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SEVERE PEDIATRIC Traumatic Brain Injury

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									                                                                                                                             By Jeremy DeWall, MD, NREMT-P




     Evidence-based
     guidelines for
     pediatric TBI care


Traumatic brain injuries (TBI) affect 475,000 children under age 14 each year in the
United States alone. Ninety percent of patients are treated in emergency departments and                                                      CONTINUING
                                                                                                                                          EDUCATION FROM EMS
released; however, more than 47,000 hospitalizations per year are a direct result of these                                                 This CE activity
                                                                                                                                           is approved by
injuries. On average, 2,685 children die annually from traumatic brain injuries, and more                                                  EMS Magazine,
                                                                                                                                           an organization
than 30,000 children per year acquire lifelong disabilities. With proper prehospital care                                                  accredited by the
                                                                                                                                           Continuing Education
of these severely injured children, we can reduce secondary injury and maximize survival                                                   Coordinating Board for
                                                                                                                                           Emergency Medical
and good neurological outcomes.                                                                                                            Services (CECBEMS),
                                                                                                                                           for 1.5 CEUs.
EPIDEMIOLOGY                                   syndrome. Adolescents and young adults         occurs when damage to a meningeal or         OBJECTIVES
  Children comprise two of three age           sustain traumatic brain injuries from          other artery causes bleeding between         • Discuss
                                                                                                                                             epidemiology of
groups most prone to traumatic brain           motor vehicle collisions; sports injuries      the skull and dura. These patients clas-       brain injuries
injuries. In particular, children younger      like skiing/snowboarding, football, ATV/       sically present with a lucid interval        • Review prehospital
than five years and adolescents to young        snowmobile riding and trampoline use;          prior to becoming rapidly unresponsive.        assessment and
                                                                                                                                             treatment of brain
adults 15 to 24 years are most vulnerable,     and other causes. Alcohol experimenta-         Subdural hematoma results from injury          injuries
due to exploration and lack of coordina-       tion is involved in a number of incidents.     to the bridging vessels between the dura     • Discuss research
tion in young children and risk-taking         This paper specifically addresses current       and brain. These bleeds may be self-           findings related
                                                                                                                                             to TBI care in
behaviors in adolescents.                      recommendations for prehospital                limited or extensive, causing massive          pediatric patients
  The most common causes of traumatic          management of pediatric severe trau-           cerebral shifting. Intraparenchymal
brain injuries in the United States,           matic brain injury (GCS <9) in order to        hemorrhage results from injury to the
in order of prevalence, include falls,         maximize outcomes.                             vessels within the brain itself, causing
motor vehicle collisions and struck by/                                                       bleeding within one or multiple spots
against events. TBIs occur in toddlers         BRAIN INJURIES                                 within the brain matter. Lastly, diffuse
falling down stairs, as well as from non-        Traumatic brain injury is a spectrum of      axonal injury (DAI) is microscopic
accidental trauma such as shaken-baby          insults to the brain. Epidural hematoma        damage to the axons of the brain nerves.

                           Go online to EMSResponder.com/CEtest to download a .pdf of the test that accompanies this article, or go
                           online to www.centrelearn.com to take the test. The deadline to take the test is October 30, 2009.


                                                                                                  www.emsresponder.com EMS SEPTEMBER 2009              53
   ce article

                 This type of injury is most common in       demonstrated no difference in outcomes          oxygenation and ventilation. In general,
                 traumatic brain injuries, is not seen on    in TBI patients, but fewer complications        an adult or pediatric bag-valve mask
                 CT-scanning and can result in devas-        with BVM in general trauma. Current             should be used to assure adequate chest
                 tating outcomes. All of these injuries      guidelines do not recommend endotra-            rise. Neonatal bag-valve masks are no
                 can cause cerebral edema, further wors-     cheal intubation over bag-valve mask            longer recommended in any prehospital
                 ening patient outcome.                      ventilation in prehospital care. Some           pediatric care according to the American
                   Numerous multidisciplinary teams          indicators suggesting a potential need          Heart Association’s 2005 Pediatric
                 have been formed to provide guide-          for intubation include a GCS <9 (severe         Advanced Life Support Guidelines.
                 lines for management of both adult and      TBI), hypoxemia, hypercarbia, aspiration        Proper BVM skills are necessary to avoid
                 pediatric severe TBI. Specific guide-        or signs of elevated intracranial pressure.     prehospital hypoxia.
                 lines for management of pediatric TBI          If intubation is indicated, proper endo-       Hypoxia, defined as a SpO2 (pulse
                 include Guidelines for the Acute Medical    tracheal tube sizing is key in pediatric        oximetry) of less than 90%, increases
                 Management of Severe Traumatic              airway management (see Figure 1). The           
								
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