Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
Protocol for Management of Pediatric Patients (Birth to Age 17) Emergency Department Phase of Care1-4
| Parameter | Goal for Resuscitation |
| Neurological Checks | Assess GCS at time of admission to ED (prior to intubation and sedation when possible), at post-resuscitation, and as needed in between. Utilize pediatric GCS. |
| Oxygenation | Patient to be on 100% FiO2 Goal O2 saturation 100% Goal arterial PaO2 ≥ 100 mm Hg unless otherwise instructed RSI is preferred method of intubation unless contraindicated. iSTAT ABG for baseline ABG is preferred; if ABG unobtainable, obtain VBG. Venous goal for PO2is 25 to 40 mm Hg and PCO2 35 to 40 mm Hg Goal arterial PaCO2 30 to 35 mm Hg unless otherwise instructed. Avoid hyperventilation unless ICP> 30 mm Hg and/or there are signs of progressive neurological deterioration unresponsive to other measures. Hyperventilate to ICP of 25 mm Hg Keep PaCO2> 25 mm Hg All intubated patients must have an end-tidal CO2 monitor. |
| Blood Pressure Management and Fluid Resuscitation5 | Goal SBP For children ages 1-10; Minimum SBP 70 + 2X their age for goal SBP 50th percentile for age, sex, and height For children > age 10: Use adult parameters 100 mm Hg Maintain pressures with fluids, crystalloid (NS) with colloids and blood products as needed. If fluids unsuccessful, begin blood pressure support with dopamine 2.5 to 20 mg/kg/min. ASAP change to norepinephrine 0.01 to 1 mg/kg/min |
| Intracranial Pressure Monitoring | Placement in ED at discretion of neurosurgery staff/MD or chief resident MD Goal ICP < 15 mm Hg |
| CPP Management6 | Goal for Infants: 35 to 40 mm Hg; children > 1 year will vary from 40 to 65. Individual goals determined by neurosurgery staff. Regardless of age, CPP < 40 is associated with poor outcome. |
| Fluid Management | NS unless otherwise instructed. Bolus of 20 mL/kg. May repeat PRN. No dextrose-containing solutions. |
| Electrolyte Management and Hyperosmolar Therapy7 | Begin infusion of 5% NaCl 3 mL/kg to a maximum of 150 mL IV over 15 minutes x 1 patients with progressive neurological deterioration or a CT scan showing tight cisterns or midline shift. May infuse peripherally in a new large vessel site. Change infusion to a central line as soon as possible. |
| Glucose Management | Goal range: < 150 mg/dL No treatment required in the ED phase of care unless glucose > 300 mg/dL as risk of hypoglycemia is greater than risk of hyperglycemia |
| Anti-convulsant Therapy5 |
Phenytoin load 18 mg/kg IV in NS at a rate of 25 mg/min
in central line or secure peripheral line. (Fosphenytoin 18 mg/kg “PE”) If contraindication to phenytoin/fosphenytoin consider valproic acid (Depacon) 20 mg/kg over 5 to 10 minutes |
| Sedation | Midazolam (Versed) is initial drug of choice in
children. Initiate midazolam drip 0.05 to 0.1 mg/kg/h for patients with
agitation or increased ICP, after the patient is intubated and titrate
up to desired level of sedation per MD order. In situations where the benefit outweighs the risk, consider propofol. Loading dose 1 mg/kg. Maintenance dose 10-67 mg/kg/min |
| Analgesia | Fentanyl to be initiated at admission after initial
neurological exam. IV infusion 1-3 mg/kg/h and titrate to effect. |
| Paralytic | Vecuronium to be used at the discretion of physician. Begin 0.1 mg/kg/dose to maximum of 10 mg. |
| Radiological Imaging | Non-contrast CT scan ASAP |
References
- Management of Severe Traumatic Brain Injury. Brain Trauma Foundation. 3rd ed. May 2007. Available at www.braintrauma.org. Accessed September 7, 2011.
- Guidelines for the Management of Severe Traumatic Brain Injury, 3rd ed. New York, New York: Brain Trauma Foundation, 2007. Available at https://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdf. Accessed September 3, 2010.
- Carney NA, Chestnut R, Kochanek PM. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med. 2003;4:S1.
- Hennepin County Medical Center Traumatic Brain Injury Center. Available at http://www.hcmc.org/braininjury. Accessed September 3, 2010.
- Neurosurgery Focus/Volume 15/ December 2003; Blood Pressure Levels for Boys and Girls by Age and Height Percentile. (See chart.)
- Hennepin County Medical Center Emergency Department Protocol (Biros, Jancik, and GL Rockswold)
- Tsai A, Jancik J. HCMC Pediatric Emergency Drug Book. Minneapolis, MN (in press, 2011).