Aggressive Physiologic Monitoring of Pediatric Head Trauma Patients with Elevated Intracranial Pressure

The management of pediatric patients with severe head trauma often requires aggressive physiologic monitoring and treatment. As intracranial pressure (ICP) increases, so does mortality. Yet attempts to decrease elevated ICP can cause physiologic and hemodynamic problems. In this retrospective analysis of 25 patients treated with ICP monitoring alone, ICP measurements plus mannitol, or ICP measurements plus pentobarbital (PB) induced coma/mannitol, survival rates were higher than predicted, particularly among the most severely injured. These results were apparently due to the intensive care and aggressive monitoring. Although barbiturates are known to decrease ICP, the adverse effects encountered, including hypotension, cardiovascular depression and arrhythmias, often outweigh the benefits. Hemodynamic abnormalities are unpredictable and monitoring with Swan-Ganz catheter is useful in managing patients with PB-induced comas. Many failures of PB therapy in pediatric patients may be related to undiagnosed decreases in cardiac output, resulting in decreased cerebral blood flow, even with well-controlled ICP.