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Kim HJ, Eun S, Yoon SH, Kim MK, Chung HS, Koo C. Paediatric Trauma Score as a non-imaging tool for predicting intracranial haemorrhage in patients with traumatic brain injury. Sci Rep 2021; 11:20911. [PMID: 34686729 PMCID: PMC8536669 DOI: 10.1038/s41598-021-00419-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
To identify a useful non-imaging tool to screen paediatric patients with traumatic brain injury for intracranial haemorrhage (ICH). We retrospectively analysed patients aged < 15 years who visited the emergency department with head trauma between January 2015 and September 2020. We divided patients into two groups (ICH and non-ICH) and compared their demographic and clinical factors. Among 85 patients, 21 and 64 were in the ICH and non-ICH groups, respectively. Age (p = 0.002), Pediatric trauma score (PTS; p < 0.001), seizure (p = 0.042), and fracture (p < 0.001) differed significantly between the two groups. Factors differing significantly between the groups were as follows: age (odds ratio, 0.84, p = 0.004), seizure (4.83, p = 0.013), PTS (0.15, p < 0.001), and fracture (69.3, p < 0.001). Factors with meaningful cut-off values were age (cut-off [sensitivity, specificity], 6.5 [0.688, 0.714], p = 0.003) and PTS [10.5 (0.906, 0.81), p < 0.001]. Based on the previously known value for critical injury (≤ 8 points) and the cut-off value of the PTS identified in this study (≤ 10 points), we divided patients into low-risk, medium-risk, and high-risk groups; their probabilities of ICH (95% confidence intervals) were 0.16-12.74%, 35.86-89.14%, and 100%, respectively. PTS was the only factor that differed significantly between mild and severe ICH cases (p = 0.012). PTS is a useful screening tool with a high predictability for ICH and can help reduce radiation exposure when used to screen patient groups before performing imaging studies.
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Affiliation(s)
- Heoung Jin Kim
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sohyun Eun
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seo Hee Yoon
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moon Kyu Kim
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Soo Chung
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Department of Emergency Medicine, Severance Hospital, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Chungmo Koo
- Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Diyora B, Gawali S, Patel M, Dhall G. Iron Rod Penetrating Head Injury in a Child. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1732786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractCivilian penetrating brain injury (PBI) is a rare form of traumatic brain injury (TBI) and is rarer in the pediatric population. Pediatric PBI due to various objects has been reported in the literature. Pediatric PBI with an iron rod has not been previously described. We reported a case of civilian penetrating injury in a 6-year-old girl child patient who fell over a projecting iron rod at a construction site from a height of 6 to 8 feet. She was lifted off from the iron rod and taken to the emergency medical services. CT scan of the brain revealed linear intracerebral hemorrhage along the iron rod’s track with a depressed fracture. She underwent emergency surgery because of a compound depressed fracture. She recovered well from his injury without neurological deficit with an excellent clinical outcome.
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Affiliation(s)
- Batuk Diyora
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
| | - Sagar Gawali
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
| | - Mehool Patel
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
| | - Gagan Dhall
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
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Thresholds for identifying pathological intracranial pressure in paediatric traumatic brain injury. Sci Rep 2019; 9:3537. [PMID: 30837528 PMCID: PMC6401127 DOI: 10.1038/s41598-019-39848-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 11/27/2018] [Indexed: 01/22/2023] Open
Abstract
Intracranial pressure (ICP) monitoring forms an integral part of the management of severe traumatic brain injury (TBI) in children. The prediction of elevated ICP from imaging is important when deciding on whether to implement invasive ICP monitoring for a patient. However, the radiological markers of pathologically elevated ICP have not been specifically validated in paediatric studies. Here in, we describe an objective, non-invasive, quantitative method of stratifying which patients are likely to require invasive monitoring. A retrospective review of patients admitted to Cambridge University Hospital's Paediatric Intensive Care Unit between January 2009 and December 2016 with a TBI requiring invasive neurosurgical monitoring was performed. Radiological biomarkers of TBI (basal cistern volume, ventricular volume, volume of extra-axial haematomas) from CT scans were measured and correlated with epochs of continuous high frequency variables of pressure monitoring around the time of imaging. 38 patients were identified. Basal cistern volume was found to correlate significantly with opening ICP (r = -0.53, p < 0.001). The optimal threshold of basal cistern volume for predicting high ICP ([Formula: see text]20 mmHg) was a relative volume of 0.0055 (sensitivity 79%, specificity 80%). Ventricular volume and extra-axial haematoma volume did not correlate significantly with opening ICP. Our results show that the features of pathologically elevated ICP in children may differ considerably from those validated in adults. The development of quantitative parameters can help to predict which patients would most benefit from invasive neurosurgical monitoring and we present a novel radiological threshold for this.
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Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst 2017; 33:1677-1681. [PMID: 29149393 DOI: 10.1007/s00381-017-3535-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population. CHALLENGES IN PEDIATRICS Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development. IMAGING CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge. FURTHER DEVELOPMENTS Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines. CONCLUSIONS The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.
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Affiliation(s)
- Navneet Singh
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada.
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Krishnamoorthy V, Prathep S, Sharma D, Fujita Y, Armstead W, Vavilala MS. Cardiac dysfunction following brain death after severe pediatric traumatic brain injury: A preliminary study of 32 children. Int J Crit Illn Inj Sci 2015; 5:103-7. [PMID: 26157654 PMCID: PMC4477386 DOI: 10.4103/2229-5151.158409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population. Materials and Methods: We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003–2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death. Results: In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2–6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024). Conclusions: The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Sumidtra Prathep
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Deepak Sharma
- Department of Anesthesiology and Pain Medicine, Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Yasuki Fujita
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - William Armstead
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Pediatrics, Radiology, University of Washington, Seattle, Washington, USA
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DiMaggio C, Li G. Emergency department visits for traumatic brain injury in a birth cohort of medicaid-insured children. Brain Inj 2013; 27:1238-43. [DOI: 10.3109/02699052.2013.809552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Charles DiMaggio
- Departments of Anesthesiology and Epidemiology, Columbia University, College of Physicians and Surgeons
New York, NYUSA
| | - Guohua Li
- Departments of Anesthesiology and Epidemiology, Columbia University, College of Physicians and Surgeons
New York, NYUSA
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Farrell CA. La prise en charge du patient d’âge pédiatrique victime d’un traumatisme crânien aigu. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.5.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sigurtà A, Zanaboni C, Canavesi K, Citerio G, Beretta L, Stocchetti N. Intensive care for pediatric traumatic brain injury. Intensive Care Med 2012. [PMID: 23179331 DOI: 10.1007/s00134-012-2748-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSES The aims of this study are to describe a cohort of head-injured pediatric patients, focusing on current practice for intracranial pressure (ICP) monitoring and treatment and to verify the relationship between clinical and radiological parameters and the six-month outcome in a multivariable statistical model. METHODS A retrospective review was done of a prospectively collected database considering patients younger than 19 years admitted to three neuro-intensive care units (ICU). Patients were divided into four age groups: 0-5 (infant), 6-12 (children), 13-16 (pre-adolescent) and 17-18 years (adolescent). The ICP and cerebral perfusion pressure (CPP) were analyzed calculating average data and values exceeding thresholds for more than 5 min. Outcome was assessed 6 months after trauma using the Glasgow Outcome Score. RESULTS There were 199 patients, 155 male, included. Sixty percent had extracranial injuries. Pupils were abnormal in 38 %. Emergency evacuation of intracranial hematomas was necessary in 81 cases. The ICP was monitored in 117 patients; in 87 cases ICP was higher than 20 mmHg, with no differences among age groups. All but six patients received therapy to prevent raised ICP; barbiturates, deep hyperventilation or surgical decompression were used in 31 cases. At 6 months, mortality was 21 % and favorable outcome was achieved by 72 %. Significant predictors of outcome in the multivariable model were the Glasgow Coma Scale (GCS) motor score, pupils and ICP. CONCLUSIONS Pediatric head injury is associated with a high incidence of intracranial hypertension. Early surgical treatment and intensive care may achieve favorable outcome in the majority of cases.
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Affiliation(s)
- A Sigurtà
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Neurointensive Care Unit and University of Milan, Milan, Italy.
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Post-traumatic morbidity is frequent in children with frontobasilar fractures. Int J Pediatr Otorhinolaryngol 2012; 76:670-4. [PMID: 22370240 DOI: 10.1016/j.ijporl.2012.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity. METHODS A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger. RESULTS The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae. CONCLUSIONS Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.
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Abstract
PURPOSE OF REVIEW The developing brain is particularly vulnerable to traumatic brain injury (TBI), leading to frequent disability or death. This article is an update of the pediatric specificities of TBI management. RECENT FINDINGS We review the evidences with regards to general management and therapeutic goals to prevent secondary injuries in pediatric TBI patients. Recent controversies in neurocritical care, such as multimodal neuromonitoring, hyperventilation, barbiturate coma, hypothermia, and decompressive surgery, are also highlighted. SUMMARY Many therapeutic modalities in pediatric TBI have a low level of evidence. Further research is needed to establish clear resuscitation goals. Universal objectives may not be suitable for all patients; intensive neuromonitoring may help in identifying individual therapeutic goals and guiding the selection of treatments.
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Wright J, Zhang G, Yu TS, Kernie SG. Age-related changes in the oligodendrocyte progenitor pool influence brain remodeling after injury. Dev Neurosci 2010; 32:499-509. [PMID: 21160162 DOI: 10.1159/000322081] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 10/14/2010] [Indexed: 11/19/2022] Open
Abstract
Brain remodeling occurs after all forms of brain injury, though the mechanisms underlying this phenomenon are mostly unknown. Neural stem and progenitor cells are one source of endogenous cells that may contribute to brain remodeling and subsequent recovery. In addition, certain populations of progenitors are particularly susceptible to injury, and their depletion may lead to the impairment of developmental processes that vary with age. We particularly focus on glial progenitors, which are more abundant postnatally and particularly susceptible to acquired brain injuries such as traumatic brain injury. We have recently characterized a novel transgenic mouse that expresses herpes thymidine kinase under the control of the neural-progenitor-specific nestin promoter and allows for temporally induced ablation of dividing progenitors. By genetically depleting dividing cortical progenitors at various times, we identify postnatal day 7 (P7) to P14 as a critical period for oligodendrogenesis. Targeted ablation of dividing progenitors during this window leads to cell-specific depletion of oligodendrocyte precursors expressing platelet-derived growth factor receptor-α and corresponding myelination and motor deficits. This modeling provides insight into how the age at which white matter injury occurs influences both injury severity and subsequent recovery.
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Affiliation(s)
- Jamie Wright
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Perheentupa U, Kinnunen I, Grénman R, Aitasalo K, Mäkitie AA. Management and outcome of pediatric skull base fractures. Int J Pediatr Otorhinolaryngol 2010; 74:1245-50. [PMID: 20800299 DOI: 10.1016/j.ijporl.2010.07.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 07/26/2010] [Accepted: 07/28/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures. METHODS Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed. RESULTS A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome. CONCLUSIONS We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.
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Affiliation(s)
- Ulla Perheentupa
- Department of Otolaryngology - Head and Neck Surgery, Turku University Hospital and University of Turku, Finland.
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Abstract
Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.
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Abstract
PURPOSE OF REVIEW Traumatic brain injury is the main cause of childhood disability and death. In this review, we highlight recent original findings and emerging themes from published literature on children with serious traumatic brain injury. RECENT FINDINGS We focus this review on lessons learned from our recent randomized clinical trial of hypothermia therapy in severe traumatic brain injury in children and on bedside neuromonitoring. We propose that integrating the measurement of biomarkers into clinical care as surrogate endpoints and as potential prognostic markers would allow us to evaluate earlier the effect of injury and clinical care in children after traumatic brain injury. Several methods are now more readily available to monitor cerebral physiology in children. These methods include indices evaluating the integrity of cerebral autoregulation, such as the pressure reactivity index derived from values obtained from intracranial pressure measurements, flow velocity measurements from transcranial Doppler ultrasonography or from cerebral oximetry. Other methods allow the evaluation of coma with the nonlinear analysis of electroencephalography or the evaluation of cerebral metabolism and cell death pathways with biomarkers from serum, cerebral spinal fluid, and cerebral microdialysis. SUMMARY We suggest expanding clinical functional neuromonitoring to help clinicians understand the burden of exposure to physiological variables and response to therapies during intensive care in order to enhance the management of critically ill children with traumatic brain injury.
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