1398 SECTION XII Pediatric Critical Care Environmental Injury and Trauma occur as a result of disconnection between inhibitory centers in the upper brainstem and diencephalon and excitatory centers in[.]
1398 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma occur as a result of disconnection between inhibitory centers in the upper brainstem and diencephalon and excitatory centers in lower brainstem or spinal cord processes.269 Treatment typically involves the use of benzodiazepines, central a2-agonists, baclofen, b-blockers, gabapentin, and opioids to reduce the frequency and severity of symptoms TBI Contemporary View Link between traumatic brain injury and various chronic neurodegenerative diseases Linking Rehabilitation and Acute Care Rehabilitation can have dramatic effects after a severe TBI is sustained, particularly in the setting of focal injury Successful rehabilitation may require prolonged therapy (months or even years).270 Underscoring the potential importance of the subacute and rehabilitation phases for targeted therapy in severe TBI, Giacino and associates271 reported on a successful clinical multicenter RCT in severe TBI in 184 adults In that work, a 4-week exposure to amantadine—an NMDAR antagonist and dopamine agonist—resulted in significantly faster recovery of the Disability Rating Scale Given that RCTs of hypothermia, decompressive craniectomy, erythropoietin, and progesterone,231,244,245,272,273 among other agents, have failed in the acute phase after TBI, therapeutic trials in the subacute or rehabilitation phases after severe TBI merit additional investigation Recent studies suggest potential benefits of early rehabilitation in all pediatric critical care.274 Finally, novel approaches, such as the use of stem cells, are also in the exploratory phase of clinical testing and warrant investigation in children after severe TBI.275 Outcomes Outcomes from severe TBI often have been assessed as a function of age at the time of injury and in relationship to three diagnostic categories: noninflicted (accidental) closed-head injuries, AHT, and penetrating injury (predominantly gunshot wounds) Accurate assessment of long-term outcome has been hampered in infants and children by the lack of validated outcome assessment tools Application of modifications of adult outcome tools (e.g., the Glasgow Outcome Scale) has been the general approach; however, these tools have limitations when applied across the pediatric age spectrum.276 Levin and colleagues13 highlighted the dramatic effect of age on outcome About two-thirds of children between the ages of and 10 years had favorable outcome (i.e., normal or moderate disability), whereas over 60% of children age years or younger died Rates of favorable outcome as high as 73% have been reported in clinical trials in pediatric TBI.189 Studies of AHT and gunshot wounds have reported poorer outcome than series of accidental TBI However, even in these two high-risk diagnostic categories, favorable outcome has been as high as 35% in patients with severe TBI resulting from AHT and 24% in patients with severe TBI resulting from gunshot wounds.240,277 Public interest in the field of TBI has soared related to the emerging recognition of a potential link between repetitive mild TBI and neurodegenerative diseases such as Alzheimer disease, Parkinson disease, and chronic traumatic encephalopathy, among others (Fig 118.14).278 This could also occur in severe TBI, is likely in AHT, and is under investigation Conclusion Optimal care of the infant or child with severe TBI requires a multidisciplinary approach Prompt and vigorous resuscitation, including stabilization and control of ventilation, is essential Amyloid β Tau α-Synuclein Other Microglia/Macrophage Parkinson’s Disease Alzheimer’s Disease Other Neurodegenerative Diseases ALS CTE • Fig 118.14 Contemporary view of the link between traumatic brain in- jury (TBI) and the ultimate development of neurodegenerative diseases This includes the progressive accumulation of amyloid b or a-synuclein in traditional neurodegenerative diseases or tau protein in chronic traumatic encephalopathy (CTE) ALS, Amyotrophic lateral sclerosis After initial evaluation and surgical intervention, where indicated, monitoring and titrated management of raised ICP are essential to optimize cerebral perfusion and facilitate metabolic homeostasis Meticulous and optimal neurointensive care is the basis for the future delivery of targeted therapies as additional information on the evolution of secondary neuronal damage becomes available The goal of contemporary pediatric neurointensive care is the prevention of secondary injury Much of that care focuses on preventing secondary insults The goal of future pediatric neurointensive care will be to overlay, on this therapeutic plan, strategies manipulating tissue injury in the evolution of secondary damage at a cellular level, along with strategies to foster regeneration and rehabilitation.36 Key References Adams JH, Doyle D, Ford I, et al Diffuse axonal injury in head injury: definition, diagnosis, and grading Histopathology 1989;15:49-59 Adelson PD, Clyde B, Kochanek PM, et al Cerebrovascular response in infants and young children following severe traumatic brain injury: a preliminary report Pediatr Neurosurg 1997;26:200-207 Adelson PD, Srinivas R, Chang Y, et al Cerebrovascular response in children following severe traumatic brain injury Childs Nerv Syst 2011; 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