Severe Traumatic Brain Injury - Guideline for the Management of Children with

Publication: 23/11/2015  --
Last review: 25/01/2018  
Next review: 01/01/2021  
Clinical Guideline
CURRENT 
ID: 4394 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Children with Severe Traumatic Brain Injury

1. Introduction
2. Objective
3. Initial stabilisation in Emergency Department
     3.1 Primary Survey
     3.2 Endotracheal Intubation
     3.3 Initial treatment targets and interventions prior to admission to PICU
     3.4 Indications for osmotic therapy prior to placement of ICP monitoring
4. Cervical spine stabilisation
     PICU cervical spine management flowchart
5. PICU management
     5.1 General measures
     5.2 Medications
     5.3 Monitoring and Investigations
     5.4 Respiratory management
     5.5 Suctioning / physiotherapy
     5.6 Circulation
     5.7 Analgesia, sedation and muscle relaxation
     5.8 Fluids and Nutrition
6. ICP and CPP management
     6.1 ICP monitoring
     6.2 ICP waveforms
     6.3 Prevention and management of raise in ICP
     6.4 Management of inadequate CPP
7. Seizure control

Management of Intracranial Pressure (ICP)
Management of Cerebral Perfusion Pressure (CPP)
Appendix A: Glasgow Coma Score

Appendix B: List of abbreviations

1.  Introduction

Traumatic brain injury is one of the most common causes to childhood mortality. TBI is classified based on the post-resuscitation Glasgow Coma Score (Appendix A).

Mild TBI:

GCS 13-15

Moderate TBI:

GCS 9-12

Severe TBI:

GCS 3-8

This classification helps to assess the severity of the Primary Brain Injury (initial injury sustained at the scene of the incident).

Consequences of the head injury will commonly include combinations of:

  • Cerebral oedema
  • Subarachnoid haemorrhage
  • Subdural haemorrhage
  • Intracerebral haemorrhage
  • Intraventricular haemorrhage +/- hydrocephalus
  • Skull fractures
  • Vascular injury & consequent stroke

These factors contribute to increases in Intra-Cranial Pressure (ICP). As ICP rises, there is a significant risk of Secondary Brain Injury – where additional injury occurs due to raised intracranial pressure after the Primary Brain Injury has occurred.

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2.  Objective

The main objective of the initial management of children with TBI is to prevent or reduce secondary injury to the brain or spinal cord.

The treatment principles are:

  1. Avoid hypoxia and hypotension
  2. Avoid abnormal pCO2
  3. Maintain normothermia
  4. Keep cervical spine immobilised
  5. Keep ICP <20 mmHg
  6. Maintain adequate Cerebral Perfusion Pressure (CPP). For age appropriate CPP threshold refer to section 6.4

CPP is calculated as follows: CPP = MAP - ICP

If an ICP monitor is not in place, assume ICP of 20 mmHg and aim to maintain MAP high enough to ensure adequate CPP.

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3.  Initial stabilisation in Emergency Department

Children admitted to Emergency department resus with severe or moderate TBI should be assessed by Paediatric trauma team.

3.1    Primary survey:

Airway with cervical spine control
Breathing with ventilator support
Circulation with haemorrhage control
Disability: GCS and pupillary reaction
Exposure with temperature control

Non-accidental injury should be considered as a possible cause in all children, especially those under 2 years, presenting with apparent TBI.

Children with a GCS <9 should be intubated to facilitate urgent CT head and cervical spine.

Children with GCS ≥9 may need CT head and cervical spine, please refer to NICE Imaging algorithm (Scroll down to pages 2 and 4 of the linked page for guidance on children). Some of these children may need intubation to facilitate neuroimaging.

Inform the on-call Neurosurgery Registrar (Bleep 1817) before the CT scan, if any of the following are present:

  • Severe TBI (GCS 3-8)
  • Lateralising signs
  • Unequal pupil responses
  • Falling conscious level

The Neurosurgical Registrar (bleep 1817) should be alerted immediately if the CT scan is abnormal.

3.2    Endotracheal Intubation:

  • Intubation should be performed by the most experienced operator present, with manual C-spine immobilisation.
  • Use modified rapid sequence intubation.
  • The cervical collar may be removed for intubation but this must only be done if an appropriately trained person is providing manual in-line stabilisation of the neck. Intubation is a 3 person procedure.
  • Use Oral route only. Nasal intubation should be avoided because of the possibility of base of skull fracture.
  • A jaw thrust should be used to open the airway.

The collar must be re-applied immediately after intubation.

3.3    Initial treatment targets and interventions prior to admission to PICU

Once orally intubated:

  • Keep cervical spine immobilised (sandbags + tapes + collar)
    • If patient is fully sedated and chemically paralysed, the collar can be removed to prevent obstruction of the neck veins and consequent ICP increases (see section 4).
    • This also has the secondary benefit of helping prevent pressure sores.
    • However, the collar must be re-attached for chest physiotherapy, log-rolling and any other manoeuvres that involve moving the patient.
  • Maintain normocapnia to pCO2 4.5 – 5.0 kPa
  • Maintain adequate oxygenation: PaO2 10.0 – 13.0 kPa, SaO2 > 95%.
  • Maintain Adequate Blood Pressure. Assume ICP of 20 mmHg and target Mean Arterial Pressure to achieve adequate Cerebral Perfusion Pressure for age. (Refer to section 6.4)
  • Ensure adequate analgesia and sedation:
    • Midazolam 0.1 mg/kg bolus then infusion at 2 microgram/kg/min
    • Morphine 0.1 mg/kg bolus then infusion at 20 microgram/kg/hr
    • Propofol infusion (1.5 to 9 mg/kg/hr) could be used in haemodynamically stable children who are deemed to be likely to be woken up after CT Scan. Propofol infusion should not be continued beyond a maximum of 6 hours in children.
  • Continue muscle relaxation unless clinical seizures have been noted. (Refer to section 7). Atracurium 0.5 mg/kg bolus then infusion at 1mg/kg/hr
  • Position 30° head up if possible while keeping the bed straight. Keep head & neck in neutral position.
  • Maintain normothermia: 36 to 37°C

3.4    Indications for osmotic therapy prior to placement of ICP monitoring:

  • Lateralising signs
  • Unequal pupil responses
  • Falling conscious level
  • CT showing space occupying lesion, prior to definitive management in theatre

Recommended Drugs:

  • 2.7% Hypertonic saline: 3-5ml/kg over 15 min, or
  • Mannitol 0.5g/kg (2.5ml/kg of 20% solution preferred) over 20 min

Follow osmotic therapy with volume as required to maintain blood pressure. Repeat osmotic therapy as needed.

If you suspect herniation (coning) give a further osmotic therapy and consider mild hyperventilation, PaCO2 4-4.5 kPa with 100% oxygen.

Proceed to CT scan to facilitate definitive management without undue delay.

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4.  Cervical spine stabilisation

Please refer to NICE guidelines for the indications for CT imaging for cervical spinal injuries in children with head injury.

Cervical spine management in PICU:

Cervical spine immobilisation must remain in position in children with severe TBI until:

  • Cleared Radiologically: Adequate radiological examination (CT) confirmed as normal with a written Consultant NeuroRadiologist report. (This must be a Consultant report not the on-call radiology registrar)
    AND
  • Cleared Clinically: Full neurological examination shows equal movement in all four limbs and no pain or tenderness over the cervical spine in a fully alert child who is free from any distracting injuries

If in doubt, maintain immobilisation.

Once the patient is admitted to PICU, adequate immobilisation can be achieved with a collar.

  • Use an appropriately sized collar based on patient’s age. See product information that comes with the collars to ascertain the correct size and fit.
  • Place ‘C-spine not cleared’ sign above bed
  • Log roll the patient every 4 to 6 hours to assess occipital area for skin integrity and document in the age appropriate Paediatric pressure ulcer prevention / Purpose T form
  • Collar can be removed if the child is adequately sedated and muscle relaxed
  • Reapply collar for log rolling (even of muscle relaxed)
  • Reapply collar for muscle relaxant holiday or if muscle relaxant is stopped
  • See flowchart below for an overview of suspected cervical spine injury management.

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5.  PICU MANAGEMENT

5.1    General measures

  • Keep head in midline and in neutral position
  • Straight tilt head end of the bed up by 30°
  • Use foam mattress
  • Avoid tight dressings around the neck. Check tightness of cervical collar
  • Record pupillary responses hourly
  • Mouth care (use VAP bundle)
  • Care of head and neck. These children are at risk of developing pressure sores to the occiput and lower head regions and these may be hidden by the collar and the hair
    • Remove collar when muscle relaxed to reduce risk of pressure areas
    • 4 to 6 hourly log rolls or as tolerated. Pressure sores may develop underneath the collar at a level lower than the occiput. Check for boggy/swollen areas
    • Reapply collar for log rolling
    • Reapply collar for muscle relaxant holiday or when the muscle relaxant is stopped
    • Continue to log roll 4 to 6 hourly or as tolerated.
    • Keep neck clean and dry at all times
    • Document in Paediatric pressure ulcer prevention / Purpose T form following each log roll
  • Orogastric tube (use oral route until base of skull fracture is ruled out). Aspirate when sited and keep on free drainage
  • Allow patients to re-warm passively if hypothermic on admission to PICU. Maintain oesophageal or rectal temperature between 36.0° and 37.0°C. Use paracetamol orogastric/per rectal and the cooling blanket if necessary.
    • Ensure strict normothermia at all times
    • Avoid shivering (muscle relaxants)
  • Lubricating eye ointment or gel pads on eyes while neuromuscular blockade is administered 

5.2    Medications

Use BNFc and Trust formulary for dosage information.

  • Paracetamol prn for analgesia
  • Ranitidine for GI bleeding prophylaxis
  • Phenytoin loading dose and maintenance for seizure prophylaxis in all patients who need ICP monitoring. Phenytoin to be continued for one week if there are no seizures. Discuss choice and duration of anti-epileptic drugs with Neurology team if the child has had seizures. PICU Phenytoin monograph
  • Consider antibiotics if there is evidence of open fractures, CSF leak or if the patient is febrile. Culture ET secretions, arterial line, central line, peripheral blood and catheter urine prior to or as soon as possible after starting antibiotics
  • Check Tetanus and Pneumococcal vaccination status. All children with polytrauma should receive Tetanus vaccine if not previously vaccinated. Children with CSF leak should receive Pneumococcal vaccine if previously not vaccinated.

5.3    Monitoring and Investigations

  • Record GCS every hour in non-muscle relaxed patients
  • Monitor end tidal CO2 continuously and check correlation with pCO2 on arterial blood gases
  • Arterial blood pressure and CVP should be monitored in all ventilated patients with traumatic brain injury (avoid internal jugular venous route if possible). Ensure transducers are levelled to the right atrium i.e. junction between mid-axillary line and 4th intercostal space, check every 12 hours
  • Intra cranial pressure monitor levelled to tragus
  • Monitor oesophageal or rectal temperature continuously
  • Record ICP, CPP, CVP, systolic, diastolic and mean arterial pressure while the patient is being monitored and treated for cerebral oedema and intra-cranial hypertension. Monitor hourly fluid balance.
  • Check ABG, lactate and electrolytes 4 to 6 hourly for as long as cerebral oedema and raised ICP are being treated. May need more frequent estimates especially if diuretics have been given
  • Routine blood investigations as per PICU Guideline
  • CFAM monitoring in all patients who are muscle relaxed or on thiopentone infusion for head injury. A full EEG is needed within the first 24hrs if using one of the older monitors without an EEG trace to exclude status epilepticus

5.4   Respiratory management

  • Hourly blood gases until stable.
  • Monitor end tidal CO2 continuously and check correlation with PaCO2 on arterial blood gases
  • Aim PaCO2 4.5 – 5.0 kPa. Do not hyperventilate except as a temporary measure prior to re-scanning / surgery.
  • Oxygen: PaO2 10 to 13 kPa. Sats >95%.
  • PEEP 5cm H2O. Set PIP to achieve 6 to 10 mls/kg tidal volume. Adjust rate to achieve PaCO2 target.
  • Nasal intubation and nasogastric tube contraindicated until base of skull fracture has been excluded

5.5    Suctioning / physiotherapy

Physiotherapy – clinical judgement needed. If chest physiotherapy neglected then may have later problems with chest secretions and oxygenation.

  • Ensure adequate sedation and analgesia. Consider Fentanyl 1-3 micrograms/kg IV prior to suctioning if ICP known to be unstable.
  • Remember to re-attach the cervical spine collar prior to physiotherapy / suction.
  • Regular suction. Side to side turning 2 - 4 hourly if ICP doesn’t rise in response ensuring the neck remains in line.
  • Pre-oxygenate with100% O2 on ventilator for 5 minutes prior to suctioning
  • If ICP>20 mmHg for >5 minutes or > 25 mmHg for any length of time after suctioning, refer to section 6.3 for ICP management

5.6     Circulation

  • Maintain BP to keep CPP above age specific threshold. (Refer to section 6.4)
  • Keep haemoglobin >100 g/L during acute phase when treating cerebral oedema and intracranial hypertension. Haemoglobin > 70 g/L in stable children.
  • Urine output >0.5 ml/kg/hr

5.7       Analgesia, sedation and muscle relaxation

  • Midazolam (1-6 microgram/kg/min). Morphine (10-40 microgram/kg/hr)
  • Use muscle relaxation only while
    • patient is receiving active cooling (to prevent shivering)
    • in response to raised or unstable ICP
    • in severe respiratory failure
  • Boluses of Fentanyl (1 to 3 microgram/kg), may be used to attenuate rises in ICP with physio or other procedures

5.8       Fluids and Nutrition

  • Maintenance fluids – 80% for IV fluids, 100% for enteral nutrition. Start enteral feeds early unless contraindicated due to abdominal injury.
  • Start TPN if enteral (gastric or jejunal) feeding not established in 48 hours and continue small volume enteral feeds where possible
  • Maintenance fluid choice: Sodium chloride 0.9% for children >2 years and 5% dextrose with 0.9% Sodium Chloride for children < 2 years initially. Add potassium chloride to fluids as appropriate
  • If hypoglycaemic (serum glucose < 3 mmol/L) give 2 ml/kg of 10% glucose iv and recheck serum glucose within 30 minutes.
  • Add or increase glucose content of the maintenance fluid. Give enough glucose to maintain blood glucose 4 -10 mmol/l range
  • Avoid hyperglycaemia. If glucose is > 12 mmol/L on two different samples 30 minutes apart use Guideline for management of hyperglycaemia in non-diabetic critically ill children for glycaemic control
  • Monitor input and output. Aim to maintain a neutral to slightly negative fluid balance after the first 24 hours.

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6.  Intracranial pressure (ICP) and Cerebral perfusion pressure (CPP) management

6.1    ICP monitoring:

Indication: All children who need to be kept mechanically ventilated following traumatic brain injury should have ICP monitoring.

ICP Bolt:
Intracranial parenchymal pressure monitoring device usually inserted by Neurosurgeons and can be done in theatre or PICU.

  • The ICP wire is zeroed prior to insertion. The Zero Reference and Opening ICP reading must be documented in patient records.
  • Once inserted, the ICP device can be connected to the bedside Phillips monitor.

EVD: External ventricular drain
EVD’s will usually be inserted in theatre by the neurosurgeon. They can potentially be used to monitor ICP, although a reliable ICP cannot be measured whilst the EVD is open to drain CSF. It is preferable to have continuous measurement of ICP from an ICP bolt and to use the EVD to drain CSF to lower ICP.

  • Once inserted the ICP transducer must be levelled and zeroed to tragus
  • The ICP should be read from the EVD system intermittently every 30 minutes (if there is no ICP bolt in situ).

6.2    ICP Waveforms:

Under normal circumstances, ICP pulse waveforms (Figure 1) generally have 3 characteristic peaks;

P1 (percussion wave): Originates from arterial pulsation

P2 (tidal wave): Represents the rebound after the initial arterial percussion.

P3 (dicrotic wave): Follows the dicrotic notch of arterial waveform associated with aortic valve closure.

As the ICP increases, initially all components of the waveform increase simultaneously so that 3 characteristic peaks remain visible. If ICP continues to increase, distinctive P2 increases to a greater extent than P1 so that P2 is predominant (Figure 2). With further increase in ICP all peaks become indistinguishable described as “rounding” or “monotonous” appearance of the ICP pulse waveform (Figure 3).

6.3    Prevention and Management of raise in ICP:

Intracranial pressure treatment thresholds:

  • ICP>20mmHg for 5 minutes or >25mmHg for any length of time should trigger measures to decrease ICP

Routine measures:

  • Normocapnia: pCO2 of 4.5 to 5.0 kPa
  • Adequate oxygenation: PaO2 of 10 to 13 kPa and age appropriate cerebral perfusion pressure
  • Head end elevated to 30 degrees, with the head in midline
  • Normothermia: core temperature between 36.0 and 37.0 degree Celsius
  • Adequate sedation and analgesia. Consider Fentanyl boluses for painful procedures / log rolling etc.
  • Anti-seizure prophylaxis: Phenytoin loading dose followed by maintenance

Interventions for raised ICP:

First line interventions:

  • Ensure all the above routine measures are instituted
  • Drain CSF, 5-10ml, if the patient has an EVD (External Ventricular Drain). Repeat at 5 minute intervals, as necessary
  • 2.7% hypertonic saline bolus 2-5ml/kg over 5-20 minutes or as an infusion titrated between 0.1-1ml/kg/hr infusion to maintain ICP <20mmHg (Avoid if Serum Na > 160mmol/l)
  • Mannitol 0.25g/kg over 20 min. Maximum 2 doses in a four hour period. (Avoid if Serum Osmolality >320). Mannitol may need to be followed by volume expansion (10ml/kg) to keep CVP >8mmHg.
  • Seizures, is there evidence of clinical or electrical seizures (on CFAM) treat as per Acute Seizure guideline
  • Neuromuscular blockade, Atracurium 500microgram/kg bolus followed by standard infusion
  • Ensure adequate cerebral perfusion pressure (Refer to section 6.4)
  • Mild hyperventilation: PaCO2 4.0-4.5kPa only as a temporising measure while other therapies are being started.

Second line interventions:
If the ICP cannot be reduced despite all first line interventions the following should be considered in discussion with PICU Consultant:

  • Repeat CT brain: this should be discussed with Neurosurgical team.
  • Barbiturate coma. Thiopentone bolus followed by infusion to achieve a reduction in ICP. Use CFAM to monitor degree of EEG suppression. Titrate Thiopentone infusion rate to achieve burst suppression. Reduce dose if CFAM shows prolonged suppression (greater than 10 seconds of suppression on raw EEG trace between bursts) or a ‘flat’ isoelectric EEG. Development of fixed dilated pupils also suggests Thiopentone toxicity.
  • Decompressive craniectomy: in discussion with Neurosurgical team.

6.4    Management of inadequate CPP:

CPP = MAP – ICP

Age (years)

Minimum CPP (mmHg)

<1

40 

1-2

45

3-5

50

6-10

55

>10

60

If ICP > 20 mm Hg and CPP < threshold, commence measures to decrease ICP first. Often it is necessary to increase MAP simultaneously to optimise CPP.

  • Assess circulating volume, if CVP <8mmHg, consider IV fluid bolus 10ml/kg over 10 to 20 minutes
  • Consider commencing noradrenaline (start at 0.05mcg/kg/min) if CVP > 8 mmHg, to increase MAP and hence CPP above the threshold value for age
  • Consider adding adrenaline (start at 0.05mcg/kg/min) if there are signs of reduced cardiac function, specifically in patients with pulmonary oedema

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7. Seizure Control

Seizures increase cerebral metabolic demand and contribute to secondary brain injury.

All patients who need ICP monitoring should receive a loading dose of Phenytoin (20 mg/kg) IV followed by prophylactic Phenytoin for 7 days (unless contra-indicated). PICU Phenytoin monograph

If a patient with TBI has seizures they should be managed as per Acute Seizure guideline. If your patient has already received Phenytoin loading dose there is no need to repeat this.

All children who had ICP monitoring instituted and are under neuromuscular blockade should have CFAM monitoring.

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Provenance

Record: 4394
Objective:
Clinical condition:

Severe traumatic brain injury

Target patient group: Children presenting to LTHT following severe TBI
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Triage, assessment, investigation and early management of head injury in children, young people and adults. Issued: January 2014. NICE clinical guideline 176. guidance.nice.org.uk/cg176
  2. Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents. Ped Crit Care Med. January 2012 - Volume 13 - Supplement 1, p S1-S82

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Flowchart

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Appendix A: Glasgow Coma Score

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Appendix B: List of abbreviations

Abbreviation 

Term 

ABG

Arterial blood gas

AXR

Abdominal X ray

BP

Blood pressure

C-spine

Cervical spine

CFAM

Cerebral Function Analysing Monitor

CPP

Cerebral perfusion pressure

CSF

Cerebrospinal fluid

CT

Computed tomography

CVP

Central venous pressure

CVS

Cardiovascular system

CXR

Chest X ray

DI

Diabetes Insipidus

EEG

Electro-encephalogram

ETT

Endotracheal tube

EVD

External ventricular drain

FBC

Full blood count

GCS

Glasgow Coma Score

HCG

Human chorionic gonadotrophin

HR

Heart rate

ICP

Intracranial Pressure

IJ

Internal jugular

LFT

Liver function test

MAP

Mean arterial pressure

NBM

Nil by mouth

PEEP

Positive end-expiratory pressure

PICU

Paediatric Intensive Care Unit

RR

Respiratory rate

TBI

Traumatic brain injury

TPN

Total parenteral nutrition

U&E

Urea and electrolytes

VAP

Ventilator associated pneumonia

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.