Traumatic Brain Injury

Guidelines

1. Perform rapid, thorough neurological assessment to include GCS, pupils, and focal or lateralizing neurologic deficits. Document this initial assessment, and repeated neurologic assessments throughout transport.
2. Head should be maintained in midline position. Patients with cleared lumbar spines may be transported with HOB elevated 30 degrees. Patients on backboards who are not hypotensive can have the head of the bed elevated while on a backboard.
3. Injuries to the scalp with bleeding should be controlled by direct pressure. Scalp lacerations/avulsions may be re-approximated and stapled for immediate control of exsanguinating hemorrhage.
4. Patients with traction devices (i.e. Gardner Wells tongs) should be converted to C-collar.
5. Check for signs of rapidly expanding hematoma or increasing intracranial pressure:
   1. Deteriorating mental status/GCS
   2. Unilateral dilated pupil with decreased LOC
   3. Significant bradycardia and hypertension
6. If signs of expanding hematoma or increasing intracranial pressure exist, treat as follows:
   1. Ventilate with 100% O2 to maintain a PaCO2 of approximately 35-40 mm Hg.
   2. Maintain normal MAP for age. For a low MAP, assess for hypovolemia (incomplete resuscitation or continued bleeding) and treat as appropriate with blood and saline.
   3. If the MAP is too high, treat with analgesia and sedation, repeat as necessary.
   4. Consider hypertonic saline (HTS) 3% for signs of increasing ICP: 5-10 ml/kg IVPB over 20-30 minutes. If HTS not readily available, use mannitol 0.5-1 gm/kg bolus.

Citations/References:

1. 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–S82