**6.2 Moderate and severe TBI**

Detecting moderate and severe TBI cases are more straightforward with commonly accepted classification based on the level of consciousness measured in pediatric Glasgow Coma Scale (GCS) [29] and evidence of pathological imaging findings. GCS level lower than 9 is considered severe TBI, while GCS level within the range of 9–13 is considered moderate TBI. Based on anatomical structure


#### **Table 3.**

*Diagnostic features of primary TBI manifestations [5, 13, 30].*

involvement, primary TBI clinically manifests as skull fracture, extraparenchymal injury, intraparenchymal injury, and vascular injury, while secondary TBI manifests as diffuse cerebral swelling [13]. TBI manifestations are summarized in **Table 3**.

The appropriate imaging modality choice according to the American College of Radiology appropriateness criteria [31] depends on TBI onset and severity, risk assessment by PECARN criteria, and cognitive and neurologic signs. This guideline requires the exclusion of abusive head trauma in all cases and posttraumatic seizure in chronic cases. CT scan is recommended for acute and subacute cases, whilst magnetic resonance imaging (MRI) is recommended in subacute and chronic cases.

### **7. Management**

Management strategy contingent on the severity of TBI. Management of mild cases highlights the importance of gradual rehabilitation while maintaining strict adherence to injury prevention. Indispensable emergency and intensive care in more severe cases warrant separate management planning.

The general strategy to manage mild TBI cases begins with complete rest. Once the child advance to a gradual return to regular activity, it is imperative to avoid any movement or activity that would provoke symptoms. Each of the next steps should be taken for at least 24 hours long, and any worsening of symptoms would render the child retreat to the previous step (**Table 4**). Similar gradual progression should also be applied to cognitive activities, especially in cases where mental activities exacerbate the symptoms. General preventive measures in commuting and playing sports should be exercised regularly [5].

Unconscious pediatric TBI patients need emergent tracheal intubation is recommended, along with the appropriate sedative or analgesic agent. Benzodiazepines are proven for their antiepileptic, anxiolytic, and amnestic properties. The dosage of benzodiazepine and opiate administrated is guided by proper preservation of mean arterial and cerebral perfusion pressure. The risk of respiratory depression as

**93**

*Traumatic Brain Injury in Children*

Heavy noncontact

activity

**Table 4.**

hypocapnia, and hypoxia [32–34].

*Step-by-step to achieve the return to play [5].*

and < 38 °C [33].

**8. Future directions**

*DOI: http://dx.doi.org/10.5772/intechopen.96010*

Moderate activity Light resistance

Competitive activity Full competitive

activities

activities

**Step Activities Time Goal** Rest No activity 24–48 hours —

Nonaerobic activity Normal daily activities — School or work activities Light activity Exercises at slow pace 5–10 minutes Mild increase in heart rate

Full contact activity Normal activities Normal Return to usual full-contact

Reduced than usual

Noncontact exercises Near usual Intense activity

Limited movement

activities

Normal No restriction

the side effect of sedative agents could be prevented by securing airway and optimizing ventilation. Controlled mechanical ventilation for initial support by FiO2 titration to achieve target SpO2 of 92–99% or PaO2 75–100 mmHg is recommended. The most recent proper ventilation goal involves preventing hyperventilation,

Optimal intravascular volume status encompasses central venous pressure (CVP) and urine output monitoring, blood urea nitrogen and serum creatinine assessment, fluid management, and nutrition therapy. Normovolemic status is achieved by administering normal saline as much as 75% of the maintenance requirement to maintain CVP between 4–10 mmHg and urine output >1 ml/ kg/hour. Initial use of 5% dextrose in normal saline infusion may be necessary to avoid hypoglycemia in younger patients. Nutrition therapy should start as early as 72 hours. The core temperature should be maintained within >35 °C

The first tier after baseline care is maintaining ICP threshold below 20 mmHg. Levels above this threshold urge intervention by methods in the following order: CSF drainage, hyperosmolar therapy, analgesic and/or sedation escalation, or neuromuscular blocker initiation should be considered. Coupling nature of ICP and CPP means that the increase in ICP is often followed by CPP improvement. Permissive intracranial hypertension remains an option, although the second tier of maintaining the CPP threshold should be decided carefully due to precipitous herniation risk. Age-specific CPP threshold ranges between 40–50 mmHg in concordance with increasing pediatric age extremes. Refractory increase in ICP despite first tier treatment requires a repeat CT scan when surgical option is indicated. Surgical intervention to remove mass and/or decompressive craniectomy is

Pediatric TBI poses a great challenge with wide-ranged prognosis. Both mild and severe extremes in the TBI severity spectrum necessitate thorough assessment and management strategies. Future endeavors should be directed to establish universal definition of concussion, more reliable biomechanical models, optimal treatment

indicated when new or expanding lesion is detected [33].

algorithm, and effective prevention strategies.

#### *Traumatic Brain Injury in Children DOI: http://dx.doi.org/10.5772/intechopen.96010*


#### **Table 4.**

*Advancement and New Understanding in Brain Injury*

**Intracranial bleeding**

Hyperdense lesion in specific configurations **Cerebral contusion**

Seizure (SAH) — Coma,

Mixeddensity lesion surrounded by perilesional hypodense area

**Diffuse axonal injury**

decorticate or decerebrate posturing, neuropsychiatric impairment

Foci of reduced diffusion and increased susceptibility

**Abusive head trauma**

Abnormal shaking behavior as mechanism of injury, seizure, retinal hemorrhage, rib fracture

Coexistence of multiple hematomas with different onsets

**Skull fracture**

Linear, depressed, basal skull, or growing skull fracture

*Diagnostic features of primary TBI manifestations [5, 13, 30].*

*SAH, subarachnoid hemorrhage*

Subcutaneous swelling

Clinical findings

Main radiological evidence

**Table 3.**

involvement, primary TBI clinically manifests as skull fracture, extraparenchymal injury, intraparenchymal injury, and vascular injury, while secondary TBI manifests as diffuse cerebral swelling [13]. TBI manifestations are summarized in **Table 3**. The appropriate imaging modality choice according to the American College of Radiology appropriateness criteria [31] depends on TBI onset and severity, risk assessment by PECARN criteria, and cognitive and neurologic signs. This guideline requires the exclusion of abusive head trauma in all cases and posttraumatic seizure in chronic cases. CT scan is recommended for acute and subacute cases, whilst magnetic resonance imaging (MRI) is recommended in subacute and chronic cases.

Management strategy contingent on the severity of TBI. Management of mild cases highlights the importance of gradual rehabilitation while maintaining strict adherence to injury prevention. Indispensable emergency and intensive care in

The general strategy to manage mild TBI cases begins with complete rest. Once the child advance to a gradual return to regular activity, it is imperative to avoid any movement or activity that would provoke symptoms. Each of the next steps should be taken for at least 24 hours long, and any worsening of symptoms would render the child retreat to the previous step (**Table 4**). Similar gradual progression should also be applied to cognitive activities, especially in cases where mental activities exacerbate the symptoms. General preventive measures in commuting and playing

Unconscious pediatric TBI patients need emergent tracheal intubation is recommended, along with the appropriate sedative or analgesic agent. Benzodiazepines are proven for their antiepileptic, anxiolytic, and amnestic properties. The dosage of benzodiazepine and opiate administrated is guided by proper preservation of mean arterial and cerebral perfusion pressure. The risk of respiratory depression as

more severe cases warrant separate management planning.

sports should be exercised regularly [5].

**92**

**7. Management**

*Step-by-step to achieve the return to play [5].*

the side effect of sedative agents could be prevented by securing airway and optimizing ventilation. Controlled mechanical ventilation for initial support by FiO2 titration to achieve target SpO2 of 92–99% or PaO2 75–100 mmHg is recommended. The most recent proper ventilation goal involves preventing hyperventilation, hypocapnia, and hypoxia [32–34].

Optimal intravascular volume status encompasses central venous pressure (CVP) and urine output monitoring, blood urea nitrogen and serum creatinine assessment, fluid management, and nutrition therapy. Normovolemic status is achieved by administering normal saline as much as 75% of the maintenance requirement to maintain CVP between 4–10 mmHg and urine output >1 ml/ kg/hour. Initial use of 5% dextrose in normal saline infusion may be necessary to avoid hypoglycemia in younger patients. Nutrition therapy should start as early as 72 hours. The core temperature should be maintained within >35 °C and < 38 °C [33].

The first tier after baseline care is maintaining ICP threshold below 20 mmHg. Levels above this threshold urge intervention by methods in the following order: CSF drainage, hyperosmolar therapy, analgesic and/or sedation escalation, or neuromuscular blocker initiation should be considered. Coupling nature of ICP and CPP means that the increase in ICP is often followed by CPP improvement. Permissive intracranial hypertension remains an option, although the second tier of maintaining the CPP threshold should be decided carefully due to precipitous herniation risk. Age-specific CPP threshold ranges between 40–50 mmHg in concordance with increasing pediatric age extremes. Refractory increase in ICP despite first tier treatment requires a repeat CT scan when surgical option is indicated. Surgical intervention to remove mass and/or decompressive craniectomy is indicated when new or expanding lesion is detected [33].

### **8. Future directions**

Pediatric TBI poses a great challenge with wide-ranged prognosis. Both mild and severe extremes in the TBI severity spectrum necessitate thorough assessment and management strategies. Future endeavors should be directed to establish universal definition of concussion, more reliable biomechanical models, optimal treatment algorithm, and effective prevention strategies.

*Advancement and New Understanding in Brain Injury*
