Advanced Trauma Life Support ATLS Student Course Manual 2018

HEAD TRAUMA 203
the outcome in children younger than 3 years
of age is worse than that following a similar
injury in an older child. Children are particularly
susceptible to the effects of the secondary brain
injury that can be produced by hypovolemia
with attendant reductions in cerebral perfusion,
hypoxia, seizures, and/or hyperthermia. The
effect of the combination of hypovolemia and
hypoxia on the injured brain is devastating,
but hypotension from hypovolemia is the most
serious single risk factor. It is critical to ensure
adequate and rapid restoration of an appropriate
circulating blood volume and avoid hypoxia.
2. Although infrequent, hypotension can occur in
infants following significant blood loss into the
subgaleal, intraventricular, or epidural spaces,
because of the infants’ open cranial sutures and
fontanelles. In such cases, treatment focuses on
appropriate volume restoration.
3. Infants, with their open fontanelles and mobile
cranial sutures, have more tolerance for an
expanding intracranial mass lesion or brain
swelling, and signs of these conditions may
be hidden until rapid decompensation occurs.
An infant who is not in a coma but who has
bulging fontanelles or suture diastases should be
assumed to have a more severe injury, and early
neurosurgical consultation is essential.
4. Vomiting and amnesia are common after brain
injury in children and do not necessarily imply
increased intracranial pressure. However,
persistent vomiting or vomiting that becomes
more frequent is a concern and mandates CT of
the head.
5. Impact seizures, or seizures that occur shortly
after brain injury, are more common in children
and are usually self-limited. All seizure activity
requires investigation by CT of the head.
6. Children tend to have fewer focal mass lesions
than do adults, but elevated intracranial
pressure due to brain swelling is more common.
Rapid restoration of normal circulating blood
volume is critical to maintain cerebral perfusion
pressure (CPP). If hypovolemia is not corrected
promptly, the outcome from head injury can be
worsened by secondary brain injury. Emergency
CT is vital to identify children who require
imminent surgery.
7. The Glasgow Coma Scale (GCS) is useful in
evaluating pediatric patients, but the verbal
score component must be modified for children
younger than 4 years (n TABLE 10-6).
table 10-6 pediatric verbal score
VERBAL RESPONSE
Appropriate words or social
smile, fixes and follows
Cries, but consolable
Persistently irritable
Restless, agitated
None
8. Because increased intracranial pressure
frequently develops in children, neurosurgical
consultation to consider intracranial pressure
monitoring should be obtained early in the
course of resuscitation for children with (a) a
GCS score of 8 or less, or motor scores of 1 or
2; (b) multiple injuries associated with brain
injury that require major volume resuscitation,
immediate lifesaving thoracic or abdominal
surgery, or for which stabilization and
assessment is prolonged; or (c) a CT scan of
the brain that demonstrates evidence of brain
hemorrhage, cerebral swelling, or transtentorial
or cerebellar herniation. Management of intracranial
pressure is integral to optimizing CPP.
9. Medication dosages are determined by
the child’s size and in consultation with a
neurosurgeon. Drugs often used in children with
head injuries include 3% hypertonic saline and
mannitol to reduce intracranial pressure, and
Levetiracetam and Phenytoin for seizures.
Criteria are available to identify patients who are at
low risk for head, cervical spine, and abdominal injury
and therefore do not require CT (n FIGURE 10-7).
Management
V-SCORE
Management of traumatic brain injury in children
involves the rapid, early assessment and management
of the ABCDEs, as well as appropriate neurosurgical
involvement from the beginning of treatment.
Appropriate sequential assessment and management of
the brain injury focused on preventing secondary brain
injury—that is, hypoxia and hypoperfusion—is also
critical. Early endotracheal intubation with adequate
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