Emergency treatment options for pediatric traumatic brain injury

Abstract

Traumatic brain injury is a leading killer of children and is a major public health problem around the world. Using general principles of neurocritical care, various treatment strategies have been developed to attempt to restore homeostasis to the brain and allow brain healing, including mechanical factors, cerebrospinal fluid diversion, hyperventilation, hyperosmolar therapies, barbiturates and hypothermia. Careful application of these therapies, normally in a step-wise fashion as intracranial injuries evolve, is necessary in order to attain maximal neurological outcome for these children. It is hopeful that new therapies, such as early hypothermia or others currently in preclinical trials, will ultimately improve outcome and quality of life for children after traumatic brain injury.

Figure 1. The Munro–Kellie Doctrine explains the relationship between intracranial volumes and intracranial pressure in physiological and pathophysiological conditions

The volume of the intracranial vault (the area represented by the rectangle) is generally fixed in adults and most children. The contents of the intracranial vault in the normal condition include the brain, arterial blood, venous blood and CSF, and are maintained at a relatively low ICP (Panel 1; normal). After an injury, swelling/edema/pathological tissue can increase within the brain (Panel 2; compensated). Compensatory mechanisms, including increased CSF absorption, extrusion of CSF into the spinal canal and extrusion of venous blood into the thorax, initially limit any changes in ICP. When these compensatory changes are exhausted (Panel 3; uncompensated), any further increases in intracranial volumes are associated with concomitant increases in ICP that eventually can compromise arterial blood flow, ultimately leading to cerebral herniation. CSF: Cerebrospinal fluid; ICP: Intracranial pressure.