Preoperative Preparation For Pediatric Head Trauma (PART 2)

The release of tissue thromboplastin may lead to widespread activation of the coagulation and disseminated intravascular coagulation (DIC). Hypothermia and large blood transfusion futher increase the incidence of clotting abnormal therefore coagulation studies should be perfomed routinely and replacement of clotting factors is advised.

Endocrine and electrolyte abnormality often accompany severe head injury. Stress induced of adrenergic stimulation, respiratory alkalosis from hyperventilation and diuretic therapy may result hipokalimia.

Damage to hypothalamic/pituitary axis may lead to a lack of ADH secretion and diabetes insipidus can result hypernatremia due to loss of large volume of dilute urine(20L/day), it's contrast with SIADH that result hyponatremia.

The stress response is also associated with an increased risk of gastric ulceration and gastro intestinal bleeding.

H2 antagonist or sucralfate are commonly used for prophylaxis.

Hyportermie can result hypoxic, apnetic and produce metabolic, reduced surfactant production, impaire coagulation and prolong drug action especially for neonate and premature newborn.

Heat loss is particular problem in pediatric neosurgery because 30% of convective heat loss through the head in infants.

Unintentional hypothermia can often be avoided by having operating bed and overhead radiant  heater, warm anesthetic gas and intravenous fluid and warm irrigation solution.

Serial heamtocriet measurement are the most the reliable method to ensure an adequate haemoglobine. 
It should be kept in mind that normal Hb levels and blood
volumes are age dependent.

The preoperative anesthetic evaluation of the child undergoing neurosurgery includes the following:

1. An assessment of ICP.

2. An assessment of respiratory and cardiovascular

3. An assessment of spesific disturbance in the patients 
    neurologic function.

For any operation on head injured patient, management priorities remain avoidance of cerebral ischemia, optimation of CPP and prevention of intracranial hypertension(ICP).

Intubation must be accomplished with minimal manipulation of the cervical spine, the neck must be stabilized.

Premedication that result marked sedation should be avoided if are given. 
The patient must closely monitored to prevent respiratory depression, hypercarbia and increased ICP.

A Balance anesthetic technique of oxygen, a short acting opioid, a muscle relaxant and low dose agent (Isoflurane or sevoflurane) is probably the technic of choice for most neuroanesthetic.

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Preoperative Preparation For Pediatric Head Trauma (PART 1)

Head trauma is major cause of morbidity and mortality in the pediatric population.


Head injury can cause several different pathologic event including intracranial hematomas, cerebral edema and systemic effects.

The goals of early management of the patient with head trauma are two fold.

First, Prevention of secondary injury must be attempted aggresively.

Second, A rapid decision needs to be made as to wether emergency surgical exploration is required.

Brain damage a result of head injury can be devide into primary and secondary injury. Primary injury is the injury occuring during the trauma event itself, cannot be minimized.

Secondary injury is the injury occuring after the traumatic events, as a result of hypoxia, hypercapnia, and ischaemia induced by hypotension, vasospasm or Increase Intracranial pressure (ICP).

The most important contribution to secondary injury are hypoxaemia and hypovolemic with hypotension.

Mechanical Injury, hemorrhage, edema and Ischaemia are the most important causes of brain damage in patients with head injury.

Particularly the edema and Ischemia that are concern to anesthesiologist.

The importance of secondary injury to outcome is most clearly demonstrated by those patients who, at some point after injury are concious and talk, only to subsequently deteriorate and die. The children have more commonly diffuse cerebral edema.

Up to 50% of head trauma will have significant often life threatening associated injuries. Associated injuries usually involve the neck, chest and abdominal organ.

Although massive head injury and neck injury may result in shock, intrathoracic and abdominal bleeding should always

be considered in differential diagnosis of hypotension.

The anesthesiologist should be fully aware of these associated injuries because their presence may have a significant impact on anesthetic management. Single episode of hypotension occuring between injury and resuscitation will increase in mortality of almost 50%.

65% of spontaniously breathing head injured patients may be hypoxaemia even though they may not appear to be in respiratory distress.

Providing a secure airway is crucial in the management of head trauma but stabilization for cervical is mandatory.

Fluid balance is important, a combination of crystaloid (to replace normal fluid requirement), colloid and blood may be needed.

The target is normovolemia, Isoosmular, normoglygaemic. Dextrose containing solutions are avoided except in infants or where documented hypoglycaemia, because hypergly
lycaemia is thought worse tissue damage caused by Local cerebral Ischaemia.

Coagulation disturbances occur up to 24% of patient with severe, are indicative of poor outcome.

To be continued

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