Intracranial pressure: influence of head-of-bed elevation, and beyond

Computed Tomography Practice Standards for Severe Pediatric Traumatic Brain Injury in the Emergency Department: a National Survey

Acute medical management of traumatic brain injury (TBI) can be challenging outside of the resuscitation bay, specifically while obtaining a computed tomography (CT) scan of the brain. We sought out to determine the management practices of Canadian traumatologists for pediatric patients with severe TBI requiring CT in the emergency department (ED). In 2019, surveys were sent to trauma directors in hospitals across Canada to ascertain their clinical practices. Team members present in the CT scan included physicians (89%), registered nurses (100%), and respiratory therapists (38%). The average time to and from the CT scanner was one hour. Over half of respondents (56%) had experienced an adverse event in CT with variable access (11-56%) to necessary resuscitation equipment and medications. Significant hypotension (44%) was the most common adverse event experienced. With the exception of an end tidal CO2 monitoring (56%), heart rate, rhythm, respiratory rate, saturation, and blood pressure were always monitored during a CT scan. Head of bed elevation had an approximately equal distribution of flat (44%) versus elevated (56%). The practice variability of Canadian traumatologists may reflect a lack of evidence to guide patient management. Future research and knowledge translation efforts are needed to optimize patient care during neuroimaging.

Pre-Trauma Center Management of Intracranial Pressure in Severe Pediatric Traumatic Brain Injury

OBJECTIVES

Pre-trauma center care is a critical component in severe pediatric traumatic brain injury (TBI). For geographically large trauma catchment areas, optimizing increased intracranial pressure (ICP) management may potentially improve outcomes. This retrospective study examined ICP management in nontrauma centers and during interfacility transport to the trauma center.

METHODS

Charts from a pediatric level I trauma center were reviewed for admissions between 2008 and 2013. Patients with a Glasgow Coma Scale score of 8 or less, head Abbreviated Injury Scale score of 3 or higher, and requiring intubation at a nontrauma center were included. Exclusion criteria included head injury secondary to drowning, stroke, obstetrical complications, asphyxia, and afflicted head trauma (younger than 5 years). Trauma center charts contained coalesced data from first responders, nontrauma centers, and transport.

RESULTS

Twenty-five patients (74%) had increased ICP upon admission at trauma center, 48% experienced ICPs greater than 20 cm H2O within 12 hours of admission, 12% required an urgent craniotomy, and 16% had herniation syndromes on neuroimaging. Pre-trauma center ICP management included osmotherapy and head-of-bed elevation. Sixty-four percent of patients with increased ICP at trauma center admission received pre-trauma center ICP management.

CONCLUSIONS

Early increased ICP is a common presentation of severe pediatric TBI during pre-trauma center management. However, what constitutes optimal care remains unknown. Given the difficulties of diagnosing early increased ICP in this setting, prophylactic raising ICP-lowering strategies may be considered.

Elevation of the head during intensive care management in people with severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain-injured people. Special interventions in the intensive care unit are required to minimise factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head-of-bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people. The aim of this review is to evaluate the evidence related to the clinical effects of different backrest positions of the head on important clinical outcomes or, if unavailable, relevant surrogate outcomes.

OBJECTIVES

To assess the clinical and physiological effects of HBE during intensive care management in people with severe TBI.

SEARCH METHODS

We searched the following electronic databases from their inception up to March 2017: Cochrane Injuries' Specialised Register, CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers. The Cochrane Injuries' Information Specialist ran the searches.

SELECTION CRITERIA

We selected all randomised controlled trials (RCTs) involving people with TBI who underwent different HBE or backrest positions. Studies may have had a parallel or cross-over design. We included adults and children over two years of age with severe TBI (Glasgow Coma Scale (GCS) less than 9). We excluded studies performed in children of less than two years of age because of their unfused skulls. We included any therapeutic HBE including supine (flat) or different degrees of head elevation with or without knee gatch or reverse Trendelenburg applied during the acute management of the TBI.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked all titles and abstracts, excluding references that clearly didn't meet all selection criteria, and extracted data from selected studies on to a data extraction form specifically designed for this review. There were no cases of multiple reporting. Each review author independently evaluated risk of bias through assessing sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias.

MAIN RESULTS

We included three small studies with a cross-over design, involving a total of 20 participants (11 adults and 9 children), in this review. Our primary outcome was mortality, and there was one death by the time of follow-up 28 days after hospital admission. The trials did not measure the clinical secondary outcomes of quality of life, GCS, and disability. The included studies provided information only for the secondary outcomes intracranial pressure (ICP), cerebral perfusion pressure (CPP), and adverse effects.We were unable to pool the results as the data were either presented in different formats or no numerical data were provided. We included narrative interpretations of the available data.The overall risk of bias of the studies was unclear due to poor reporting of the methods. There was marked inconsistency across studies for the outcome of ICP and small sample sizes or wide confidence intervals for all outcomes. We therefore rated the quality of the evidence as very low for all outcomes and have not included the results of individual studies here. We do not have enough evidence to draw conclusions about the effect of HBE during intensive care management of people with TBI.

AUTHORS' CONCLUSIONS

The lack of consistency among studies, scarcity of data and the absence of evidence to show a correlation between physiological measurements such as ICP, CCP and clinical outcomes, mean that we are uncertain about the effects of HBE during intensive care management in people with severe TBI.Well-designed and larger trials that measure long-term clinical outcomes are needed to understand how and when different backrest positions can affect the management of severe TBI.

Intracranial pressure and cerebrovascular autoregulation in pediatric critical illness

Protecting the brain in vulnerable infants and children with critical illness involving the brain is a central aspect of pediatric intensive care and neurocritical care. Collectively, illness-induced derangements in intracranial pressure, circulatory homeostasis, and pressure autoregulation are all fundamental in informing bedside management. Therefore, this review provides an understanding of these entities and a physiological approach to bedside care and monitoring.