PEDIATRIC

TRAUMATIC
BRAIN INJURY
P R E S E N T E D B Y: A N A S E S A T T Y & B R I T T A N Y W I S E

HISTORY & PHYSICAL

8 y.o. female, 2nd grade student
Admitted for TBI secondary to MVA
Active and healthy except for severe myopia
Vitals
Temp: 97
27

Pulse: 100

Respiratory Rate:

MEDICAL DIAGNOSIS
Dx: TBI secondary to MVA
Traumatic brain injury (TBI) refers to
any of the following:
brain injury
skull fractures
extraparenchymal hemorrhage

epidural, subdural, subarachnoid

hemorrhage into the brain tissue itself

TBI DAMAGE
MRI: hemorrhagic edema in deep white matter of L
frontal lobe
Frontal lobe functions:
motor skills
conscious thought
emotions
sexual behavior
Personality
Brain Injury Institute, 2015

TBI PATHOPHYSIOLOGY
Hypermetabolic stress response
Ebb and Flow Phase
Hormonal changes
Gluconeogenesis
Acute inflammation
Protein preferred energy
Rapid decrease of LBM

DIAGNOSTIC TESTS
Glasgows Scale
Measures motor, verbal
and eye response

Score

Type of Injury

<8

severe brain
injury

9 - 12

moderate brain
injury

> 13

minor brain
injury

SIGNS & SYMPTOMS

Eye
Respons
e

Verbal
Respons
e

Spontaneous

to voice

to pain

none

Pt score: 10

Motor
Respons
e
Smiles, oriented
to sounds,
follows objects,
interacts
cries, but
consolable

moves
spontaneously

withdraws from
touch

withdraws to pain

inconsistently
inconsolable,
moaning

decorticate
posture

inconsolable.
agitated

decerebrate

none

MEDICAL TREATMENTS

Admit to PICU
Provide IV fluids @ 65 mL/hr
Zantac 25 mg q6h
Tylenol 450 mg q6h
Zofran 2 mg IV q6h
PT/OT/ST

ADMISSION LABORATORY VALUES

Laboratory Tests

Ref. Range

4/22 (day 1)

Interpretation

Glucose (mg/dL)

70-110

145

Stress response

Bilirubin total (mg/dL)

< 1.5

1.6

Hemolysis

Bilirubin direct
(mg/dL)

< 0.3

0.8

Hemolysis

Alkaline phosphatase
(U/L)

30-120

122

Trauma

Lactate (mmol/L)

< 1.00

2.1

Anaerobic metabolism associated

with decreased oxygenation of the
brain

Fibrinogen (mg/dL)

160-450

472

Blood coagulation

C-reactive protein
(mEq/L)

0.3-2.3

2.5

Acute inflammation

DAY 11 LABORATORY VALUES

Laboratory Tests

Ref. Range

5/2 (day 11)

Interpretation

Protein total (g/dL)

6-8

5.1

Protein catabolism

Albumin (g/dL)

3.5-5

2.8

Acute inflammation

Alkaline phosphatase
(U/L)

30-120

138

Trauma

Fibrinogen (mg/dL)

160-450

460

Blood coagulation

C-reactive protein
(mEq/L)

0.3-2.3

3.2

Acute inflammation

Hemoglobin (g/dL)

12-15 F

11.5

Blood loss

Hematocrit (%)

37-47 F

35

Blood loss

NUTRITION ASSESSMENT
Height: 52
Weight: 61 lbs.
BMI = 16 kg/m2
Height for Age: 75th percentile (normal)
Weight for Age: 75th percentile (normal)
BMI for Age: 50th percentile (normal)
Diet Hx: normal appetite and growth PTA

ESTIMATED ENERGY NEEDS

EER = 135.3 - 30.8 x Age + PA x (10 x kg + 934 x ht) + 20
EER = 135.3 - 30.8 x 8 + 1 x (10 x 27.7 kg + 934 x
1.3208) + 20
EER= 1,642 kcal/day
Institute of Medicine: Girls age 3-8 yrs for BMI 5-85th percentile

TEE = 1,642 kcal x 130-160%

TEE = 2,141-2,635 kcal/day

ESTIMATED PROTEIN & FLUID

NEEDS
Protein needs = 27.7 kg x 1.5-2.0 g/kg
Protein needs = 42-55 g/day
Fluid needs = 50-60 mL/kg
Fluid needs = 50-60 mL/kg x 27.7 kg
Fluid needs = 1,385-1,662 mL/day
Krause's Food & the Nutrition Care Process

CURRENT DIET ORDER

Pediasure 1.5 at a goal rate of
57 cc/hr.
Energy: 2052 kcal/d
Protein: 81 g/d
Fluid: 1949 mL/d

DAY 12 NUTRITIONAL STATUS

Rx EEN: (1539 kcal 2052 kca)l x 100 = 75%
needs met
Rx PRO: (61 g 81 g) x 100 = 75% needs met
Our EEN:(1539 kcal 2141 kcal) x 100 = 72%
needs met
Our PRO: (61 g 49 g) x 100 = 124% needs met

DAY 12 NUTRITIONAL STATUS

Unintentional weight loss is 16%
Weight for age decreased to the
25th percentile
BMI for age < the 5th percentile

NUTRITION DIAGNOSIS
Inadequate enteral nutrition infusion rate (NI-2.3)
related to infusion volume not reached or
schedule for infusion interrupted as evidenced by
unintentional weight loss of 16% in the past 12
days and BMI for age below 5th percentile.

ADIME NOTE
A: 8 y.o. female admitted for TBI from MVA.
Ht: 52, Wt: 61#, Wt for Age: 75th percentile, BMI for age: 50th percentile
EEN: 2141 kcal/d, PRO: 42-55 g/d, FLUID: 1500 mL/d
D: Inadequate enteral nutrition infusion rate (NI-2.3) related to infusion
volume not
reached or schedule for infusion interrupted as evidenced by
unintentional
weight loss of 16% in the past 12 days and BMI for age below 5th
percentile.
I: Stop unintended weight loss to promote normal growth and recover
nutritional
status. Achieve goal enteral nutrition continuous drip infusion rate of 60
mL/hr

TREATMENT PLAN DAY 12

Continue PT, OT, ST and current medical care
plan.
Failed speech/swallowing evaluation
Continue enteral feeding
PediaSure 1.5 goal rate 60 mL/hr + 73 mL water flushes
4x/d

Progress to soft mechanical diet when tolerated

REFERENCES
Brainline. What is the Glaslow Coma Scale? Brainline website.
http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma
-scale.html
. Published n.d. Accessed March 1, 2015.
Brain Injury Institute. Frontal Lobe Damage. Brain Injury Institute
website. http://
www.braininjuryinstitute.org/Brain-Injury-Types/Frontal-Lobe-Damag
e.html
. Published date n.d. Accessed March 1, 2015.
Mahan LK, Escott-Stump S, Raymond JL et al. Krause's Food & the
Nutrition Care Process. Elsevier Health Sciences; 2012.