PEDIATRIC HEAD TRAUMA: CEREBRAL PERFUSION PRESSURE AS AN .
PEDIATRIC HEAD TRAUMA: CEREBRAL PERFUSION PRESSURE AS ANINDICATOR OF OUTCOMEByLESLEY CYNTHIA MORGANA DISSERTATION PRESENTED TO THE GRADUATE SCHOOLOF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF PHILOSOPHYUNIVERSITY OF FLORIDA2003
Copyright 2003byLesley Cynthia Morgan
This dissertation is dedicated to my parents who always believed.
ACKNOWLEDGMENTSI would like to thank my committee chairman, Dr. James Jessup, for his guidance,encouragement, and patience throughout this research study. I have appreciated hisknowledge of physiology, nursing and his commitment to provide leadership for thisstudy.I gratefully acknowledge and extend my appreciation to the members of mycommittee, Charles Wood, PhD., Claydell Horne, PhD., and Hossein Yarandi, PhD.Each of them provided unique talents, time, and moral support during this study. Iwould like to thank Dr. Wood for his support during my physiology classes, Dr. Yarandifor his patience in dealing with the data and more importantly for improving myunderstanding of statistical analysis and Dr. Horne for continual calm and encouragementand editorial expertise.I want to thank Joseph Tepas, M.D., and Pamela Pieper, R.N., M.S.N., for theirassistance with the Pediatric Trauma Registry, the DELTA outcome score and for sharingtheir tremendous knowledge of the pediatric trauma patient. I also want to thank andoffer my undying appreciation to Shannon Bourne, L.P.N., for helping me weave throughthe obstacle course that is the IRB.iv
TABLE OF CONTENTSpageACKNOWLEDGMENTS . ivLIST OF FIGURES . viiiABSTRACT. ixCHAPTER1INTRODUCTION .1Background of the Problem .1History of Pediatric Trauma Care.2Epidemiology .2Safety Systems.3Pathophysiology of Pediatric Head Injury .4Mechanisms of Injury.7Mechanical Causes of Brain Injury .8Pattern of Brain Injury.9Mortality and Morbidity .9Clinical Presentation.10Purpose of the Study.11Conceptual Framework.12Significance of the Study.12Study Questions .14Definition of Terms .14Glasgow Coma Scale.14DELTA Disability and Injury Score.14Glasgow Outcome Scale.15Cerebral Blood Flow .15Cerebral Blood Volume.15Cerebral Metabolic Rate of Oxygen.16Arteriovenous Difference of Oxygen .16Volume-Pressure Index .162REVIEW OF LITERATURE .17Physiology of Cerebral Circulation and Metabolism .17Cerebral Edema .19v
Intracranial Pressure .19Cerebral Perfusion Pressure .25Cerebral Autoregulation .35Poiseuille’s Law .40Cerebral Compliance .41Mannitol and Fluid Balance .42Hypercapnia.44Physiology of Pediatric Cerebral Circulation and Metabolism .46Pediatric Traumatic Brain Injury .46Diffuse Brain Swelling .50Hyperemia .51Hyperventilation .54Summary.543METHODS .57Research Design .57Research Setting .57Sample Size .57Sample Criteria .57Measures .58Pediatric Blood Pressure.58Mean Arterial Pressure (MAP).59Intracranial Pressure .59Cerebral Perfusion Pressure .60Heart Rate (Pulse).60Temperature.60Data Collection Procedure.60Data Collection .61Procedure for the Protection of Human Subjects .62Data Analysis.624ANALYSIS AND RESULTS.63Subject Demographics .63Subject Age, Sex and Ethnicity .63Mechanism of Injury .65Research Findings.66Research Questions.665CONCLUSIONS AND RECOMMENDATIONS .70Discussion of Findings .70Cerebral Perfusion Pressure.70Conclusions.75Limitations of the Study .76Study Design Limitations .76vi
Statistical Analysis Limitations.77Strengths of the Study .77Recommendations for Further Research .77Implications for Clinical Practice .78APPENDIXADATA COLLECTION TOOL .80BGLASGOW COMA SCALE (GCS) .83CMODIFIED GLASGOW COMA SCORE FOR INFANTS .85DDELTA DISABILITY AND INJURY SCORE .86EGLASGOW OUTCOME SCALE.87LIST OF REFERENCES.88BIOGRAPHICAL SKETCH .100vii
LIST OF FIGURESFigurepage4-1. Age Distribution.644-2. Distribution of DELTA severity and outcome score .644-3. Distribution of Admission GCS Score .654-4. Mechanism of Injury .66viii
Abstract of Dissertation Presented to the Graduate Schoolof the University of Florida in Partial Fulfillment of theRequirements for the Degree of Doctor of PhilosophyPEDIATRIC HEAD TRAUMA: CEREBRAL PERFUSION PRESSURE AS ANINDICATOR OF OUTCOMEByLesley Cynthia MorganMay 2003Chair: James JessupMajor Department: NursingBrain injury is a common and devastating event in the United States impacting boththe adult and the pediatric populations. In the pediatric population there are over 100,000children under the age of 15 treated annually for neurological trauma with many sufferingsignificant long-term disability and death. There are extensive data and researchevaluating the impact of cerebral trauma in the adult population. Optimization ofcerebral perfusion pressure (CPP) has gained recognition as a therapeutic endpoint in themanagement of brain-injured adults. This study evaluated the relationship between CPPand intracranial pressure (ICP) in children with severe traumatic brain injury. This studyfocused on the effectiveness of perfusion of injured neurons and the relationship tooutcome.Fifty-five children, aged 1.5 to 15 years, admitted for severe blunt head trauma(Glasglow Coma Score 8) were retrospectively studied looking at systolic bloodpressure, heart rate, temperature, mean arterial pressure, intracranial pressure, andix
cerebral perfusion pressure as an indicator of outcome as measured by the DELTA injuryand disability score. Demographic data collected included age, sex, ethnicity, andadmission Glasgow Coma Scale score. Data were analyzed using the SAS software.Results indicate that the first 48 hours after an injury is the critical period to influenceoutcome with mean arterial pressure, intracranial pressure, and cerebral perfusionpressure significant indicators of outcome (p 0.0005).When subjects were divided into two groups, children who died and children whosurvived, temperature was significant (p 0.0005) for the first four days post injury.Temperature continued to maintain significance when subjects were divided intosurvivors with poor outcome and good outcome. The relationship between outcome andtherapeutic interventions is unclear and requires further evaluation in a larger prospectivestudy.x
CHAPTER 1INTRODUCTIONBackground of the ProblemThe management of traumatic brain injury (TBI) is a fairly new discipline. Until40 years ago TBI was regarded as an untreatable insult. Since that time, treatment forTBI has improved significantly. The improvement in therapy is credited to emergingtechniques and concepts in intracranial pressure control and cerebral perfusionmanagement. However, there is little consensus regarding the management of thesepatients (Chestnut, 1997b). This problem is exacerbated when discussing theneurotrauma care of children. From research now available, there are strong supportingdata from prospectively collected, observational studies that there is a biologicaladvantage toward favorable outcome associated with younger age. There is alsoevidence that the path of physiological events underlying the brain’s response to injury inchildren is somewhat different than seen in adults (Aldrich et al., 1992; Bruce et al.,1979; Bruce, Schut, Brumo, Wood, & Sutton, 1978; Luerssen, Klauber, & Marshall,1988; Muizelaar et al., 1989; Obrist, Langfitt, Jaggi, Cruz, & Gennarelli, 1984).Injury is the leading cause of death among children and adolescents in the UnitedStates. Death from unintentional injury for age groups 1 to 4 years, 5 to 9 years, 10 to 14years, and 15 to 19 years was 36%, 43%, 39%, and 46% respectively for the year 1998.This represents a total drop in the death rate of 38% between the years 1979 and 1998(Guyer et al., 1999). The impact of childhood injury is immense in terms of direct coststo society and the tremendous emotional toll of death and disability. Brain injury is a1
2common and devastating event. In the pediatric population, there are over 100,000children under the age of 15 treated annually for neurologic trauma with many sufferingsignificant long-term disability and death (Guyer & Ellers, 1990; Lehr & Baethmann,1997; Tepas, DiScala, Ramenofsky, & Barlow, 1990).History of Pediatric Trauma CareIn 1917 a French munitions ship and a Norwegian freighter collided causing anenormous explosion at a narrow point in the harbor of Halifax, Nova Scotia, Canada.Two thousand were killed, 9,000 injured and over 31,000 left homeless. Pleas formedical help were issued throughout Canada and the United States. A health care teamfrom Boston led by William E. Ladd responded. Dr. Ladd was moved by the specialmedical needs of the children and upon his return to Boston dedicated himself to thesurgical care of infants and children. This is considered the birth of pediatric surgery asan independent surgical specialty. At this time infectious diseases were the most lethalchildhood illnesses. But by 1947, with the advent of sulfa drugs, penicillin, and smallpoxand polio vaccines, the death rate from these illnesses began to fall. During the l940s,trauma became the leading cause of death in children (Dietrich, 1954; Godfrey, 1937;Goldbloom, 1986; Press, 1947).EpidemiologyIn 1937 Edward Godfrey, M.D., commissioner of the New York State Departmentof Health, wrote of the failure of health care workers to give important consideration tochildhood accidents. “What is the net gain if a child, through breast feeding andpasteurized milk, is prevented from dying of gastroenteritis if he pulls a stewpan ofboiling water off the stove and is fatally scalded? What use to protect him againstdiphtheria to be killed by an automobile” (p. 153).
3Today, trauma remains the major cause of death in children between the ages of 1and 14, with head injury accounting for 40 % of fatal childhood injuries. Head injuryaccounts for 100,000 pediatric hospitalizations per year in the United States. Theincidence of head injury is approximately 200 per 100,000, with an ensuing mortality rateof 10 %. For comparison, the next leading cause of death in the pediatric age group isleukemia, with a rate of death of approximately 2 deaths per 100,000 (Francel, Park,Shaffrey, & Jane, 1996). When the pediatric population is evaluated as a whole, the mostcommon cause of head injury are falls at approximately 35% of patients and motorvehicle accidents at 25% of patients. When severe trauma is isolated from the abovenumbers, motor vehicle accidents account for about 75% to 80% of the injuries. Fallsdrop to 15% (Waxweiler, Thurman, Sniezek, Sosin, & O’Neil, 1995).Bicycle accidents are a common cause of traumatic injury in children and youngadolescents. Bicycle accidents resulted in more than 400,000 emergency departmentvisits and 500 to 600 deaths in the United States in 1986. In 1982, 70% of all bicyclerelated injuries occurred in children younger than 15 years of age. Most of these severeaccidents involved a motor vehicle. Similar to bicycle accidents are pedestrian injuries tochildren between the ages of 1 to 14 years. Fatal pedestrian injuries are more commonthan fatal passenger injuries in preschool and school-aged children (Campbell, 1992;Pautler, Henning, & Buntain, 1995).Safety SystemsYoung people are at risk of head injury as pedestrians, as cyclists, and as occupantsof motor vehicles. The risks and consequences vary with age and maturity (Simpson,Blumbergs, McLean, & Scott, 1992). Infant and child safety is an ongoing concern. Theadvent of seat belts with the subsequent addition of shoulder straps or the three point
4restraints decreases the fatality rate of accidents by 40% to 50% and the severity of injuryby 55% to 60% (Rivera, 1999). Car seats, when used properly with a five-point restraintsystem, make fatality 11% less likely. The use of bike helmets by children hassignificantly decreased severe head injury (DiGuiseppi, Rivara and Koepsell, 1990;Goldsmith, 1992). A study by Spaite, Murphy, Criss, Valenzuela, and Meisen (1991)showed that not wearing a helmet in a serious crash was strongly associated with majorhead injury in 22% of all patients evaluated, whereas, only 1 in 116 patients wearinghelmets during a crash had major head trauma. A mandatory bicycle helmet lawinstituted in Victoria, Australia, reduced the number of cyclists admitted to the hospitalwith a marked reduction in the proportion with head injuries when compared with thesame period in the year before (Ryan, 1992; Vulcan, Cameron, & Watson, 1992).Pathophysiology of Pediatric Head InjuryOne of the most striking differences between the p
Today, trauma remains the major cause of death in children between the ages of 1 and 14, with head injury accounting for 40 % of fatal childhood injuries. Head injury accounts for 100,000 pediatric hospitalizations per year in the United States. The incidence of head injury is approximately 200 per 100,000, with an ensuing mortality rate of 10 %.
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
Cerebral Metabolism—CMRO 2 Oxygen Consumption 3-3.8mL/100g/min . Perfusion Pressure & Cerebral Blood Flow producing regional & general ischemia. P1—Percussion wave Atrial pulsation . Cerebral edema—Trauma Cerebral ischemia—Hypoxia Hypercarbia
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
Pediatric trauma centers and hospital-based care are only one aspect of a larger trauma system. An . Special planning considerations must be made for pediatric patients based on the availability of pediatric trauma resources within the geographic area that the trauma
Objectives Review current pediatric trauma statistics at UMC/EPCH Understand why children are not small adults Discuss tools to evaluate the pediatric trauma patient How to perform an initial evaluation of the pediatric trauma patient Discuss
4 Flexural Strength Kp/cm 950 ASTM D 790 5 Elongation at Break % 80 ISO R 527 6 Yield Stress Kp/cm 400 ISO R 527 7 Resistance to Heat mm 2 BS 4607 PART 2:70 CHEMICAL PROPERTIES Properties at 20_C Unit Values Method of Evaluation 1 Resist to Sulphuric Acid .g/45cm -0.13 3.19 2 Resist to Methylene Chloride % 3 ISO 2508/81 3 Resist. Water Absortion .mg/cm 2.0 ISO 2508/81 & DIN 8061 .
