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Craniocerebral and Spinal Trauma 197

and should be treated with intravenous fluids, nil per os (NPO), and severe lesions improve with time but hardly regain normal function.
nasogastric tube decompression. Uncommonly, ulceration, haemor- Only children with mild to moderate deficits can hope for full recovery.
rhage and perforation may occur. Therefore, proton pump inhibitors or Mortality in the acute setting is 20%.
H -receptor antagonists should be started immediately. Prevention
2
Skin and pressure areas The majority of spinal cord injury is caused by pedestrian-motor
The patient must be turned every 2 hours manually or automatically, vehicle accidents and falls. Enforcement of traffic rules cannot be over-
and all pressure areas must be padded to prevent pressure sores. 26 emphasized. Prevention of children from engaging in activities that are
Joints and limbs detrimental, such as climbing trees and unprotected heights or depths
27,28
Joints must be passively moved and splinted if necessary to prevent must be ensured.
contractures. Ethical Issues
Those who survive spinal cord trauma develop life-long disabilities.
Autonomic dysreflexia
Treatment is often not curative. The decision to operate must be care-
Autonomic dysreflexia is seen particularly in patients with cervical
fully discussed with the family, and the prospective multidisplinary
injury above the sympathetic outflow. It occurs after spinal shock and
mode of subsequent management should be instituted.
usually is due to distended bladder or detrusor-sphincter dyssynergia.
Distended bladder causes reflex sympathetic overactivity below the Evidenced-Based Research
level of the spinal cord lesion, causing vasoconstriction and severe Table 30.5 is a review of paediatric severe head injuries that compares
hypertension. The carotid and aortic baroreceptors respond via the two age groups. Table 30.6 is a review of paediatric spine fractures that
vasomotor centre with increased vagal tone and bradycardia, but these compares parameters of the injuries.
stimuli cannot pass distally through the injured cord. Table 30.5: Evidence-based research.
Patient suffers headache, profuse sweating, and flushing above
the level of the cord lesion. Without prompt treatment, intracranial Title Severe head injury in children: early prognosis and outcome
haemorrhage may occur. Authors Zuccarello M, Facco E, Zaampieri P, Zanardi L, Andrioli GC
Another cause of autonomic dysreflexia includes urinary tract infection. Institution Department of Neurosurgery and Institute of Anesthesiology
Treatment is by removing the cause, sitting the patient up, and and Intensive Care, University Hospital, Padova, Italy
administering nifedipine or glycryl trinitrate; spinal or epidural Reference Child’s Nervous System 1985; 1:158–162
anaesthetics are used occasionally. Problem Identifying indicators for early prognosis and outcome in
Hyponatraemia children with severe head injury.
Hyponatraemia is usually caused by fluid overload, diuretic usage, and Intervention Controlled hyperventilation and bolus infusion of hypertonic
the sodium-depleting effect of some drugs such as carbamazepine and (20%) mannitol, surgical removal of any mass lesions.
inappropriate ADH secretion. It is treated by treating sepsis, fluid restric- Comparison/ Sixty-two children with severe head injury were divided into
tion, and administration of frusamide with potassium supplements. control two groups: infants aged <36 months (24.2%) and children
(quality of aged 36 months–14 years (75.8%). The study was limited to
Hypercalcaemia evidence) patients who remained in coma for at least 6 hours.
Hypercalcaemia is caused by prolonged immobility and manifests
with constipation, abdominal pain, and headache. Treatment involves Outcome/ The difference between good and poor results in patients
hydration, achieving diuresis, and the use of sodium etidronate or effect with GCS 4 or less and those with score of 5 points or better
disodium pamidronate. was significant (p < 0.001). There was a correlation between
the best motor response and outcome. Of flaccid patients,
Para-articular heterotopic ossification 85% did poorly or died, whereas 69% of those who withdrew
New bone is often deposited in soft tissue around paralysed joints. Best in response to pain did well (p<0.001).
treatment is surgical excision after 18 months when the bone is matured. The presence or absence of brainstem dysfunction
Spasticity (assessed on basis of pupil reaction and oculocephalic
reflex) was statistically related to good or poor result
Spasticity is seen only in patients with an upper motor neurone lesion but oculocephalic reflex was considered to be the most
whose intact spinal reflex arcs below the level of the lesion are isolated indicative (p<0.001).
from the higher centres. It enhances the tendency to contractures.
The necessity for assisted ventilation at admission was
Aggravating factors are detected and treated, pain is managed,
associated with a less favourable outcome (p<0.001). An
and spastic muscles are passively stretched. Oral baclofen is usually intracranial haematoma was not associated with a worse
helpful. In intractable cases, however, the use of butulinum toxin, motor outcome.
point injection, intrathecal baclofen pump, tenotomy, neurectomy, or
The authors observed that recovery was almost complete
Intrathecal block may be employed.
when the duration of coma was less than 2 weeks, with 93%
Urologic complications of patients moderately disabled or with a good recovery.
After spinal cord injury, dysfunctional voiding patterns may soon There was high incidence of poor outcome in those with
coma lasting >2 weeks (p = 0.0002).
emerge. These are associated with serious sequelae. Therefore, as part of
early management, intermittent catheterisation, tapping and expression, Overall mortality was 32%.
indwelling catheterisation, suprapubic cystostomy, or intermittent self- Historical This study provides a useful insight into the early prognostic
catheterisation can be used. Later management may involve augmenta- significance/ factor in children with severe head injury. Clinical features
tion cystoplasty, neuromodulation and sacral anterior root stimulation comments available soon after injury that are important indicators of
treatment and outcome are identified.
(SARS), or intermittent self-catheterisation (Mitrofanoff’s technique).
Prognosis and Outcome
The neurological examination and age of the patient are the most criti-
cal prognostic factors for short- and long-term recovery. Children with
complete lesions rarely improve, whereas those with incomplete but