For detailed assessment and management see RCH Head injury guidelineThe principles of management of traumatic brain injury (TBI) in children are similar to those in adults. Secondary brain injury may be prevented by avoiding hypoxaemia and/or hypotension. In addition, maintenance of adequate ventilation (maintaining mild hypocarbia) to maintain cerebral perfusion is essential.
Assessment should follow the basic principles of primary and secondary survey as described previously; however, it is important to note:
Expediting transfer to an appropriate trauma facility is the goal in management. Consider early consultation with PIPER to obtain specialist neurosurgical advice and to expedite retrieval in the following scenarios:
The assessment of a small child with a TBI is often very difficult. It is recommended that specialist consultation with PIPER takes place early.
|HOW TO ASSESS SEVERITY OF HEAD INJURY|
Once the assessment has taken place, decide on the severity of the head injury in order to guide investigations and management.
Management principles focus on maintaining cerebral perfusion and adequate ventilation in order to prevent secondary brain injury.
Severe Head Injury
Early neurosurgical advice is vital.
Ensure patent airway and cervical spine immobilisation.
Intubate and ventilate the child who is unresponsive, has a GCS <8, is unable to protect their airway or has any hypoventilation or respiratory irregularity. Once performed, it is vital to provide adequate sedation and muscle relaxation to prevent coughing and agitation.
Care needs to be taken with selection of anaesthetic agents to maintain BP and cerebral perfusion pressure while minimising ICP spikes at time of intubation. Ketamine is the agent of choice in almost all circumstances.
Mechanical ventilation must be monitored to maintain end-tidal CO2 to 32-35mmHg. Hypercarbia (>45mmHg) and extreme hypocarbia (<30mmHg) must be avoided.