Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children

2021 ◽  
Vol 30 (5) ◽  
pp. 402-406
Author(s):  
Hengameh B. Pajer ◽  
Anthony M. Asher ◽  
Dennis Leung ◽  
Randaline R. Barnett ◽  
Benny L. Joyner ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cerebrospinal Fluid ◽  
Critical Care ◽  
Brain Injury ◽  
Specific Treatment ◽  
Neuromuscular Blocking ◽  
World Federation ◽  
Optimal Timing ◽  
Pediatric Tbi ◽  
The Impact

Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. Of 24 institutions identified and contacted, 10 did not respond and 5 did not have a pediatric TBI protocol. Pediatric TBI protocols were successfully collected from 9 institutions. These 9 protocols were separated into treatment tiers analogous to those in the 2019 Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies guidelines, and the intervention variables were identified and compared across the 9 institutions. First-line therapies were similar between institutions, including seizure prophylaxis, maintenance of normoglycemia and normothermia, and avoidance of hypoxia, hyponatremia, and hypotension. However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.

scholarly journals Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

2020 ◽  
Vol 29 (1) ◽  
pp. e13-e18
Author(s):  
Karin Reuter-Rice ◽  
Elise Christoferson
Keyword(s):  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Current Evidence ◽  
Care Providers ◽  
The Third ◽  
Guideline Document ◽  
Severe Tbi ◽  
Pediatric Tbi

Background Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. Objectives To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. Methods and Results After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. Conclusions The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.

scholarly journals Increased S-Nitrosothiols and S-Nitrosoalbumin in Cerebrospinal Fluid after Severe Traumatic Brain Injury in Infants and Children: Indirect Association with Intracranial Pressure

2003 ◽  
Vol 23 (1) ◽  
pp. 51-61 ◽  
Author(s):  
Hülya Bayir ◽  
Patrick M. Kochanek ◽  
Shang-Xi Liu ◽  
Antonio Arroyo ◽  
Anatoly Osipov ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cerebrospinal Fluid ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Fold Increase ◽  
Infants And Children ◽  
No Production ◽  
Secondary Damage ◽  
Severe Tbi ◽  
Pediatric Tbi

Nitric oxide (NO) is implicated in both secondary damage and recovery after traumatic brain injury (TBI). Transfer of NO groups to cysteine sulfhydryls on proteins produces S-nitrosothiols (RSNO). S-nitrosothiols may be neuroprotective after TBI by nitrosylation of N-methyl-D-aspartate receptor and caspases. S-nitrosothiols release NO on decomposition for which endogenous reductants (i.e., ascorbate) are essential, and ascorbate is depleted in cerebrospinal fluid (CSF) after pediatric TBI. This study examined the presence and decomposition of RSNO in CSF and the association between CSF RSNO level and physiologic parameters after severe TBI. Cerebrospinal fluid samples (n = 72) were obtained from 18 infants and children on days 1 to 3 after severe TBI (Glasgow Coma Scale score < 8) and 18 controls. Cerebrospinal fluid RSNO levels assessed by fluorometric assay peaked on day 3 versus control (1.42 ± 0.11 μmol/L vs. 0.86 ± 0.04, P < 0.05). S-nitrosoalbumin levels were also higher after TBI (n = 8, 0.99 ± 0.09 μmol/L on day 3 vs. n = 6, 0.42 ± 0.02 in controls, P < 0.05). S-nitrosoalbumin decomposition was decreased after TBI. Multivariate analysis showed an inverse relation between CSF RSNO and intracranial pressure and a direct relation with barbiturate treatment. Using a novel assay, the presence of RSNO and S-nitrosoalbumin in human CSF, an ∼1.7-fold increase after TBI, and an association with low intracranial pressure are reported, supporting a possible neuroprotective role for RSNO. The increase in RSNO may result from increased NO production and/or decreased RSNO decomposition.

Validation of prognostic models in intensive care unit–treated pediatric traumatic brain injury patients

2019 ◽  
Vol 24 (3) ◽  
pp. 330-337 ◽  
Author(s):  
Era D. Mikkonen ◽  
Markus B. Skrifvars ◽  
Matti Reinikainen ◽  
Stepani Bendel ◽  
Ruut Laitio ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Scoring Systems ◽  
Predictive Performance ◽  
Classification Systems ◽  
Prognostic Models ◽  
Pediatric Traumatic Brain Injury ◽  
Pediatric Tbi ◽  
The Impact

OBJECTIVEThere are few specific prognostic models specifically developed for the pediatric traumatic brain injury (TBI) population. In the present study, the authors tested the predictive performance of existing prognostic tools, originally developed for the adult TBI population, in pediatric TBI patients requiring stays in the ICU.METHODSThe authors used the Finnish Intensive Care Consortium database to identify pediatric patients (< 18 years of age) treated in 4 academic ICUs in Finland between 2003 and 2013. They tested the predictive performance of 4 classification systems—the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) TBI model, the Helsinki CT score, the Rotterdam CT score, and the Marshall CT classification—by assessing the area under the receiver operating characteristic curve (AUC) and the explanatory variation (pseudo-R2 statistic). The primary outcome was 6-month functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4–5).RESULTSOverall, 341 patients (median age 14 years) were included; of these, 291 patients had primary head CT scans available. The IMPACT core-based model showed an AUC of 0.85 (95% CI 0.78–0.91) and a pseudo-R2 value of 0.40. Of the CT scoring systems, the Helsinki CT score displayed the highest performance (AUC 0.84, 95% CI 0.78–0.90; pseudo-R2 0.39) followed by the Rotterdam CT score (AUC 0.80, 95% CI 0.73–0.86; pseudo-R2 0.34).CONCLUSIONSPrognostic tools originally developed for the adult TBI population seemed to perform well in pediatric TBI. Of the tested CT scoring systems, the Helsinki CT score yielded the highest predictive value.

Performance discrepancies on the California Verbal Learning Test–Children's Version (CVLT–C) in children with traumatic brain injury

2004 ◽  
Vol 10 (4) ◽  
pp. 482-488 ◽  
Author(s):  
JACOBUS DONDERS ◽  
MICHAEL T. MINNEMA
Keyword(s):  
Traumatic Brain Injury ◽  
Information Processing ◽  
Brain Injury ◽  
Verbal Learning ◽  
California Verbal Learning Test ◽  
Cerebral Lesions ◽  
Speed Of Information Processing ◽  
Learning Test ◽  
Pediatric Tbi ◽  
The Impact

One hundred sixty-seven children with traumatic brain injury (TBI), selected from an 8-year series of consecutive referrals to a Midwestern rehabilitation hospital, completed the California Verbal Learning Test–Children's Version (CVLT–C) and the Wechsler Intelligence Scale for Children–Third Edition (WISC–III) within 1 year after injury. A large proactive interference (PI) effect, defined as performance on the second list that was at least 1.5 standard deviations below that on the 1st one, was statistically significantly more common in this clinical sample (21%) than in the CVLT–C standardization sample (11%). Other performance discrepancies, including retroactive interference, rapid forgetting, and retrieval problems, occurred at approximately the same rate in the clinical and standardization samples. Children with anterior cerebral lesions were about 3 times less likely to have a large PI effect than children without such lesions, but the former group performed worse on the first CVLT–C list. The impact of pediatric TBI on a wide range of CVLT–C quantitative variables was mediated by speed of information processing, as assessed by the WISC–III Processing Speed factor index. It is concluded that failure to release from PI is somewhat common, although certainly not universal, in children with TBI. Unlike with adults, anterior cerebral lesions are not associated selectively with an increased risk for PI after pediatric TBI but rather with a reduced efficiency of allocation of cognitive resources. Deficits in speed of information processing appear to be primarily responsible for the learning deficits on the CVLT–C after pediatric TBI. (JINS, 2004, 10, 482–488.)

scholarly journals Quantification of Poly(ADP-Ribose)-Modified Proteins in Cerebrospinal Fluid from Infants and Children after Traumatic Brain Injury

2008 ◽  
Vol 28 (9) ◽  
pp. 1523-1529 ◽  
Author(s):  
Ericka L Fink ◽  
Yichen Lai ◽  
Xiaopeng Zhang ◽  
Keri Janesko-Feldman ◽  
P David Adelson ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cerebrospinal Fluid ◽  
Brain Injury ◽  
Parp Inhibitors ◽  
Enzyme Linked Immunosorbent Assay ◽  
Parp Activation ◽  
Protein Levels ◽  
Male Sex ◽  
Modified Proteins ◽  
Pediatric Tbi

Poly-ADP-ribosylation (PAR) of proteins by poly(ADP-ribose) polymerases (PARP) occurs after experimental traumatic brain injury (TBI) and modulates neurologic outcome. Several promising pharmacological PARP inhibitors have been developed for use in humans, but there is currently no clinically relevant means of monitoring treatment effects. We therefore used an enzyme-linked immunosorbent assay to measure PAR-modified proteins in cerebrospinal fluid (CSF). Cerebrospinal fluid samples from 17 pediatric TBI patients and 15 controls were plated overnight and then incubated with polyclonal antibody against PAR. Histone-1, a PARP substrate, was incubated with active PARP, NAD, and nicked DNA, and served as the standard. Both peak and mean CSF PAR-modified proteins were increased in TBI patients versus controls. Peak CSF PAR-modified protein levels occurred on day 1 and levels remained increased on day 2 after TBI. Increases in peak CSF PAR-modified protein concentrations were independently associated with age and male sex, but not initial Glasgow Coma Scale score, Glasgow outcome score, or mechanism of injury. The increase in PAR-modified proteins in CSF after TBI may be because of increased PARP activation, decreased PAR degradation, or both. As PAR-modified protein concentration correlated with age and male sex, developmental and sex-dependent roles for PARP after TBI are implicated.

scholarly journals Use of magnetic resonance imaging in severe pediatric traumatic brain injury: assessment of current practice

2019 ◽  
Vol 23 (4) ◽  
pp. 471-479 ◽  
Author(s):  
Peter A. Ferrazzano ◽  
Bedda L. Rosario ◽  
Stephen R. Wisniewski ◽  
Nadeem I. Shafi ◽  
Heather M. Siefkes ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Pediatric Patients ◽  
Optimal Timing ◽  
Pediatric Traumatic Brain Injury ◽  
Mri Studies ◽  
Severe Tbi ◽  
Mri Sequences ◽  
Pediatric Tbi ◽  
Clinical Mri

OBJECTIVEThere is no consensus on the optimal timing and specific brain MRI sequences in the evaluation and management of severe pediatric traumatic brain injury (TBI), and information on current practices is lacking. The authors performed a survey of MRI practices among sites participating in a multicenter study of severe pediatric TBI to provide information for designing future clinical trials using MRI to assess brain injury after severe pediatric TBI.METHODSInformation on current imaging practices and resources was collected from 27 institutions participating in the Approaches and Decisions after Pediatric TBI Trial. Multiple-choice questions addressed the percentage of patients with TBI who have MRI studies, timing of MRI, MRI sequences used to investigate TBI, as well as the magnetic field strength of MR scanners used at the participating institutions and use of standardized MRI protocols for imaging after severe pediatric TBI.RESULTSOverall, the reported use of MRI in pediatric patients with severe TBI at participating sites was high, with 40% of sites indicating that they obtain MRI studies in > 95% of this patient population. Differences were observed in the frequency of MRI use between US and international sites, with the US sites obtaining MRI in a higher proportion of their pediatric patients with severe TBI (94% of US vs 44% of international sites reported MRI in at least 70% of patients with severe TBI). The reported timing and composition of MRI studies was highly variable across sites. Sixty percent of sites reported typically obtaining an MRI study within the first 7 days postinjury, with the remainder of responses distributed throughout the first 30-day postinjury period. Responses indicated that MRI sequences sensitive for diffuse axonal injury and ischemia are frequently obtained in patients with TBI, whereas perfusion imaging and spectroscopy techniques are less common.CONCLUSIONSResults from this survey suggest that despite the lack of consensus or guidelines, MRI is commonly obtained during the acute clinical setting after severe pediatric TBI. The variation in MRI practices highlights the need for additional studies to determine the utility, optimal timing, and composition of clinical MRI studies after TBI. The information in this survey describes current clinical MRI practices in children with severe TBI and identifies important challenges and objectives that should be considered when designing future studies.

scholarly journals Relationship between admission coagulopathy and prognosis in children with traumatic brain injury: a retrospective study

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Cheng-yan You ◽  
Si-wei Lu ◽  
Yue-qiang Fu ◽  
Feng Xu
Keyword(s):  
Traumatic Brain Injury ◽  
Logistic Regression ◽  
Regression Analysis ◽  
Brain Injury ◽  
Logistic Regression Analysis ◽  
Multiple Logistic Regression Analysis ◽  
Cart Analysis ◽  
Severe Tbi ◽  
Pediatric Tbi ◽  
The Impact

Abstract Background Coagulopathy in adult patients with traumatic brain injury (TBI) is strongly associated with unfavorable outcomes. However, few reports focus on pediatric TBI-associated coagulopathy. Methods We retrospectively identified children with Glasgow Coma Scale ≤ 13 in a tertiary pediatric hospital from April 2012 to December 2019 to evaluate the impact of admission coagulopathy on their prognosis. A classification and regression tree (CART) analysis using coagulation parameters was performed to stratify the death risk among patients. The importance of these parameters was examined by multivariate logistic regression analysis. Results A total of 281 children with moderate to severe TBI were enrolled. A receiver operating characteristic curve showed that activated partial thromboplastin time (APTT) and fibrinogen were effective predictors of in-hospital mortality. According to the CART analysis, APTT of 39.2 s was identified as the best discriminator, while 120 mg/dL fibrinogen was the second split in the subgroup of APTT ≤ 39.2 s. Patients were stratified into three groups, in which mortality was as follows: 4.5 % (APTT ≤ 39.2 s, fibrinogen > 120 mg/dL), 20.5 % (APTT ≤ 39.2 s and fibrinogen ≤ 120 mg/dL) and 60.8 % (APTT > 39.2 s). Furthermore, length-of-stay in the ICU and duration of mechanical ventilation were significantly prolonged in patients with deteriorated APTT or fibrinogen values. Multiple logistic regression analysis showed that APTT > 39.2 s and fibrinogen ≤ 120 mg/dL was independently associated with mortality in children with moderate to severe TBI. Conclusions We concluded that admission APTT > 39.2 s and fibrinogen ≤ 120 mg/dL were independently associated with mortality in children with moderate to severe TBI. Early identification and intervention of abnormal APTT and fibrinogen in pediatric TBI patients may be beneficial to their prognosis.

scholarly journals The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

2019 ◽  
Vol 8 (9) ◽  
pp. 1422 ◽  
Author(s):  
Charlene Y. C. Chau ◽  
Claudia L. Craven ◽  
Andres M. Rubiano ◽  
Hadie Adams ◽  
Selma Tülü ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cerebrospinal Fluid ◽  
Brain Injury ◽  
Clinical Effectiveness ◽  
External Ventricular Drainage ◽  
Optimal Timing ◽  
Ventricular Drainage ◽  
Contemporary Practice ◽  
Economic Considerations

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

Early Coagulopathy in Pediatric Traumatic Brain Injury: A Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Retrospective Study

Neurosurgery ◽  
2021 ◽  
Author(s):  
Shu-Ling Chong ◽  
Gene Yong-Kwang Ong ◽  
Charles Qishi Zheng ◽  
Hongxing Dang ◽  
Meixiu Ming ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Multiple Trauma ◽  
Functional Outcomes ◽  
Critical Care Medicine ◽  
Intracranial Bleed ◽  
Severe Tbi ◽  
Logistic Regressions ◽  
Pediatric Tbi

Abstract BACKGROUND Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI. OBJECTIVE To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes. METHODS Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients &lt;16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes. RESULTS Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS &lt; 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P &lt; .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006). CONCLUSION Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

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