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Severe traumatic brain injury in children: Initial evaluation and management

Authors
Monica S Vavilala, MD
Robert C Tasker, MBBS, MD
Section Editors
Richard G Bachur, MD
Adrienne G Randolph, MD, MSc
Deputy Editor
James F Wiley, II, MD, MPH

INTRODUCTION

This topic will review the initial evaluation and management of children with severe traumatic brain injury. The evaluation and management of inflicted head injury, diagnosis and management of elevated intracranial pressure, and minor head injury are discussed separately:

(See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

(See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Elevated intracranial pressure (ICP) in children: Management".)

(See "Minor head trauma in infants and children: Evaluation" and "Minor head trauma in infants and children: Management".)

CLASSIFICATION

The severity of traumatic brain injury is typically defined by the initial Glasgow Coma Scale (GCS) or Pediatric Glasgow Coma Scale score (table 1) [1]:

                             

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Literature review current through: Feb 2017. | This topic last updated: Thu Mar 16 00:00:00 GMT+00:00 2017.
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References
Top
  1. Centers for Disease Control and Prevention. Traumatic brain injury & Concussion. Severe TBI. https://www.cdc.gov/traumaticbraininjury/severe.html (Accessed on March 06, 2017).
  2. Langlois JA, Rutland-Brown W, Thomas KE. The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 2005; 20:229.
  3. Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM. Epidemiology of Global Pediatric Traumatic Brain Injury: Qualitative Review. World Neurosurg 2016; 91:497.
  4. Schneier AJ, Shields BJ, Hostetler SG, et al. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118:483.
  5. Stanley RM, Bonsu BK, Zhao W, et al. US estimates of hospitalized children with severe traumatic brain injury: implications for clinical trials. Pediatrics 2012; 129:e24.
  6. Shi J, Xiang H, Wheeler K, et al. Costs, mortality likelihood and outcomes of hospitalized US children with traumatic brain injuries. Brain Inj 2009; 23:602.
  7. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta 2006.
  8. Parslow RC, Morris KP, Tasker RC, et al. Epidemiology of traumatic brain injury in children receiving intensive care in the UK. Arch Dis Child 2005; 90:1182.
  9. Dunning J, Daly JP, Malhotra R, et al. The implications of NICE guidelines on the management of children presenting with head injury. Arch Dis Child 2004; 89:763.
  10. Mayer T, Walker ML, Johnson DG, Matlak ME. Causes of morbidity and mortality in severe pediatric trauma. JAMA 1981; 245:719.
  11. Mayer T, Matlak ME, Johnson DG, Walker ML. The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 1980; 15:719.
  12. White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534.
  13. Chiaretti A, Piastra M, Pulitanò S, et al. Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 2002; 18:129.
  14. Vavilala MS, Bowen A, Lam AM, et al. Blood pressure and outcome after severe pediatric traumatic brain injury. J Trauma 2003; 55:1039.
  15. Michaud LJ, Rivara FP, Grady MS, Reay DT. Predictors of survival and severity of disability after severe brain injury in children. Neurosurgery 1992; 31:254.
  16. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000; 90:523.
  17. Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988; 68:409.
  18. Michaud LJ, Rivara FP, Longstreth WT Jr, Grady MS. Elevated initial blood glucose levels and poor outcome following severe brain injuries in children. J Trauma 1991; 31:1356.
  19. Nakayama DK, Copes WS, Sacco WJ. The effect of patient age upon survival in pediatric trauma. J Trauma 1991; 31:1521.
  20. Vavilala MS, Dunbar PJ, Rivara FP, Lam AM. Coagulopathy predicts poor outcome following head injury in children less than 16 years of age. J Neurosurg Anesthesiol 2001; 13:13.
  21. Jennett B, Teasdale G, Braakman R, et al. Prognosis of patients with severe head injury. Neurosurgery 1979; 4:283.
  22. Kokoska ER, Smith GS, Pittman T, Weber TR. Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma. J Pediatr Surg 1998; 33:333.
  23. Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg 1993; 28:310.
  24. Keenan HT, Hooper SR, Wetherington CE, et al. Neurodevelopmental consequences of early traumatic brain injury in 3-year-old children. Pediatrics 2007; 119:e616.
  25. Massagli TL, Michaud LJ, Rivara FP. Association between injury indices and outcome after severe traumatic brain injury in children. Arch Phys Med Rehabil 1996; 77:125.
  26. Bruce DA, Alavi A, Bilaniuk L, et al. Diffuse cerebral swelling following head injuries in children: the syndrome of "malignant brain edema". J Neurosurg 1981; 54:170.
  27. Tasker RC. Changes in white matter late after severe traumatic brain injury in childhood. Dev Neurosci 2006; 28:302.
  28. Tasker RC, Westland AG, White DK, Williams GB. Corpus callosum and inferior forebrain white matter microstructure are related to functional outcome from raised intracranial pressure in child traumatic brain injury. Dev Neurosci 2010; 32:374.
  29. John SM, Jones P, Kelly P, Vincent A. Fatal pediatric head injuries: a 20-year review of cases through the Auckland coroner's office. Am J Forensic Med Pathol 2013; 34:277.
  30. Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics 2012; 130:315.
  31. Levi L, Guilburd JN, Linn S, Feinsod M. The association between skull fracture, intracranial pathology and outcome in pediatric head injury. Br J Neurosurg 1991; 5:617.
  32. Stewart TC, Alharfi IM, Fraser DD. The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury. J Trauma Acute Care Surg 2013; 75:836.
  33. Walker ML, Storrs BB, Mayer T. Factors affecting outcome in the pediatric patient with multiple trauma. Further experience with the modified injury severity scale. Childs Brain 1984; 11:387.
  34. Qualls D, Leonard JR, Keller M, et al. Utility of magnetic resonance imaging in diagnosing cervical spine injury in children with severe traumatic brain injury. J Trauma Acute Care Surg 2015; 78:1122.
  35. Zwienenberg M, Muizelaar JP. Severe pediatric head injury: the role of hyperemia revisited. J Neurotrauma 1999; 16:937.
  36. Sharples PM, Stuart AG, Matthews DS, et al. Cerebral blood flow and metabolism in children with severe head injury. Part 1: Relation to age, Glasgow coma score, outcome, intracranial pressure, and time after injury. J Neurol Neurosurg Psychiatry 1995; 58:145.
  37. Adelson PD, Clyde B, Kochanek PM, et al. Cerebrovascular response in infants and young children following severe traumatic brain injury: a preliminary report. Pediatr Neurosurg 1997; 26:200.
  38. Vavilala MS, Muangman S, Tontisirin N, et al. Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings. Dev Neurosci 2006; 28:348.
  39. Ruppel RA, Kochanek PM, Adelson PD, et al. Excitatory amino acid concentrations in ventricular cerebrospinal fluid after severe traumatic brain injury in infants and children: the role of child abuse. J Pediatr 2001; 138:18.
  40. Vavilala MS, Lee LA, Boddu K, et al. Cerebral autoregulation in pediatric traumatic brain injury. Pediatr Crit Care Med 2004; 5:257.
  41. Lang DA, Teasdale GM, Macpherson P, Lawrence A. Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 1994; 80:675.
  42. Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng 2000; 122:364.
  43. Coats B, Margulies SS. Material properties of human infant skull and suture at high rates. J Neurotrauma 2006; 23:1222.
  44. Kochanek PM. Pediatric traumatic brain injury: quo vadis? Dev Neurosci 2006; 28:244.
  45. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 2012; 13 Suppl 1:S1.
  46. Vavilala MS, Kernic MA, Wang J, et al. Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 2014; 42:2258.
  47. Graves JM, Kannan N, Mink RB, et al. Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med 2016; 17:438.
  48. Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr 2009; 4:40.
  49. Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21:163.
  50. Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg 1994; 78:469.
  51. Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J 2001; 18:373.
  52. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics 2009; 124:56.
  53. Samant UB 4th, Mack CD, Koepsell T, et al. Time of hypotension and discharge outcome in children with severe traumatic brain injury. J Neurotrauma 2008; 25:495.
  54. Chaiwat O, Sharma D, Udomphorn Y, et al. Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric traumatic brain injury. J Neurotrauma 2009; 26:657.
  55. Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 4. Resuscitation of blood pressure and oxygenation and prehospital brain-specific therapies for the severe pediatric traumatic brain injury patient. Pediatr Crit Care Med 2003; 4:S428.
  56. Stevens RD, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2015; 23 Suppl 2:S76.
  57. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000; 49:237.
  58. Johnson DL, Krishnamurthy S. Send severely head-injured children to a pediatric trauma center. Pediatr Neurosurg 1996; 25:309.
  59. Ramenofsky ML, Ramenofsky MB, Jurkovich GJ, et al. The predictive validity of the Pediatric Trauma Score. J Trauma 1988; 28:1038.
  60. Eichelberger MR, Gotschall CS, Sacco WJ, et al. A comparison of the trauma score, the revised trauma score, and the pediatric trauma score. Ann Emerg Med 1989; 18:1053.
  61. Phillips S, Rond PC 3rd, Kelly SM, Swartz PD. The need for pediatric-specific triage criteria: results from the Florida Trauma Triage Study. Pediatr Emerg Care 1996; 12:394.
  62. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg 2000; 35:82.