Pre-retrieval care package for the patient with traumatic brain injury
All patients should be taken to an agreed area for retrieval when initial resuscitation has been done
Aim- To protect airway, adequately ventilate and oxygenate, achieve euvolaemia and sedate to transfer as rapidly as possible if surgery is indicated
Ventilation
- Oral ETTube
- Insert orogastric tube
- CXR to confirm ETT position
- Aim for arterial pCO2 4.5-5kPa
- End tidal pCO2 monitoring mandatory
- Minimum PEEP 4cm H2O
C-Spine immobilisation even if radiology is normal
Circulation
- IV access x2
- Consider central line and arterial line
- N saline infusion at 100% maintenance
- Aim for euvolaemia
- Blood transfusion to keep Hb >10g/dL
- Volume and Vasopressors to maintain BP;
- Urinary catheter if time permits
NB early signs of impending hypotension include tachycardia
Low urine output
Low peripheral pulse volume
Raised cap refill time
Neurology
- 15 minutely neuro obs
- Phenytoin loading dose 20mg/kg
- CT scan
Environment
- Allow passive warming for hypothermia. Aim for temp 36.5-37 degreesC
- Monitor for hyperthermia, and actively cool if necessary to maintain normothermia.
- Tilt head of bed to 30 degrees
Sedation/analgesia
- Morphine + midazolam infusion
- Consider further boluses of morphine for pain relief
If there are clinical signs of raised intracranial pressure
- Mannitol 0.25g/kg up to 0.5g/kg 6hrly
- Give 10ml/kg N saline with mannitol to avoid hypovolaemia
- Aim for Na >140mmol/l.
- Ensure adequate sedation
CT Head
- Discuss films with neurosurgeons directly
- Immediate surgery may be indicated, bypassing PICU direct to theatres
- Time constraints may necessitate transfer by referring hospital staff
Lab Investigations
- ABG and electrolytes 6hrly (more frequently if clinical scenario requires)
- Glucose, FBC, coag screen
- Mg, Ca, PO4
Secondary survey with appropriate management of identified injuries
Documentation
- Clear history charting mechanism of injury
- Copy of all notes, medication and observations charts
- CT film to be sent with patient if not transferred digitally
Reference
Mazzola CA, 2002. Critical care management of head trauma in children
Crit Care Med. 30(11 Supp) S393-401
Charles Stewart
May 2007