INTERVENTION FOR PEDIATRIC AHT PATIENTS

Resuscitation (attention to airway, breathing, and circulation) and stabilization efforts for patients with traumatic brain injury take priority because of the often life-threatening presentation of the child with AHT. Intervention then focuses on detection of primary injury (as discussed above), treatment of that injury, and prevention or treatment of secondary brain injury.

Acute Management of Traumatic Brain Injury

The Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies publishes Guidelines for the Acute Management of Severe Traumatic Brain Injury for Infants, Children, and Adolescents based on a review of the pediatric traumatic brain injury (TBI) literature. (A brief synopsis of the guidelines is discussed here; see Kochanek et al. in “References” at the end of this course to access the full guidelines) (Rasmussen, 2018).

INITIAL MANAGEMENT

The initial management (first-tier therapy) of a child with a traumatic brain injury begins with strict attention to the maintenance of the patient’s airway, breathing, and circulation (blood pressure).

Those with decreased consciousness (GCS <9), marked respiratory distress, or hemodynamic instability require advanced airway management to enhance oxygenation and ventilation and prevent aspiration of gastric contents. Early airway management involves providing proper airway position, removal of debris while maintaining cervical spine precautions, and orotracheal intubation. Adequate ventilation is needed to prevent both hypercarbia and hypoxia, as they are both potent cerebral vasodilators that result in increased cerebral blood flow and volume and, potentially, increased intracranial pressure (ICP) and intracranial hypertension (ICH).

Orotracheal intubation allows for not only airway protection in patients who are severely obtunded but also for better control of oxygenation and ventilation. Nasotracheal intubation should be avoided because of the risk of cervical spine injury and direct intracranial injury, especially in patients with basilar skull fractures.

Oxygenation is best monitored using pulse oximetry, with supplemental oxygen administered when necessary to ensure adequate oxygenation. For initial monitoring of ventilation of children with traumatic brain injury, capnography is recommended to monitor end-tidal CO2 in order to avoid excessive hyperventilation and resultant hypocapnia, thereby leading to vasoconstriction and decreased cerebral perfusion.

PREVENTING SECONDARY BRAIN INJURY

A primary goal in the acute management of the severely head-injured pediatric patient is to prevent or ameliorate the factors that promote secondary brain injury. Secondary brain injury involves an endogenous cascade of cellular and biochemical events in the brain that occurs within minutes and continues for months after the primary brain injury and that leads to ongoing or “secondary” traumatic axonal injury (TAI) and neuronal cell damage (delayed brain injury) and, ultimately, neuronal cell death.

The following treatable conditions can exacerbate secondary brain injury:

  • Hypoxemia
  • Hypotension
  • Elevated intracranial pressure (ICP) leading to intracranial hypertension (ICH)
  • Hypercarbia or hypocarbia
  • Hyperglycemia or hypoglycemia
  • Electrolyte abnormalities
  • Enlarging hematomas
  • Coagulopathy
  • Seizures
  • Hyperthermia

In order to prevent secondary brain injury, intracranial pressure management is crucial. Raising the head of the bed to decrease venous obstruction may help to control ICP. Traditionally, elevation of the head to 30° in the midline position was recommended, but titration of head elevation to achieve the lowest ICP is optimal.

Every effort should be made to avoid hypotension in these patients, because hypotension has been shown to increase morbidity and mortality. Euvolemia should be maintained. However, isolated TBI rarely leads to severe hypotension. Other causes of trauma-related hypotension include, but are not limited to:

  • Intra-abdominal injuries
  • Pericardial tamponade
  • Hemothorax
  • Pneumothorax
  • Spinal cord injury causing spinal shock

Intracranial monitoring. For patients with severe TBI or a GCS score of ≤8 and suspected ICH, an ICP monitor may be placed. Intracranial hypertension is associated with poor neurologic outcome. The following treatments may also be considered by the neurosurgical team.

  • Neuromuscular blockade
  • Hyperosmolar therapy
  • Hyperventilation
  • Temperature control
  • Decompressive craniectomy
  • Antiseizure prophylaxis
    (Rasmussen, 2018)

Nursing Care Planning

Nursing care planning for children with AHT and their families may be very complex and includes addressing the following diagnoses and issues:

  • Risk for altered parenting (defined as inability of the primary caregiver to create, maintain, or regain an environment that promotes the optimum growth and development of the child)
  • Risk for violence related to history of family violence
  • Risk for injury related to physical or psychological conditions in the environment
  • Hopelessness related to long-term family stress
  • Post-trauma response related to physical or psychosocial abuse

Nursing care will generally involve significant discharge planning and referral to appropriate healthcare and social services. The treatment of child abuse is complex and often involves long-term psychotherapy for the parents or other perpetrators as well as the child. Most states require some kind of counseling for the parents (see also below under “Prevention Strategies”).

SECONDARY TRAUMA IN HEALTHCARE PROFESSIONALS

The development of secondary traumatic stress (STS) is a common occupational hazard for professionals working with traumatized children. The symptoms of secondary trauma may include feelings of isolation, anxiety, dissociation, physical ailments, and sleep disturbances, and can be associated with a sense of confusion, helplessness, and a greater sense of isolation from supporters than is seen with typical job burnout. It is not uncommon for traumatized professionals to believe they can no longer be of service to their clients and end up leaving their jobs or the serving field altogether.

Protecting against the development of secondary traumatic stress includes factors such as longer duration of professional experience and the use of evidence-based practices in the course of providing care. The most important strategy for preventing secondary traumatic stress is the triad of psychoeducation, skills training, and reflective supervision to both reduce risk and increase resiliency to secondary stress. Specific strategies may include:

Organizational Strategies

  • Provide adequate clinical supervision, including reflective supervision
  • Maintain trauma caseload balance
  • Support workplace self-care groups
  • Enhance the physical safety of staff
  • Offer flextime scheduling
  • Incorporate STS training for clinical staff
  • Create external partnerships with STS intervention providers
  • Train organizational leaders and nonclinical staff on STS
  • Train organizational leaders on organizational implementation and assessment
  • Provide ongoing assessment of staff risk and resiliency

Individual Strategies

  • Use supervision to address STS
  • Increase self-awareness of STS
  • Maintain healthy work-life balance
  • Exercise and good nutrition
  • Practice self-care
  • Stay connected
  • Develop and implement plans to increase personal wellness and resilience
  • Continue individual training on risk reduction and self-care
  • Use Employee Assistance Programs or counseling services as needed
  • Participate in a self-care accountability buddy system

(NCTSN, 2021)

Rehabilitation and Recovery

Because the brains of infants and young children are still developing, AHT can result in widespread impairment and dysfunction. AHT can impact the trajectory in all developmental domains. The long-term outcomes of AHT often include impairments in a child’s sensory-motor, cognitive, behavioral, and emotional functioning. Together, these problems can cause long-term consequences in everyday functioning, social and academic areas, and participation in society and community integration (Lind et al., 2016). The recovery process is influenced by the child’s pre-injury status, the acute care, and the responses of the patient’s family, school, and community.

HEALTH AND DEVELOPMENT CONDITIONS RELATED TO AHT
  • Learning disabilities
  • Physical disabilities
  • Visual disabilities or blindness
  • Hearing impairment
  • Speech disabilities
  • Cerebral palsy
  • Seizures
  • Behavior disorders
  • Cognitive impairment
  • Death
    (NCSBS, 2021)

Rehabilitation includes teaching strategies and providing supports to both the child and family to compensate for impaired or lost functions and to optimize abilities. Partnering with a child’s school is vital to making sure the child receives the services needed to achieve academically in a safe and appropriate manner.

A multidisciplinary approach to both the inpatient and outpatient phases of rehabilitation care is essential. Interventions might include, but are not limited to: pharmacologic, physical, occupational, vision, hearing, speech-language, psychological, behavioral, and/or educational therapies. Rehabilitation continues as long as it results in improvements in function.

When interventions no longer yield improvements in function, the child transitions into a period of “habilitation.” Professionals must now understand that recovery may be a lifelong process for the child’s entire circle of family, friends, and healthcare providers.

Researchers have found that higher-quality early and later home environments and family functioning predict better outcomes for children with traumatic brain injury, including AHT. The overall quality of the home environment was measured according to eight different factors:

  • Learning materials, provision of appropriate play materials
  • Language stimulation
  • Physical environment, including regularity and predictability of the environment
  • Parental responsivity
  • Learning stimulation
  • Modeling of social maturity
  • Variety in experience
  • Acceptance of child (i.e., parental acceptance of suboptimal behavior and avoidance of restriction and punishment)
    (Durber et al., 2017)
CASE

Nina is now a 6-year-old girl who suffered a traumatic brain injury due to AHT as an infant. Per court records, her mother came home from her second day back at work and found Nina, then a 3-month-old, with her arms twitching. Nina was being cared for by her father, the mother’s boyfriend. Her mother took Nina to the emergency department of the local hospital, but by the time they arrived, the twitching had stopped. After several hours of observation, they were sent home.

That evening Nina ate poorly and vomited. The next morning Nina’s mom found her unresponsive, with abnormal posturing. Her mother called 911. Nina was stabilized in the ED and transferred to a tertiary care pediatric medical center. She was in the intensive care unit for two weeks and the pediatric rehabilitative unit for three weeks. Nina was discharged to a foster home.

The father reported that he had accidently dropped Nina the day before, but the history and clinical presentation did not match up, and the father was arrested for child abuse. He was later convicted for child abuse because of the physical findings associated with Nina’s case.

Nina’s mother was able to regain custody of her after three months and a lengthy police and child welfare investigation. To regain custody of Nina, her mother was required to take parenting classes and was referred to Public Health Nursing, Early Head Start, and early intervention services. The maternal-child health specialist, public health nurse, and early intervention service coordinator helped Nina’s mother learn ways to organize Nina’s daily medical care and walked her through how to access and advocate for the variety of services and supports that the family was going to need to support Nina’s special needs.

Nina was diagnosed with cerebral palsy, neurologic (cortical) vision impairment, seizure disorder, and global developmental delay. She is technologically dependent on a gastrostomy tube for her nutrition needs. Nina continues to have severe developmental disabilities and delays (she is both nonambulatory and nonverbal) and receives special education and physical, occupational, and speech therapy services. The school nurse, county health department public health nurse, IFSP (Individualized Family Service Plan), and IEP (Individualized Education Plan) team members work regularly with Nina’s family to ensure that her educational, therapeutic, and medical needs are met. Nina also has a home care nurse who provides respite care. Nina will need care for all of her activities of daily living for the rest of her life.