Traumatic Brain Injury and Spinal Cord Injury
Traumatic brain injury
Distinguish focal (contusion, hematoma) from diffuse (axonal) injury and primary from secondary injury. Secondary injury prevention is the nurse's core role: avoid hypoxia and hypotension (the two strongest predictors of poor outcome), maintain normocapnia, control fever, prevent hyperglycemia, and position to optimize venous drainage with head of bed about 30 degrees and midline head. Understand the Monro-Kellie doctrine (brain, blood, CSF in a fixed vault) and why hyperventilation is reserved for impending herniation because it causes vasoconstriction and ischemia. Recognize the child with a lucid interval after a fall as a possible epidural hematoma.
Spinal cord injury
Know the difference between spinal shock (flaccid paralysis, loss of reflexes, transient) and neurogenic shock (loss of sympathetic tone causing hypotension with bradycardia). Suspect concomitant cervical injury in any significant trauma; maintain spinal precautions until cleared. Monitor respiratory function closely in high cervical lesions because diaphragmatic innervation (C3–C5) may be impaired. Watch for autonomic dysreflexia in lesions above T6, presenting as severe hypertension, headache, and bradycardia triggered by bladder or bowel distension.
Traps
Questions may imply that hypotension is acceptable in neurotrauma (it is not), that steroids improve pediatric TBI outcomes (they do not), or that hyperventilation is a routine therapy. Autonomic dysreflexia is often misattributed to pain alone.
Rule of thumb
For suspected herniation, brief hyperventilation to a lower PaCO2 buys time to definitive treatment, then return to normocapnia.