1. Severe Pediatric Head Injury – tips and tricks Jonathan Duff MD Division of Pediatric Critical Care University of Alberta

2. Conflicts of Interest Nothing to declare

4. “…children exhibit almost limitless creativity with regard to sustaining injury”

5. Kids aren’t little adults Immature/pliable skull Weak neck musculature Large head:body ratio

6. A four-year-old boy is involved in a MVC – car is T- boned at high speeds On arrival of medics, child is found restrained in the car. Unresponsive, moaning and with stiffening movements What’s his GCS? And why do we care?

7. Severe TBI: GCS < 9 Standard GCS for verbal patients Non-verbal patients 4Coos/babbles 3Irritable/cries 2Cries to pain 1Moans to pain

8. Motor testing Most important prognostic factor – get a history!! Assessment is key

9. Arrival to ED Child arrives in full spinal precautions HR: 143; BP 74/33; Sats 99% on 15lpm; RR 8

10. Prevention of secondary injury is the key Hypoxia, hypotension, hypercarbia, hyperthermia

11. Cerebral Autoregulation Pressure (mmHg) Cerebral Blood Flow 50180 PaCO 2 CPP PaO 2

12. Mono-Kellie Doctrine

13. Intubation Considerations C-spine precautions Medications: Usual recommendation: Propofol vs. fentanyl/midazolam Etomidate? Ketamine?

14. Intubation Considerations How fast do we bag? The role of hyperventilation pCO 2 45pCO 2 30

15. Back to the case Child has been intubated and fluid resuscitated Taken to CT scanner – reported as normal

16. Management of high ICP Remember – avoid secondary injury CPP = MAP – ICP Target CPP > 40 – 50 mmHg Adult > 65-70 mmHg Minimize cerebral metabolism

18. 5 ways to decrease ICP 1. Increase venous drainage 2. Decrease cerebral metabolism 3. Hyperosmolar therapy 4. CSF drainage 5. Decompression

19. 5 ways to decrease ICP 1. Increase venous drainage Elevate the head of the bed (if you can) Watch for a tight cervical collar

20. 5 ways to decrease ICP 2. Decrease cerebral metabolism Need to decrease cerebral oxygen requirements Hypothermia Seizure control

21. 5 ways to decrease ICP 3. Hyperosmolar therapy Mannitol 3% Saline

22. 5 ways to decrease ICP 4. CSF drainage External ventricular drain Allows measurement of ICP and treatment

23. 5 ways to decrease ICP 5. Decompression

24. Summary Traumatic brain injury is an important cause of pediatric morbidity and mortality If you can’t prevent it, the key is to prevent secondary injury