Linee guida sul trauma cranico:

sempre attuali?

Leonardo Bussolin

AOU Meyer

Vavilala MS, et al

Prehospital Arena – ED – OR - ICU

Retrospective multicenter cohort study

Each 1% increase in adherence was

associated with a 6% drop in the hazard

of death and a 1% drop in the hazard of

being severely disabled or vegetative

Monitor ICP and optimize parameters

Fluids and pressors, optimize sedation

Hypertonic saline

Mannitol

Mild hyperventilation

Coma barbiturate

Surgical measures

Summary protocol

PROTOCOL FOR MANAGEMENT OF THE SEVERE BRAIN INJURY

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

First Edition (2003) Second Edition (2012)

Corticosteroids III - The use of steroids is not recommendedfor improving outcome or reducing ICP in

severe TBI; despite two class II studies failingto show efficacy , the small sample sizes

preclude support for a treatment guidelinefor this topic

II – The use of corticosteroids is notrecommended to improve outcome or reduce

ICP in severe TBI

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

First Edition (2003) Second Edition (2012)

Analgesics, Sedative, and Neuromuscolar Blockade

III – In the absence of outcome data, the choice of dosing and sedative, analgesic,

and neuromuscolar agents should be left tothe treating phisician

III – Etomidate may be considered tocontrol severe intracranial hypertension; however the risks resulting from adrenal

suppression must be considered

- III – Thiopental may be considered tocontrol intracranial hypertension

-

In the absence of outcome data, the specific indications, choice, and dosing ofanalgesic, sedative, and neuromuscolar

agents should be left to the treatingphisician

- Continuous infusion of propofol is notrecommended

First Edition (2003) Second Edition (2012)

Temperature control III - From adult data, hyperthermia shouldbe avoided -

Temperature control III - Despite the of clinical data in children, hypothermia may be considered in

refractory intracrania pressure

II – Moderate hypothermia (32-33°C) beginning early for only 24 h duration

should be avoided

Temperature control II – Moderate hypothermia (32-33°C) beginning within 8 h for up to 48 h durationshould be considered to reduce intracranial

hypertension

Temperature control II – If hypothermia is induced, rewarmingat a rate of > 0.5 °C per h should be avoided

Temperature control III – Moderate hypothermia (32-33°C) beginning early for 48 h duration may be

considered

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

MANNITOL

vs

HYPERTONIC SALINE

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

First Edition (2003) Second Edition (2012)

Hyperosmolar therapy-

II – 3% Hypertonic saline in severe TBI withintracranial hypertension: 6.5-10 ml/kg

Hyperosmolar therapy III - Continuous infusion of 3% hypertonicsaline 0.1-1.0 ml/kg/h with the minimum dose needed to maintain ICP <20 mmHg

III - The same+

serum osmolarity should be maintained below 360 mOsm/L

Hyperosmolar therapy III - Mannitol is effective with bolus dosesrange 0.25-1 gr/Kg

Although Mannitol is commonly used no studies meeting inclusion criteria were

identified for use as evidence for this topic

2010; 5:18-21Role of hypertonic saline and mannitol in the management of

raised intracranial pressure in children: A randomized comparative study

Piyush Upadhyay, VN Tripathi, RP Singh, D Sachan

Mannitolo 3%Hypertonic

Bennet TD, et al.Crit Care Med. 2012 40(1): 208–215

SaO2:100%

vs

PtbO2: ≥ 20 mmHg

PaCO2

First Edition (2003) Second Edition (2012)

Hyperventilation III – Mild or prophylactic hyperventilation(<35 mmHg) in children should be avoided

III – Avoidance of prophylactic severe hyperventilation to a PaCO2 < 30mmHg

may be considered in the initial 48 h afterinjury

Hyperventilation III -Mild hyperventilation (PaCO2 30-35 mmHg) may be considered for longerperiods for intracranial hypertensionrefractory to sedation and analgesia,

neuromuscolar blockade, cerebrospinalfluid drainage, and hyperosmolar therapy

III – If hyperventilation is used in the management of refractory intracranial

hypertension, advanced neuromonitoringfor evaluation of cerebral ischemia may be

considered

Hyperventilation III - Aggressive hyperventilation(PaCO2<30mmHg) may be considered as a

second-tier option for refractoryhypertension; cerebral blood flow, jugularvenous oxygen saturation, or brain tissueoxygen monitoring is suggested to help

identify cerebral ischemia

Hyperventilation III – Aggressive hyperventilation titrated toclinical effect may be necessary for briefperiods in case of cerebral herniation or

acute neurological deterioration

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

MAP/CPP

Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent

Second Edition

Changes in recommendations from the first edition to the second edition

CPP

First Edition (2003) Second Edition (2012)

II - CPP > 40 mmHg should bemaintained

III – A minimum CPP 40 mmHgmay be considered

III – A CPP between 40 and 65 mmHg probably represent an age-related

continuum fo the optimal treatment threshold; there may be exceptions for this

range in some infants and neonates

III – A CPP threshold 40-50 mmHg may be considered; there may be age-specific

thresholds with infants at the lower end and adolescents at the upper end of this

range

III – Advanced cerebral physiologicalmonitoring may be useful to define the

optimal CPP in individual insatnces

Brady KM, et al. Pediatrics 2009;124:e1205

Pressure-Ractivity Index

VASOSPASM

IN CHILDREN?

J Neurosurgery Pediatr 2015 Mar;15(3):282-90

37 pazienti 8 mesi-18 anni

ESA PT e RA

CONCLUSIONS:

Children have a relatively high incidence of

angiographically detectable, moderate-to-severe CV.

Children rarely develop symptomatic CV and have

good long-term outcomes, perhaps due to robust

cerebral collateral blood flow.

Heffren J et al. 2015 Mar;52(3):356-60

CONCLUSIONS:

Oral nimodipine after subarachnoid hemorrhage in

children does not eliminate vasospasm, rebleeding, or

infarction and is associated with significant hypotension.

Nevertheless, clinical outcomes appear favorable relative

to the adult population who receive nimodipine. Further

study, with dose titration, is warranted.

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