Tia Dickson, RN, BSN

Primary Children's Hospital

Traumatic brain injury (TBI) is a topic in pediatrics that we visit often. Not only is it the leading cause of death and disability in children, but our early care can truly impact the child's outcome. The management of TBI is complex but there are some simple things you can do in the field that will improve your patient's ability to survive and recover. There is even an algorithm to guide your actions.

Hilary Hewes, MD

Pediatric Emergency Medicine

University of Utah, Department of Pediatrics, Primary Children's Hospital

Excerpts from January 8, 2024 PETOS

The CDC reports 2.8 million traumatic brain injuries (TBIs) each year and 55,000 deaths. More than 550,000 children are seen for a head injury yearly. Most of the time (75%) those are mild (not life threatening) like a concussion but even those can affect the life of a child.

In 2022 Utah recorded

• 1,485 children with head injury entered into the trauma registry
• Most had mild injury and were discharged from the EDs
• Suicide/self harm has now surpassed motor vehicle collision as the cause of severe TBI and death in children in Utah as well as many states.

• Mild TBI usually refers to those patients who have a GCS 14-15
• They will likely have good outcomes regardless of treatment
• Though mild, it is still important to optimize care
• Recognize the injury
• Assess the C-spine
• Transfer to the most appropriate hospital for evaluation
• Most will be discharged home with little to no long-term effects, but will require activity restrictions, possible alternative school schedules, and follow up.

• Those children with a GCS 4-8 (severe) and 9-13 (moderate) or those with declining mental status over time
• This is the group where careful resuscitation can make the most difference in outcome

If you ask 10 doctors to score a GCS on a 10 month old, you will likely get a different number from each. It's helpful to practice and use a scoring card, preferably one that has been modified for the pediatric verbal response.

GCS may not be the most reliable score but like everything in medicine, it's more about the trend. If you start out with a child who looks pretty good and they begin to decline (meaning they no longer respond to you, or they are not moving) and you document those changes in a GCS, that is important information.

• Those children with a GCS 3, or without signs of life on scene
• They are unlikely to survive with good neurologic outcome
• The first hours of care are still critical to determine their chance of survival

It is uncommon for children to have an isolated TBI. Severe TBI in children is often complicated by multiple trauma. Two out of 3 have trauma to other body sites although death usually results from the head injury. Cervical spine injury (CSI) must always be suspected in children with TBI.

Overall: Keep the pressure in the brain (the cerebral perfusion pressure) as normal as possible

• prevent hypotension and hypoxia to prevent further injury
• prevent coagulopathy
• get the patient to definitive care as quickly as possible (somewhere with pediatric neurosurgery and ICU care)

Why is it so important to focus your care on the above goals? There are 2 types of injury in TBI. Primary injury is the direct trauma to the brain. The secondary injury is the result of a cascade of biochemical, cellular, and metabolic responses to the direct injury which worsens in patients who develop hypoxia, hypotension, or both. We have little control of the primary injury but our care will affect the secondary injury.

There are signs that a child with TBI is experiencing increased intracranial pressure. You should be monitoring for these things.

• Lack of oxygen to the brain and other vital organs leads to cell death and irreversible neurologic damage if it is severe and sustained.
• Low oxygen levels also cause the blood vessels in the brain to dilate. which increases flow.
• While some increased blood flow is good, too much increases the pressure in the brain even further.
• Conversely, high oxygen levels (100%) can cause the blood vessels to constrict, and can decrease blood flow to the brain that it needs to heal.

Indications:

• when there is refractory hypoxia
• hypoventilation
• GCS of <8, or GCS<12 and rapidly declining
• loss of airway protective reflexes
• signs of acute herniation

If you do intubate, we recommend you use rapid sequence intubation (RSI) to minimize increasing ICP. Once intubated, monitor oxygenation and ventilation closely. PaCO2 should be maintained between 35 and 40mmHg unless there are signs of acute or impending herniation.

• Follow the algorithm below
• Place every patient on oxygen
• If not maintaining airway or sats >90, consider BMV or advanced airway
• Ensure continuous O2 monitoring: goal sats 92-99
• Critical care teams maintain paO2 around 100 mmHg
• Prevent hypo- and hyperventilation
• Target your End Tidal CO2 of 35-40

• The brain relies on cerebral perfusion pressure for blood flow, to bring the oxygen and nutrients it needs to function and heal
• Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - Intracranial pressure (ICP)
• The ICP increases when there is brain swelling
• Once MAP = or is < ICP, blood flow to the brain ceases and cell death occurs
• Normal ICP is 5-15 (with severe TBI, ICPs can be >40-50)
• Hypotension and inadequate CPP causes further damage and ischemic injury

Maintain an adequate blood pressure

• Control bleeding
• Get early IV/IO access
• Aggressively aim for a high-normal systolic blood pressure based on the child's age (you can use mean arterial pressure (MAP) instead of systolic blood pressure, goal is to keep MAP at least 60)
• Use normal saline
• 20ml/kg bolus, repeat x1
• Consider an epi drip If not achieving that goal

The Excellence in Prehospital Injury Care for Children (EPIC) Study was published in 2021. It showed improved odds (8.42 times higher) of survival in patients when prehospital care providers followed an algorithm focused on preventing hypoxia and hypotension, especially in those patients in the severe TBI group.

Another study, Timely Hemodynamic Resuscitation and Outcomes in Severe Pediatric Traumatic Brain Injury: Preliminary Findings found that hypotension occurred in 26% of patients during early care and hypoxia occurred in 17% of patients. We need to lower those numbers and, with that goal in mind, the Utah Pediatric Trauma Network (UPTN) developed an algorithm for Utah.

• Provide seizure prophylaxis
• Keppra or fosphenytoin loading
• EMS treat active seizures along the lines of your protocols
• Prevent fever
• Elevate the bed from 15 to 30 degrees while maintaining spinal precautions
• Keep them adequately sedated (and paralyzed if intubated)
• Treat pain
• Consider hyperosmolar therapy
• 3% hypertonic saline

These patients can surprise you and we at Primary Children's Hospital invite you to seek follow up on your patients. Working to improve prehospital care can have a profound effect on morbidity and mortality.

For additional guideline direction check out the UPTN website or the new app, "Utah PTN" on android and apple devices.

Training officers may review the topic above as a team training AND perform a simulation/skills check as directed here. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the DHHS Office of EMS and Preparedness.

Individuals who don't have a training officer can get CME credit on their own by viewing the PETOS in our archives associated with this topic and completing the instructions on the webpage.

1. Watch the skills refresher video on pediatric neuro exams included in this newsletter
2. Determine GCS for the following patients.

6-year old female fell out of a 2nd story window onto concrete

On arrival:

• Eyes open to voice
• Answers questions when asked, but responses are confused
• Localizes pain (i.e., swats painful stimulus away)

18-month old female fell out of a 2nd story window onto concrete

On arrival

• Eyes open to voice
• Cries, overall irritable
• Withdraws to touch

17-year old crashed on an e-bike

On scene

• Eyes open to voice
• Words are intelligible but inappropriate
• Moving all 4 extremities spontaneously, follows commands

22-month old in crash while being pulled in a trailer

On scene:

• Eyes open spontaneously
• Cries continuously, irritable
• Moving all 4 extremities spontaneously

• What's New With Pediatric Sport Concussions? | American Academy of Pediatrics (AAP)
• Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023 | American Academy of Pediatrics
• Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline Statement of Endorsement

• Brain Injury Awareness Month | Brain Injury Association of America

  March 1-31, 2024

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

The federal EMS for Children (EMSC) program works to expand and improve emergency care for children across the country through the promotion of research, partnerships, and evidence-

based practice, with a goal to improve access and quality of emergency care for children and reduce serious injury or death.

Each state and territory is now required by the federal EMSC program to develop a pediatric

pre-hospital recognition program. These programs aim to empower and prepare EMS agencies

to provide high-quality care for children in accordance with national recommendations, which is

also known as being “pediatric ready.” This month, Utah EMSC launched a workgroup to design our program. We have chosen representatives from all over the state.

Intermountain Primary Children’s Hospital, Larry H. and Gail Miller Family Campus in Lehi opens for patient care on Monday, February 12, 2024! Lehi will be a PED+ center to start and will work to obtain Level 2 trauma designation with the ACS, an 18 month process.

The University of Utah has just launched a new EMS education website put together by their Office Of Network Development and Telehealth. Here you can find upcoming and archived education from all of the service lines at the University of Utah Health.

Our own FAN rep, Jeff Wilson, was recently highlighted in EMSC Pulse (the national EMSC newsletter). Way to go, Jeff!

If your agency is interested in Jeff's autism training or in receiving the free John Wilson autism kits, contact Jeff @jeffwilson122615@gmail.com.

The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:

· families

· physicians and medical home teams

· other professionals and caregivers

The inaugural Prehospital Pediatric Readiness Project Assessment launches in May for EMS and fire-rescue agencies! Learn more and access a preview here.

PECCs, the Western Pediatric Trauma Conference returns to Utah this year and is an excellent opportunity to associate with the state's trauma and ED MDs while learning all the latest in pediatric trauma. While live attendance is pricey, there is a special virtual option for EMS that is just $25 (RN's virtual option is $100). Please spread the word and consider participating yourselves.

July 10-12, 2024 in Sundance, UT.

https://www.pedtrauma.org/

Did you receive the PECC newsletter and resources email sent out on January 29? If not, contact us at jaredwright@utah.gov

For Hospital PECCs

• EMSC has launched its first pediatric emergency care coordinator (PECC) learning module for ED-based PECCs. You are invited to view the module and provide feedback.

For EMS PECCs

• EMS PECC resources can be found on the EIIC website here.

Pediatric education for the prehospital provider

Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth