Craniocerebral Trauma

Initial Evaluation and Resuscitation

Centers that emphasize coordinated, protocol-driven care of pediatric neurotrauma victims, including stabilization in the field, emergency room evaluation, and acute and rehabilitative care, obtain the best neurological and medical outcomes and also reduce cost. Emergency medical personnel in the field follow protocols developed by local institutions, generally in accordance with American College of Surgeons trauma guidelines. Key elements of prehospital care for trauma victims with suspected nervous system injury generally include:

• Maintenance of airway, breathing and circulation.

• Stabilization of the spine using a cervical collar and backboard. The relatively high head-to-body ratio in small children often requires padding underneath the shoulders so that the cervical spine is in a neutral position.

• Assessment of level of consciousness, Glascow Coma Score and gross extremity movement.

• Treatment of hypotension using volume resuscitation with isotonic fluids.

• Strict avoidance of hypoxia, using supplemental oxygen, and avoidance of hypoventilation, using intubation (with in-line traction to avoid secondary spinal-cord injury) and assisted ventilation. Mild hyperventilation may be used temporarily in the presence of brain herniation syndrome (see below).

• In some cases, administration of mannitol for suspected intracranial hypertension and/or solumedrol for suspected spinal-cord injury.

• Sedation and pharmacological paralysis only if needed for intubation or agitation. Short-acting medications are used to allow neurological evaluation by a neurosurgeon upon arrival at the hospital.

• Rapid transport to an accredited trauma center with a neurosurgical team.

Physical Examination

In the emergency room (E.R.), the trauma team undertakes a more systematic evaluation of the patient. The neurosurgical consultant focuses on the following details:

• Pupillary examination and extraocular muscles: size, shape, reactivity ofpupil to light, eye movements (IlIrd, IVth, VIth cranial nerves and midbrain).

Pediatric Neurosurgery, edited by David Frim and Nalin Gupta. ©2006 Landes Bioscience.

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