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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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