Page 724 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 701

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agitation and movement. The critical care nurse can posi- number of head injuries of any age group. TBI is often
tion themselves to maintain in-line stabilisation while associated with MVA where the child is a vehicle occu-
talking and soothing the child, or ideally where parents pant, a pedestrian or a cyclist, with falls and with near-
are present, seek their assistance to console their child. drowning. TBI is described in detail in Chapter 17.
Specific paediatric trauma boards are available that are In 2008, 273 children were admitted to Australian and
designed to maintain the child’s head in a neutral New Zealand ICUs with a diagnosis of head trauma.
position.
About 10% of all children aged 1–15 years of age who
Fluid resuscitation is a controversial area of practice in died in Australasian ICUs had sustained a traumatic brain
4
paediatric trauma, where therapies have been generally injury. Age and gender are the most significant risk
less-well-studied than in adults. Current recommenda- factors for TBI, with peak incidence in the 0–4-years
tions from the Advanced Paediatric Life Support Group group and in males. 237,238 Other factors to consider in
indicate that fluid boluses should be given initially in children are the increased tendency of the immature
10 mL/kg amounts until uncontrolled bleeding has been brain of children to experience disruption of the blood–
15
assessed for and ruled out. However, in a child with a brain barrier and, unlike adults, for an increased cerebral
traumatic brain injury at risk of secondary brain injury blood volume to lead to cerebral oedema due to higher
from hypotension, this more conservative approach may brain water content. 11
not be appropriate. Where more than 20 mL/kg is
required, immediate surgical assessment for bleeding is In 2003, the Society of Critical Care Medicine published
indicated. 15 guidelines on the management of paediatric brain injury,
however little paediatric research evidence underpinned
Exposure of the child, with temperature control, is neces- these as they were essentially based on extrapolation
sary to assess the child completely for injuries. 234,235 As from adult research evidence and expert opinion. Since
hypothermia can develop quickly in children, overhead the clinical manifestations of TBI in children are very
heating sources and blankets are ideally used to keep the similar to those in adults, management is also very
child warm. Hypothermia in trauma patients is asso- similar. One significant change recommended in the
ciated with increased risk for coagulopathy and mortal- 2003 guidelines was tight control of CO 2 , in recognition
ity, as in adults, so providing warmth is essential of hypocarbia as a major secondary brain injury factor.
236
paediatric trauma nursing care. The child’s right to The practice of hyperventilation should be avoided as it
privacy and dignity should also be considered and expo- is associated with regional cerebral ischaemia. 239
sure minimised.
In terms of assessment, the GCS modified for children
Secondary Survey has previously been described in this book. Indications
for intracranial pressure (ICP) monitoring in children
Undertaking a secondary survey is similar in children and include all infants and children with a severe head injury,
adults and is described in Chapter 22. Specific paediatric which equates to a GCS score of 8 or below that persists
considerations are highlighted below. following adequate cardiopulmonary resusci tation, and
In children, particularly those under one year of age, if those children who present with abnormal motor postur-
237
injuries and the accompanying history do not seem to ing and hypotension. Combined with invasive haemo-
match, non-accidental injury should be considered and dynamic monitoring, targeted therapy to manage both
noted. 226 History should be obtained from the child ICP and CPP remains an important part of treatment.
where possible, from any witnesses to the accident, and While thresholds for treating intracranial hypertension in
ambulance officers if they attended. Parents or caregivers children have not been studied, it has been known since
will provide details of the child’s past medical history, any the 1980s that prolonged intracranial hypertension or
medications and any known allergies. high ICP levels will worsen outcome. An ICP of 20 mmHg
is considered high in children, with 15 mmHg considered
high in infants. ICPs of these values are the usual cut-off
SPECIFIC CONDITIONS points and are likely to be treated with the aim of lower-
Specific injuries that are seen in children are discussed ing ICP while maintaining an adequate CPP. 9,239
briefly under the headings of traumatic brain injury, chest
trauma and abdominal trauma. Obtaining an accurate Diagnostics
history of the accident or events leading up to an injury Diagnostic techniques 240 and clinical management of
is useful in determining the type of injuries that children children with TBI mirror those in adults (see Chapter
241
may have sustained. Regardless of aetiology, where a child 17). The smaller size of children means that diagnostics
has been involved in a motor vehicle accident (MVA) or such as mixed cerebral venous saturation and direct brain
sustained a fall, there are likely to be multiple injuries oxygen saturation are not yet common practice in paedi-
and the situation should be treated as such until other atrics. A high index of suspicion for spinal injuries in
injuries have been considered and excluded. 227 paediatric TBI should be maintained, as spinal cord injury
without radiological abnormality (SCIWORA) on plain
Traumatic Brain Injury X-rays is a feature of paediatric spinal injury. CT scans
233
Traumatic brain injury (TBI) is a leading cause of deaths are available in more centres than MRI, but involves
and injury worldwide in children. In Australia and other radiation exposure to the young spine. Conjecture remains
developed economies, children experience the greatest around CT imaging versus MRI in children. 233