Welcome, everybody, to our next webinar, Pediatric TBI, Early Evaluation and Stabilization. I'm really happy to have Dr. Eric Sribnick here today with us. He is a pediatric surgeon at Nationwide Children's Hospital in Columbus, Ohio. He attended medical graduate school at the Medical University of South Carolina and neurosurgery residency and pediatric neurosurgery fellowship at Emory University. Eric has a clinical and research interest in neurotrauma. His PhD work examined the use of estrogens as a neuroprotectant in spinal cord injury. His research time during residency examined the use of progesterone as a neuroprotectant in traumatic brain injury. His current work examines immune response following a combined injury, traumatic brain injury plus an external injury, and the possibility of using immunomodulation to improve outcomes. So thank you, Dr. Sribnick, for being here with us. And why don't you get us started in this webinar? Absolutely. So first of all, I just want to thank the organization for allowing me to speak on this topic. It is a personal passion of mine to talk especially about pediatric traumatic brain injury. So we'll go over some of the latest guidelines and sort of how neurosurgeons view pediatric traumatic brain injury in relation to just overall trauma. So first let me say that I have nothing to disclose. I do want to say that in this presentation I am going to show some drawings and some operative photos of neurotrauma. So if anyone does not wish to see those, you know, jump ship now. The other disclosure that I'd like to make is as you'll see very quickly, there's a lack of evidence for a lot of the things that we do in traumatic brain injury in general and especially in pediatric traumatic brain injury. And so I'll try and address that every time that I talk about a therapy or a diagnostic procedure. I'll talk about what type of evidence do we have. When we have a lack of evidence, what we try for is a consensus. And with a lack of consensus, we have opinions. And I'll try and be pretty frank about where we have evidence, where we have consensus, and where we really don't have consensus, and it's opinion. One of the things that I think about when I think about traumatic brain injury in children and in adults is I sort of view it as a metaphor of a train getting across a river. You have the traumatic brain injury over here, maybe pre-hospital intervention here, patient in the emergency room here, maybe in the OR here, the stay in the ICU, the stay on the neurosurgery floor service, and inpatient rehabilitation. And so traumatic brain injury for these children involves a number of different groups. And it's not just one person. It's not just one service. It's a team sport. And we all take ownership of these patients. If we're not careful, at any point, the train can go into the water. And that's really what we're here to prevent. So I'm going to talk about just a couple of cases that I've seen and how they relate to traumatic brain injury in general. The first case that I'll present is a one-year-old who came into the emergency room on a Friday at about 5 o'clock in the afternoon. So he was seen at an outside hospital at 5 o'clock, and this was his initial head CT. The patient presented with altered mental status, was seen at his daycare, and for no apparent reason, just started to become lethargic and really have a change in his mentation that was concerning to his caregivers. So they called the parents. The parents came and picked him up. You can see here in this head CT, there's blood here that's at hyperdensity on the left. You can see that this brain is very tight already, even at just 5 o'clock. And you can see that there's subgaleal swelling, indicating that at some point there may have been injury to the scalp. By the time we received this child at our hospital, it was about two hours later, and you can see the changes in the head CT. This extra axial collection, this collection that was outside of the brain right there, is getting squeezed. And you may think, well, you know, the subdural hematoma is going away, but what that's actually showing is that this brain is becoming tighter and tighter and tighter. Whereas you could see some differentiation between the brain, the gray-white and the white matter, here you see an obliteration of that here, and that subgaleal swelling has gotten worse. That scalp swelling has gotten worse. So when I evaluated this child, the child had essentially GCS of 3 and had brain stem reflexes. That was it. We did everything that we could for this child, full medical and surgical treatment. We gave the child mannitol in the emergency room. Could not have gotten this kid up to the operating room any faster. Did a hemicraniectomy, and we'll talk about a little bit of this later, but essentially what a hemicraniectomy is, is when you have high pressures like you see here, you want to get this bone off, and we did a left, in this case, we did a left-sided hemicraniectomy because he had blood on that left side. And so you take off the frontal, the parietal, and the temporal bone, and you can see that right here, frontal bone is gone, parietal bone is gone, temporal bone is gone. You open up the dura, and you allow that brain to herniate out. We also did an ICP monitor in this child so that we could treat elevated intracranial pressures, and we put this patient on our normal traumatic brain injury protocol. He had refractory elevated ICPs. He had intracranial pressures that we just couldn't treat. He lost all brain stem reflexes. Hair was withdrawn postoperative day one. Sort of in contradistinction, this is the case of a 16-year-old male. You can see a lot of common things here, okay? There's scalp swelling. You can see a little bit of an extra axial blood collection right there on that left side. This is an epidural hematoma, and this was taken at about 7 o'clock at an outside hospital. You can see here, basal cisterns are still open. This brain looks like it's nice and relaxed. So this child took a little bit longer to get to us, about approximately four hours to get from the outside hospital to our hospital. You can see scalp swelling here. Somebody's closed a scalp laceration right there. This epidural hematoma has grown considerably, so it's gone from being barely noticeable to being pretty sizable. In addition, this epidural hematoma is now pushing on the temporal lobe, and you can see the temporal lobe, the uncus of the temporal lobe, which is right here, is starting to drop toward the midbrain. And if you could go down a couple of slices, you'd see that this basal cistern is probably completely closed off. We did essentially the exact same thing for this child, a left-sided frontotemporoparietal hemicraniectomy. We gave him mannitol. We placed an ICP monitor. We put him on our normal TBI protocol. His ICPs were well controlled. We were able to get control of his intracranial pressure. He had a five-day ICU course, so, you know, a fairly normal ICU course for somebody who presents with this kind of injury, seven days on our neurosurgery floor service, a stay in our inpatient acute rehabilitation hospital. And by the time he was ready to have his bone flap put back on, this child was essentially decorating the helmet that I gave to him for brain protection. So we take that half of that skull off, and you give them a helmet, and he ended up making his helmet into sort of a decorative helmet. He was a big fan of a local rap artist from Cleveland called Machine Gun Kelly, and evidently this is the iconography for Machine Gun Kelly. So he did really well after this traumatic brain injury, as you can see from his artistry. And essentially, the difference between these two patients, and that's going to be my focus for the next hour, is that you have about six minutes. If you lose quality perfusion to the brain, oxygenated blood to the brain, within six minutes, after six minutes, brain cells start dying, and then you're really in trouble. And you go from having a case that's salvageable to having a case that's not. And our goal in neurotrauma is that every step of the way, we keep that from happening. So in the pre-hospital setting, I looked for guidelines for pre-hospital treatment of traumatic brain injury, and there are no real recent guidelines that I could find. The most recent that I could find from was about 2008. And essentially, it's sort of fairly pedestrian stuff that you would predict would be good for these patients, establishing a reliable airway, having a low threshold to intubate, so protecting that airway, and confirming that you have protection of that airway, both with auscultation and with an end-tidal CO2 indicator, making sure that that ET tube is in a good place, avoiding hypoxemia, using a pulse oximeter with a goal O2 sat of greater than 92%, and then giving oxygen, if oxygen is available. So again, these are very basic things, just airway, breathing, avoiding hypotension, so circulation, just your ABCs. Especially for these kids with traumatic brain injury, as you saw in that second case, they can oftentimes have scalp lacerations. And I always tell my folks that we need to pay particular attention to scalp lacerations and close or tamponade these as quickly as possible, because that can, scalp bleeds very profusely, and you can lose a considerable amount of blood that way. Use of isotonic fluids, you want to avoid hyponatremia, and this will come up in later slides, but if you have normal saline versus half-normal or D5 half-normal, you want to use the normal saline. Systems-based recommendations are pretty clear, having an organized trauma care system, and in Ohio, we're blessed with a very organized trauma care system, and I think it really positively impacts our patients and their outcomes. Routing patients with severe TBI, so GCS less than 9, to a place where they can get rapid head CT, rapid evaluation, and especially get seen by a neurosurgeon who can then go on and perform whatever diagnostic tests or treatments that patient might need, and of course, minimizing transport time in these patients. So the transition of the hospital, once the patient is through that pre-hospital setting and is going from the ambulance to the ER, what do I want to know as a neurosurgeon? So I want to know a history of the incident, if it's an MVC, was there a rollover, was the patient restrained, unrestrained, was there an airbag deployment, if it's a gunshot wound, I want to know where the entry is, where the exit wound is, if, and especially in pediatrics, if this is a young child, I want to know if there's any concerns for non-accidental or abusive trauma, because that completely changes a lot of the setup that we have. So that's a very special type of injury that has its own sort of considerations. So transfer history, so if that patient was brought in from the scene, it's certainly one thing, but if they were brought in from an outside hospital, which happens not infrequently, what tests were performed at that outside hospital, especially for pediatrics, because frequently they'll go to either a large adult center or they'll go to the nearest rural center, and they may have had certain tests or exams performed that we don't need to duplicate. What medications were given for resuscitation and whatnot. As far as the past medical history, as a neurosurgeon, I want to know, does this patient have a history of seizure? If they have a history of seizure, were they on their seizure medications? Do they have a recreational drug history? Are they on anticoagulation? And you might think, well, you know, why would a pediatric patient be on anticoagulation, but oftentimes with our children with cardiac conditions, they can either be on antiplatelets like aspirin, or they can even be on anticoagulants. Do they have hypertension? You know, what is their normal blood pressure? That's more relevant for the adult patient population, but it can also be relevant for the pediatric population, and we'll talk a little bit about that later in the presentation. Was there a possible anoxic injury? So in our children who potentially have non-accidental trauma, there's a high degree of possibility of anoxic injury. During their transport, was there loss of the airway? Do we suspect either hypoxia or hypotension? If you lose that critical perfusion to the brain, you can start getting generalized brain swelling, and when that happens, potentially there's limited treatment benefit. Was CPR required at the outside? Again, that sort of would indicate, you know, possible anoxic injury that may not be recoverable. For transfer of pediatric trauma patients from an adult facility to a pediatric facility, we strongly encourage this, obviously. Unfortunately, there aren't a ton of national guidelines to guide us. There is a pediatric readiness score, and this score correlates with, essentially what the score does is it's an evaluation of that trauma center, and it looks at different types of metrics, and you can have a score from, I believe it's zero to 100. The higher the score, the better you're doing as far as your pediatric readiness, and the readiness score tends to correlate with the presence of pediatric care coordinators, so people who are essentially there, it's their job to make sure that everybody is ready for pediatric patients, pediatric patient volume, and that center being a level one or two versus a level three or four, and these are all sort of what you would expect would engender readiness for pediatric patients. People whose job it is to make sure that you're ready for pediatric patients, the presence of pediatric patients so that you have practice in taking care of these patients, and a level of readiness as far as trauma. Self-assessment is really what I would encourage for every hospital. If you, if there's any chance that you're going to be taking care of pediatric patients, just know whether you're ready to take care of those patients or not, and if you decide that you're not able to take care of those patients, having inter-facility transfer agreements set up so that these patients can be quickly and easily transferred from your center to a pediatric center is always preferable. Having disaster plans that include plans for children, if you have a bus rollover and you get 30 patients and 10 of them are children, what are you going to do? And then QI projects and protocols with pediatric metrics, just making sure that you have smaller-sized equipment that's relevant for pediatric care, simple things like that. In Ohio, our recommendations, we don't have any official recommendations, but by and large, patients aged less than 16 years or major trauma, life or limb threatening, these are patients that it's highly recommended go to a pediatric setting, but again, national guidelines are fairly lacking in this area. Guidelines that I would recommend essentially stabilize first and then send for patients where there are issues with airway or they're requiring CPR, and obviously, they need to go to the closest appropriate hospital. Following resuscitation, once you have the patient stabilized, the goal arguably should be less than two hours, but obviously, the sooner you can get them out, the better. When in doubt, send it out. And I include this can of soda just to remind myself to tell you that for pediatric patients, it's really overwhelming how different the physiology is for these patients. In the newborn, literally the entire blood volume of that child is going to be less than would fit in a standard 12-ounce can of soda. So there are a lot of different considerations to take, especially in our youngest children, and they need to go to a place where they're going to receive the best treatment. At our hospital, we have something called a level one neuroactivation, so this would be activated either before the child reaches the emergency room or when they reach the emergency room. The criteria for this are significant penetrating injury to the head, so for instance, gunshot wound to the head, acute intracranial hematoma with greater than four millimeters midline shift, so obviously, this would be a patient who had received a head CT that showed midline shift, obvious severe open cranial injury, or a comatose patient with a unilateral fixed and dilated pupil. So if you meet any of these four criteria, it results in a full trauma team activation. All stakeholders are down in the emergency room waiting for the patient if possible, including the emergency room physicians, general surgery, anesthesia, and all other caregivers. There is an as soon as possible response from the neurosurgery team. By and large, we're down there within minutes, and there's preparation, most importantly, by the OR staff for possible cranial surgery, so that patient can go from the emergency room, plus or minus a CT, straight to the operating room. In essence, time is brain, and you just want to get these patients as quickly to the operating room as you can. The initial goals of care in the trauma bay, again, and this is going to sound repetitive, but this is the best way to take care of these kids, is to do the simple things first. So airway, breathing, circulation. Obtaining trauma labs as quickly as possible is important, CBC, BMP, typing or crossing two units of blood, just get it done, sending COAGs, and then obviously a beta HCG if the patient is of age and female. Evaluation for other sources of injury. As a neurosurgeon, the last thing I want to do is get a patient up to the operating room for cranial surgery, and then find out that they have a splenoclax that's causing them to be hemodynamically unstable. So one of the first things that I do when I've decided that I want to take a patient to the operating room is I make sure that my general surgery colleagues agree that this patient is okay to go to the operating room with me. Our goal time is to get from the emergency room to the scanner within 20 minutes, and usually we're pretty good about that. Head CT, you know, no pun intended, it's a no-brainer to get a head CT, but there are other studies that we may or may not need to get, so we may need to get a CT of the neck. Oftentimes we'll have a lateral X-ray, if that lateral X-ray shows anything that's off, we'll get a CT of the neck. Usually we'll need a CTA of the head or the neck, a CT angiogram to check for any injury to blood vessels. And then obviously we need to take into account the chest, abdomen, and pelvis, and the extremities, make sure that there's nothing that we need to take care of before we get that patient up to the operating room for a neurosurgical procedure. That can be done potentially with a FAST scan, and sometimes it requires a chest, abdomen, or pelvis CT scan. For my adult providers who are listening to this, you may be wondering, why don't you just scan everybody like that? And in the pediatric population, we try and spare these kids radiation if possible. So these are some graphic pictures that I'll show you. These are sort of some of the things that would cause us to need to go to the operating room pretty quickly with these patients. Open depressed skull fracture. So this was a patient who was involved in a motor vehicular accident whereby there was a laceration. Underlying that laceration is an open depressed skull fracture. We can see that on the head CT. This is the laceration. This is before we even did surgery. The patient is draped out, and the nose is right here. Top of the head is right here. We ended up doing what's called a bicoronal incision. So we just opened up essentially from ear to ear. We were able to retract one part of the scalp back here, one part of the scalp back here, which opened us up to essentially find that depressed skull fracture, elevate the skull fracture, and close everything up. Then we closed the laceration that the patient came with, and then our own surgical incision. I haven't been able to describe this any better than Frank Netter did in this original drawing, but essentially open depressed skull fracture. You can see the laceration overlying the skull fracture. Skull fracture is going into the brain. What you want to do with these patients is you want to open this up. You want to evacuate any hair or grass or dirt or whatever stuff gets in there. And then once you've evacuated that out and you've gotten that cleaned, generally what I do is I'll make a burr hole, maybe right here, and then take a craniotome and just go zip around that fracture, elevate that entire piece of bone out, close any dural openings, and then put that piece of bone back. One thing I want to warn people about are occult fractures. So I've seen this a couple of times in children. It tends to be from a long projectile. In this case, this is a young man who was walking in the woods with his brother, and his brother threw up one of those markers that you see on real estate, those little thin markers. It's just like a little thin metal rod, and unfortunately it came down. This is what you saw on the X-ray. Unfortunately, the fracture was not called on the initial X-ray, and he went home and came back to us several days later and had this MRI. And what you can see is on that left side, this is a piece of bone right there, a piece of bone right there, and a piece of bone right there. And this had come just left of midline, and it managed to miss his superior sagittal sinus, and it managed to miss a large cerebral vein. Either of those, had they been injured, this would have resulted in a catastrophic injury. But he came to us about two days after the initial injury, and because of swelling to the brain around here, probably a little bit of inflammation, he was having right-sided weakness, and we were able to take him back and fix his skull fracture. You can see that skull fracture preoperatively right there. Not necessarily high velocity, and they may only have a puncture wound to the scalp, but these are at high risk for infection if they're missed. So going one step lower than the skull, epidural hematoma. So this is the skull on this little cartoon, and this is the dura, and this is the epidural hematoma. It's essentially blood, a blood collection that's between the skull and the leathery covering surrounding the brain. It's a true neurosurgical emergency because it can put pressure on the brain if they're large enough. And the other reason why it's a true neurosurgical emergency is because patients can do well if you catch these soon enough. So this is a temporal epidural hematoma in a patient who obviously did not do very well. This is the dura covering the brain right here, and that's the epidural hematoma. This is a CT scan showing this, and essentially what this epidural hematoma does is it puts pressure on the brain. You can see that midline shift here. What you're worried about is enough pressure on the brain until the temporal lobe essentially herniates down into the midbrain, and that's when you start to see third nerve palsy, so a blown pupil and a decrease in mental status. Subdural hematoma is another type of hematoma that can be evacuated neurosurgically if needed, and this is blood that's underneath that leathery covering and between that leathery covering of the dura and the brain itself. These tend to do worse than epidural hematomas because of direct injury to the brain and also because they're associated with brain lacerations and brain contusions. These are particularly prone to post-traumatic seizure, and again, this is just a pathological specimen showing that's the dural covering and the subdural hematoma, and that's the brain that's been compressed. This is it on CT scan, and you can see, again, there's midline shift here. This would be one of those subdural hematomas that you would want to get out as quickly as you possibly could, and essentially, as neurosurgeons, the reason why we need to evacuate these things, get this under control, is because your head, the cranial contents, is a fixed three-dimensional space. You have room for your brain. You have room for the blood that's going to your brain, and you have room for the blood that's going away from your brain and your brain fluid. When you get mass such as, like, a small epidural hematoma, your brain can compensate for that. You can push some of that venous blood, some of that brain fluid out of the way. As that mass gets bigger, or that swelling gets bigger, it starts to push the venous blood out, the CSF out, and it can start to push in that arterial blood, and that's when you go into uncompensated pressure, and that's when the pressure starts rising. As neurosurgeons, what we can do to effectively increase that volume, to make this box a little bit bigger, is we can take half of the skull off, and that allows for an increase in the volume of those intracranial contents, and allows for the brain to expand out, and allows for us to take, you know, potentially an epidural or a subdural out. So that's why we do hemicraniectomies in general. And this is just a cartoon showing the different ways, so if you have, say, an epidural hematoma, you can herniate underneath the phalx. You can herniate down through the tentorium, so this would be an uncle herniation. This is what would cause that blown pupil and that altered mental status. If you have a gunshot wound, you can herniate out through the defect. And essentially, as neurosurgeons, what we do is we make a large defect that allows your brain to herniate out, and allows for you to lower that pressure. And you can see here, this is effectively what a hemicraniectomy looks like once we're done. Obviously, this is a very dramatic picture showing, you know, profound brain swelling. They certainly don't look like this normally. This is the top of the head. This is the bottom. Ear is somewhere around here. Back of the head is here. Front of the head is here. We flap, or somebody has flapped the scalp back this way. The temporalis, or chewing muscle, is flapped back this way. And then essentially what you would do is you would lay something, a dural replacement, over the brain. And then you would just flap the scalp back over, and then sew everything back up. Monitoring intracranial pressure, so this is something that, you know, if you take a patient back for hemicraniectomy, or if you're concerned that the patient has elevated pressure, there are several different ways that you can monitor brain pressure. Two of the more typical ways that we'll talk about are using an interparenchymal monitor, which is just a wire electrode that you thread down through the brain that monitors brain pressure. The other way that you can do this is through a ventriculostomy, or an external ventricular drain, and that's just a thin, open catheter that you pass into the brain ventricle. The beauty of the ventriculostomy is that you can both take away fluid, and you can monitor pressure at the same time. The most recent pediatric guidelines give level three evidence for recommending the use of ICP monitoring for severe traumatic brain injury. In addition, and this is new to the third guidelines that are just out, there's a recommendation to not assume normal ICPs in a patient with a normal head CT. And to sort of put that in plain English, if you have a patient with severe traumatic brain injury and a normal head CT, you should give still consideration to putting in one of these brain pressure monitors. And there has been some controversy about brain pressure monitors. There's not a ton of great evidence, as we'll talk about. And some people, frankly, prefer to not use these things. Are children with severe traumatic brain injury at risk for raised ICPs? So the evidence that we have suggests that one third of children who have severe traumatic brain injury will have elevated ICPs on initial monitor placement. Of those patients, or the patients that you place an ICP monitor in, one half of those patients will have elevated ICPs sometime during the time that you're monitoring them. And for me, as a neurosurgeon, essentially this is how I feel when I don't have a brain pressure monitor. I feel like I'm driving blind, because by definition, if you have a patient with a severe traumatic brain injury, you don't have a very good neurological examination. The patient is almost certainly going to be intubated and is going to need to be on sedation. And so I am heavily in favor of monitoring intracranial pressure. And there's indirect evidence showing that you have an improved outcome with monitoring simply because if the brain pressure is elevated, there are things that you can do to treat it. So as far as advanced neuromonitoring, so these are different types of monitors. So this can measure, this is, the most typical one is called a LICOX, and it can measure both direct brain pressure, essentially through that same mechanism using an electrode. But it can also measure the brain oxygen around the brain tissue that's surrounding the electrode. And this may sound like the perfect device for these patients. Unfortunately, it's just not that straightforward. The level three evidence that was used for the most recent recommendations for pediatrics recommends, gave essentially no recommendation to monitor brain tissue oxygenation. And the rationale behind this is that while low brain tissue oxygenation was associated with a poor outcome, there was no correlation between, quote unquote, normal brain tissue oxygenation improved outcome. And patients can have normal brain tissue oxygenation and still have elevated ICPs. So they just didn't find that this type of advanced neuromonitoring was very useful. Which monitor to use? You know, are we going to use the ventriculostomy or are we going to use an interparenchymal monitor? And you may find that different neurosurgeons have different opinions about this, but by and large, I'm going to show you two sort of clear-cut cases. So this is a patient with large ventricles with an interparenchymal and interventricular bleed. You can see the blood in the ventricles, and you can see that it's creeping out into the brain. And in a patient like this, I would be heavily in favor of placing a ventriculostomy device in a patient where I couldn't monitor the patient who had a GCS of less than nine, where I felt like I couldn't monitor the exam. And you would essentially just pass that ventriculostomy into the brain ventricle, and you could drain off some of that blood, and it'd be pretty easy to get into those ventricles. Alternatively, you could have a patient like this, where there's cerebroedema, swelling, and smaller ventricles. And in a patient like this, potentially, you might choose to place an interparenchymal monitor for fear that you would have to make several passes in order to get into those ventricles to effectively drain and monitor. Why are we checking the ICPs? Well, essentially, this is sort of the equation that I think of. So you want to know CPP, cerebral perfusion pressure. And what this is, is I think of it as two vectors, the mean arterial pressure, which is the pressure of the heart versus the pressure of the head. And the difference between the pressure of the heart and the pressure of the head is the pressure of the blood that gets up to the brain. And you want to keep that brain, like we talked about, well oxygenated. So you want to keep mean arterial pressure normalized, at least, and you want to keep the intracranial pressure low so you can get good oxygenated blood to the head. So what is a safe ICP? In the adult guidelines, there's level two evidence, so pretty good evidence as far as traumatic brain injury is concerned. Treating ICP above 22 millimeters of mercury is recommended because values above this level are associated with increased mortality. In the pediatric guidelines, we're still at level three evidence. We just don't have enough good studies to bring it to level two. But in the pediatric guidelines, treatment of an ICP targeting a threshold of less than 20 millimeters of mercury is suggested. And really, there's not much of a difference between 22 and 20. Unfortunately, for the pediatric guidelines, there was not enough data to age discriminate. What is a safe CPP? So in adults, the recommended target, cerebral perfusion pressure, is between 60 and 70 millimeters of mercury. And again, this was a level two. They had enough evidence to make this level two recommendation. In the pediatric guidelines, treatment to maintain a CPP minimum of 40 millimeters of mercury is suggested. And again, this just shows you the profound difference between the physiology of the adult and the pediatric patient. A CPP target between 40 and 50 is suggested to ensure that the minimum is not breached. So essentially, what they're saying is that so you don't get below 40, try and keep it at least between 40 and 50. There may be age-specific thresholds with infants in the lower end and adolescents at or above the upper end of this range. And so this is just suggesting that at your own institution, you've got to come up with what you're going to do for children of different age. And so what we've done with these guidelines that are just broad-based is we've just drawn lines in the sand. And so ICP for children less than one year of age, we've put a cutoff at 15 millimeters of mercury. If you're older than one year of age, we put it at less than 20 millimeters of mercury. So more in accordance with the guidelines. But we've definitely said that in our youngest children, we want to keep the ICP a little bit lower. CPP 40 to 50 is a little bit lower than what we like to see. And so the CPP that we have in our own guidelines here at Nationwide Children's Hospital is 45 to 55, since the age is less than six years. And 50 to 60, if the age is greater than six years. And we relax those CPPs. The CPP goals, if our ICPs are within normal limits. And the reason for that is, if your ICP is normal, then you don't have as much concern for your CPP. You still want to obviously keep the patient norm-intensive. Knowing your patient's baseline, where their blood pressure normally is, is essential. So if you have a normal patient who has normal blood pressure prior to the injury, then they're going to be able to essentially auto-regulate between a fairly normal range. And the brain is set up, it's just fascinating that your brain can have this very high range of cerebral blood flow and still maintain just a normal cerebral perfusion pressure. If you have chronic hypertension, then essentially you auto-regulate at a higher blood pressure. And you need to keep your blood pressure higher in order to keep your cerebral blood flow at the same point. And so what that means is that in a patient with chronic hypertension, if I let that blood pressure get to even, you know, what would for a normal intensive patient be a normal blood pressure that I would want, they may slip into a place where their cerebral blood flow goes down. Okay? And that's where they're going to be at risk of stroke. Alternatively, if I have a patient who, you know, say a younger patient who normally has a very low blood pressure, if I try and drive that blood pressure up too high, I'm going to drive my cerebral blood flow up and I may cause hyperemia or edema. One of the things that we always worry about following a traumatic brain injury is coagulopathy. Especially with severe traumatic brain injury, these patients are a perfect setup for a coagulopathy. And if you look at studies, about a quarter of these patients are going to potentially have a coagulopathy. Conventional labs would include an INR, PT, PTT INR. Generally we want to keep that INR less than 1.4. We want to keep the platelet count above 100,000 and the fibrinogen above 200. And the reason for this, as neurosurgeons, is really twofold. We don't, if the patient has intracranial bleeding, we don't want that bleeding to get any worse. And if we have to take that patient to the operating room, we don't want to have either catastrophic bleeding or bleeding that you just can't control. And so we are very concerned about coagulopathy in these neurotrauma patients. Some of the newer tests that we have are viscoelastic tests. The trade names Rotem and Teg are ones that you've probably heard of. And essentially what you're doing in these tests is you're taking blood, allowing it to clot, and you're allowing it to clot in a set of conditions that would be similar to a low flow venous environment. And what you're looking at over time is clot formation and clot breakdown. And from these numbers you can get all sorts of various and different metrics that will tell you what you're potentially missing, what you need to treat your patient with. I personally believe that these newer tests are going to be game changers overall and will allow for us to take more and more patients back to the operating room because we'll have better ideas of what the coagulopathy is due to and how best to treat it. Treating coagulopathy following traumatic brain injury, the mainstays of therapy, packed red blood cells for patients who are anemic or have a high degree of blood loss, fresh frozen plasma, cryoprecipitate for patients who have a low fibrinogen, treatment with platelets, and treatment with vitamin K. Newer therapies include NOVO7, which is recombinant factor 7. It's not really new anymore. Neither is 4-factor PCC or prothrombin complex concentrate, but these are therapies that are sort of still gaining recognition. Especially 4-factor PCC in the pediatric population I think needs to be better advertised. If you look at adult studies, this is an adult study where they were correcting non-surgical patients with either fresh frozen plasma or PCC. You can see PCC in red. The correction is just fairly instantaneous almost. Again, these are real game changers, and I can tell you from personal experience I've had patients who I think survived simply because we were able to correct coagulopathy quickly and get them to the operating room in time. So what do you do if you have an elevated ICP? So one of the first things that you do is just the simple things, positioning. Get that head of bed up. I've seen this correct. ICP is 10 millimeters of mercury or more. Checking for a tight C-collar. So sometimes the cervical collar can be so tight that you don't get good venous return. Obviously you need to get the stakeholder who's taking care of the spine to okay to this, but sometimes you can loosen that cervical collar and drop the ICPs a little bit. Maintaining normal temperatures, maintaining normal sodium levels, and maintaining normal glucose and PaCO2. And we'll touch base on all of those in the next coming slides. Seizure prevention is essential. Pediatric guidelines suggest that you use early prophylaxis to treat early post-traumatic seizures. Now they don't say whether to use Keppra or Levataracetam or Dilantin, otherwise known as Senatellin. At our hospital we tend to use Keppra. In the adult guidelines there's the recommended use of Dilantin to decrease the incidence of seizure, but only if the benefit is believed to outweigh the risk. At Nationwide Children's Hospital, at our place, all of our severe TBI patients will receive prophylaxis and our neurologists are pretty aggressive with these patients and have allowed us to put all of our severe traumatic brain injury patients on continuous EEG. And it's important because this is a graphic showing just different patients and what their ICPs do if they have a generalized tonic-clonic seizure. And as you can see, the ICPs go way up if you have a patient who suddenly starts seizing. And so keeping those seizures under control and recognizing seizure when it happens, sometimes sub-clinically, is important. Analgesia and sedatives and paralytics, the pediatric recommendations are for the appropriate use of analgesia and sedation in routine ICU care. And they recommend avoiding bolus administration of fentanyl and Verset simply because you can drop your blood pressure when you're giving boluses of these recommendations, or of these types of medications. There's no recommendation in the current guidelines for neuromuscular blockade and the most recent pediatric guidelines, but if you look at the pediatric, the first and second pediatric guidelines, they did recommend paralytics. And I'll go down and say this as a personal opinion. I like paralytics. This is early research that was done in dogs. And essentially what they did was they did sternotomy in dogs to sort of show what happens when you increase endothoracic pressure. So if you do a sternotomy, similar to giving paralytics, and you increase the endothoracic pressure, you're not going to increase your intracranial pressure. On the other hand, in the dogs that they didn't do the sternotomy on, as you increase that, actually it's interabdominal pressure. So the interabdominal pressure transmits through the intact thorax and increases that intracranial pressure. So you might wonder, how does this relate to giving paralytics or not giving paralytics? Essentially what you do when you give the paralytics is you just relax the patient. So you relax any intraabdominal pressure, you relax any intrathoracic pressure, and that has a direct impact on your intracranial pressure. Ventilation strategies. So the pediatric guidelines, prophylactic severe hyperventilation is not suggested. This is a level three guideline. You may wonder why. Because certainly if you blow the patient down, you are going to reduce your ICPs. There's no question about that. The problem with that is that when you are dropping your PaCO2, what you are in fact doing is you're reducing the caliber of those arteries that are going up to the brain, and you can cause an ischemia because of reduced perfusion to the brain. So what they suggest is that if hyperventilation is used for ICP management, they would recommend putting in one of those brain pressure monitors so you can make sure that you're perfusing the brain. And then obviously in patients where you have something like a blown pupil and you want to get immediate relief, they would recommend that you use hyperventilation to emergently reverse transtentorial herniation. But they just recommend that you not use hyperventilation for regular ICP control. CSF diversion. If you place an external ventricular drain or ventriculostomy, taking CSF away from the cranium is a great way to get your ICP under control. There are sort of two schools of thought when you place an EVD. You can intermittently drain for high ICPs, and if you were doing that, your EVD would be connected to a manometer, and you would be monitoring. And if your ICPs went up, then you would open up the drain, and you would just drain some of your fluid, and then you would get your ICPs under control and go back to watching that manometer. There's also continuous drainage, and that's where you just continually drain fluid, and then occasionally you would check your manometer to see if you have a high reading. There's no firm recommendation of the pediatric guidelines and the adult guidelines. It says the continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use. And for my own personal opinion, I like continuous drainage more than I like intermittent drainage. What I like even better is having both. And so one of the things that I'm trying to implement at our institution is use of both a ventriculostomy catheter and an ICP monitor so that you could have brain pressure monitoring at all times and all times have drainage. Hypertonic saline, typical concentrations are 3, 6, and 23.4%. Use of 3% bolus is recommended for elevated ICPs, and this is a game-changing medical therapy. Elevating the use of hypertonic saline, elevating the patient's sodium can sometimes be exactly what you need to bring down those elevated ICPs in patients who just aren't surgical candidates. For children, the recommended continuous infusion of 3% is anywhere from 0.1 to 1, and the minimum dose needed is recommended. And in the most recent guidelines, 23.4% sodium chloride, which is the highest sodium chloride can get as far as concentration room temperature, is now recommended. This was previously only used in adult patients, and folks at adult trauma centers can attest that this can be just absolutely magical stuff, especially if you have a patient where you don't want to be giving large volumes of fluid for whatever reason. Use of hypothermia. In the pediatric guidelines, prophylactic hypothermia is not recommended over normothermia. These are level 2 guidelines. Moderate hypothermia can be used for ICP control. If hypothermia is used, rewarming should occur at a rate, and this is a very, very slow rate for the rewarming. So literally going 0.5 to 1 degree of centigrade over 12 to 24 hours. So if you're going to cool your patient, you really want to rewarm them very slowly over time. In contrast with the adult guidelines, they recommend against using hypothermia. From my own experience, I can tell you that while I'm not a firm believer in hypothermia, I am strictly against allowing patients to have elevated temperatures. Sometimes we will wrap our patients for brain tumor in a bag to allow for an interoperative MRI, and occasionally these patients will get a little bit warm, and what I've seen is if you allow that patient to get too warm, brain starts herniating out. There's a direct correlation between temperature and brain pressure, and so while I'm not a firm believer in hypothermia, I'm strictly against allowing hyperthermia in these patients. Use of barbiturates and decompression. Pediatric guidelines state that the high-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension. So to translate that in patients where they've got a good blood pressure and they're not responding to other therapies, you can use these barbiturates. Decompressive craniotomy is suggested to treat neurologic deterioration, herniation, or intracranial hypertension that's not being treated by medical therapy. The adult guidelines specify a size for that hemicranioctomy of 12 by 15 centimeters, and essentially the reason for that, this is a patient that I took back for hemicranioctomy. This was a young man who was riding an ATV, got hit by a car. We took him back. If you do the measurement, we got about 12 by 15 centimeters for this hemicranioctomy, and you can see he was using every bit of this. After we took the bone flap off, as his brain relaxed, you could see where his interparenchymal hematoma or his brain contusion was, and this hemicranioctomy I would consider a life-saving measure for this young man. If you don't make your hemicranioctomy big enough, the brain is still going to herniate out, and it can pinch off here, you know, you can see it pinching off here, and that can cause further brain injury. Use of corticosteroids, the bottom line is please don't. Use of corticosteroids is not suggested to improve or reduce ICPs in children, and this was level three evidence, but the evidence is so good in the adult recommendation. So there was a huge trial that looked at 10,000 patients called the CRASH trial, and essentially what they showed was that patients who were put on steroids did poorer. Use of replacement corticosteroids for patients who need replacement therapy is fine, but just prophylactically using these is not very smart. When all else fails, consideration of decompressive surgery, hypothermia, barbiturate therapy, and moderate hyperventilation. I would consider these to be sort of secondary. Obviously, decompressive surgery is good in patients who have an obvious hematoma, but in patients who don't, using decompressive surgery just to bring that ICP down is second-tier therapy. In our own guidelines here at Nationwide Children's Hospital, first-line therapy, when all else fails, is to initiate barbiturate therapy, and essentially we do that with, usually it's pentobarbital, and what we're looking for is burst suppression on a continuous EEG. So these patients need to be hooked up to EEG and we want to see burst suppression, which is essentially just the brain at a minimal sort of minimal activity. If we're going to use moderate hypothermia, we want to see that these patients have evidence of ischemia and no contraindications to hypothermia. In contradistinction to this, if we're going to use hyperventilation, we want to see that these patients have evidence of hyperemia, so absolutely no evidence of ischemia, and the reason for this is that patients with evidence of ischemia are going to do worse if you get less blood up to their brain. So in those patients, if you needed to do something else, we would recommend moderate hypothermia, but again, this is sort of outside of the guidelines. If you want to look at the guidelines, the guidelines give a recommended protocol. It's a pretty busy diagram, as you can see here, but if you break down the most essential part to the guideline, essentially it just talks about what we spoke about. You're on an ICP pathway. If you have elevated ICPs, you need to be monitoring. If there's the risk of having elevated ICPs, you need to be monitoring those ICPs. If you have elevated ICPs and you have an external ventricular drain in place, you can consider CSF drainage. If that doesn't work, then you can try hypertonic saline. If that doesn't work, you can try additional analgesia or sedation. If that doesn't work, you can try neuromuscular blockade, and if that doesn't work, you can try additional hypertonic or hyperosmolar therapy and then move on to secondary, second tier therapies. Essentially what I would say is for places that do not have a severe TBI protocol, consider either creating one or using one that's presented in these guidelines. Essentially, the best part of having a protocol like this is that you have stepwise directions that you can follow, and in addition, you have something that you can monitor as guidelines change. You can change your protocol to match the guidelines, and also you can monitor your protocol with metrics and see if you can improve on your own guidelines rather than if you don't have a protocol and everybody's just doing whatever they want. In conclusion, if anyone has any questions about anything that I've spoken about, I'd be more than happy to answer them. Okay, great. A lot of great information there. We're just going to take a few minutes. We already have one question which I'll read, but I'd like to say that if you have any questions, you can type it into the question box on your webinar panel, or you can click on the hand to raise your hand, and then I'll call on you after this initial question. So the first question that we have is, is it difficult to tell which type of extra axial hemorrhage a patient has? Many times, all I can find on the head CT report and in the progress notes is documentation of an extra axial hemorrhage, but it does not specify if it is subarachnoid or epidural. This makes it difficult to determine which ICD code and AIS code to use. Is there a default to use if only extra axial bleed is mentioned? So that's a fantastic question. I can think of two different scenarios where that may come up. You may have a mixture of blood, so you may have a small subdural hematoma or a small epidural hematoma and some are subarachnoid blood. Additionally, you may have a brain contusion, and those brain contusions can look like a different type of bleed. If there is one overriding, overwhelming type of bleed, generally your CT report is going to document that. So if you have a large subdural hematoma that is clearly a subdural hematoma, that's what they're going to say. If there's any question, I think getting in touch with your neurosurgeon and just asking them, hey, what do you think this looks like? It wasn't very clear on the radiology report would probably be the easiest way to go. Okay, great. I've got Crystal White here. I'm going to unmute you so you can ask your question. Hi, I'm Sangeeta Trivedi from Cox South Springfield. Now, my question is that, you know, we also manage the patients with traumatic brain injury here, and we work in collaboration with our surgeons. I have seen a few surgeons who do not add dextrose at all to the maintenance fluid. Like if it is normal saline running, and even if the patient's blood glucose is going less than 100, they would stay away from adding dextrose to the solution. What is the rationale behind this? That's a great question. So the rationale behind that is that they want to keep the sodium, the blood sodium level up, and they don't want to give something like D5s, because essentially what happens is you metabolize the glucose and then you're left with free water. So I think in that case, the concern is they don't want to make the patient potentially hyponatremic. Yeah, so we are not using D5W in any case. We are, if we have to do, we will be using D5 with normal saline. It is also important to maintain the blood glucose in a certain range. But if, you know, blood glucose is going to 70 and 60s, that is also not the best scenario. And we are, if adding some dextrose to the normal saline, which is already running, would that hurt? You know, I can't give you a generalized answer to that. I mean, I think it's patient-specific, but in general, you're absolutely right that you don't want the glucose to get too low. The studies that have been done on traumatic brain injury patients looking at glucose and either and either tight or less tight control have shown that if you try and apply super tight control, that you tend to make those patients more hypoglycemic than if you allow for a broader range. The case that you're presenting is one where the patient is already hypoglycemic. And I think probably it's just like I said, they don't want to add D5 to the normal saline for concerns of hyponatremia. How quickly do you start to feed those patients? Because that would be another way to, that would be a workaround for that. Yeah, generally we try to start the early feeds, but sometimes they are vomiting. They're just not keeping anything down. No, that's very true. It's just a matter of time that, you know, maybe it will take a few hours and we didn't want to put in the jejunal, you know, feeding tube. So it was just that bridging this gap of six to eight hours that they stopped vomiting and they could feed, they could be fed through the stomach. And then this question comes up, okay, what kind of IV floods should be given? Yeah, our tendency is to use normal saline or hypertonic saline in patients with severe TBI. Yeah, thank you. Yeah, of course. Okay, we've got another question. Do you manage abusive head trauma that qualifies as STBI any differently than the presented guidelines? So that's a really good question. Unfortunately, in the severe pediatric guidelines, there's really no mention of abusive head trauma. And abusive head trauma can present with subtle differences from accidental head trauma. So things that we worry about in abusive head trauma would be that the injury wasn't reported initially. So in accidental head trauma, you know, child falls off the step and hits their head on a cinder block, that parent is going to bring that patient to the emergency room as soon as they can, you know, immediately. That's just the normal impulse for parents. With abusive head trauma, the abuser who could be a parent or, you know, a relative of a parent or, you know, some other caregiver is by and large going to be reluctant to bring that child in because they're worried about prosecution, obviously. And so in those cases, patients can have unrecognized head trauma for a very long time before they're brought in. So those patients present very differently. There is not enough evidence to really talk about a difference in either the medical or surgical management of those patients, other than to say that for the medical management of those patients, you really, really, really need to be worried about seizure because these are patients who are even more likely going to present with either clinical or subclinical seizure. As far as surgical management of these patients, the most comprehensive paper that I've ever read on that really didn't weigh in one way or another other than to say that if you're going to do surgery on those patients, if you believe that there's a surgical indication, it would be better to do it sooner rather than later. But that, I, if you're looking for strong guidelines on that, they, I have not found them, and I think it's an area that would be very, very fruitful for research. Okay. Wonderful. We'll give it another minute, see if anybody else has a question. But lots of great feedback here. Additionally, I want to just say that if you have a question that you don't want to ask or if you have any sort of, note that you want to send me, I've included my email address, and I did that because if you want to chat about anything or you have a question, I'd love to hear from you. So it's, Sribnik is a mouthful. I've got a long, complicated last name, but it's like a crib with a nick, except an S instead of a C, and I'd love to hear from you. Great. I don't see any other questions. Any other questions right now? So I guess we will just bring this to a close. So I'd like to really thank you, Dr. Sribnik, for a great presentation and for just all of the wealth of information that you provided us today. So as everyone is digesting all of this information, if you have any questions and you'd like to email me, I'll definitely forward it on to Dr. Sribnik, or you can call our office as well. So don't forget, I will send an email out immediately after this is over, and it will have the evaluation link. So please complete the evaluation for the webinar so that we can continue to improve our offering. So thank you again to Dr. Sribnik and to everyone for participating in the webinar. Have a great rest of your day. Thank you very much.

pediatric traumatic brain injury

management

team approach

evidence-based treatment

early evaluation

ICP monitoring

intracranial pressures

normal physiology

hypoxemia

abusive head trauma