Acute Management of Complications

A comprehensive review of the medical management of pediatric TBI is beyond the scope of this chapter. The interested reader is referred to the following resources for more comprehensive coverage: Adelson et al. 2003; Jankowitz and Adelson 2006; McLean et al. 1995; and Vincent and Berre 2005. In most cases, medical management of TBI focuses on the secondary injuries that arise indirectly after the initial trauma rather than on primary injuries. Thus the goal of medical management during the acute phase of TBI recovery is to prevent the occurrence of or minimize the negative effects of secondary injuries such as increased intracranial pressure and brain swelling (Jankowitz and Adelson 2006). The control of intracranial pressure is a paramount goal in the acute care of pediatric TBI patients. Following TBI, cerebral edema and hemorrhage result in a sharp increase in intracranial pressure that, if left unmanaged, can result in brain stem herniation and, ultimately, death (Vincent and Berre 2005). Specific guidelines have been developed with regard to the monitoring and assessment of intracranial hypertension following pediatric TBI (Adelson et al. 2003; Vincent and Berre 2005).

Another common complication of TBI is early posttraumatic seizures, which occur in about 3%-9% of children with head trauma and often involve focal status epilepticus, sometimes associated with mass lesions (McLean et al. 1995). Children who experience early posttraumatic seizures have been found to show worse outcomes than those who do not experience seizures (Chiaretti et al. 2000). Younger children seem especially vulnerable to early posttraumatic seizures. The occurrence of seizures soon after injury does not clearly place children at risk for later epilepsy, which occurs in about 2% of the survivors of pediatric head injury. Posttraumatic epilepsy is more common in children with penetrating injuries or depressed skull fractures, among whom the incidence is approximately 10%. It is also more likely in children with pronounced cerebral edema (Chiaretti et al. 2000). Most post-traumatic seizures occur within the first 2 years postinjury. Specific guidelines have been developed for the acute management of posttraumatic seizures in children (Adelson et al. 2003).

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