Severe Closed Head Injury GCS 3 to

Children with severe closed head injury should be intubated and ventilated at the lower end of eucapnia (pCO2 = 36 — 40). Invasive arterial blood pressure and intracranial pressure monitoring (ICP; see below) should be instituted and a bladder drainage catheter placed. Depending on institutional policy, the neurosurgeon may insert an ICP monitor in the emergency room, ICU or operating room. The child should then be managed in the pediatric ICU (see Table 3). Any change in GCS or neurological examination or new intracranial hypertension should be evaluated by the neurosurgeon, with repeat CT imaging if indicated. Repeat CT imaging should be obtained 12 to 18 hours after admission.

The use of prophylactic anti-convulsant medication (generally Dilantin) in head injury is controversial. These drugs probably do not reduce the long-term risk of seizures in head injured patients. However, because early seizures may cause secondary injury or exacerbate intracranial hypertension, severely head-injured patients may be maintained on therapeutic levels of anti-convulsant drugs for 2 weeks after injury. Any clinical evidence of seizure activity or sudden intracranial hypertension not explained by CT findings should prompt evaluation by EEG and neurological consultation. Steroid drugs (e.g., Decadron) should not be given for head injury.

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