clinical
Impact of care interventions on
children with severe traumatic
brain injury in intensive care
Lyvonne Tume is lecturer practitioner for paediatric ICU, Alder Hey Children’s Hospital and Liverpool John Moores University,
Eaton Rd, Liverpool L12 2AP UK. E-mail: Lyvonne.tume@rlc.nhs.uk
T
raumatic brain injury (TBI) continues to be a leading
cause of death and disability in children. In a UK
epidemiological study, TBI in children (1–14 years),
leading to intensive care admission occurred in 5.6 per
100 000 population (Parslow et al, 2005). The primary
aim of intensive care management of severe TBI is the
minimization of secondary injury of cerebral oedema and
worsening cerebral ischaemia (Reilly and Bullock,
2005:294; Chambers et al, 2006). The intensive care nurse
must recognize and minimize these secondary injury
processes, as well as reduce and stabilize intracranial
pressure (ICP) and cerebral perfusion pressure (CPP),
which can significantly affect the child’s outcome. This
often presents a dilemma for the nurse, who, just by
performing essential nursing interventions or giving care
to the child may produce significant physiological
instability. The purpose of this article is to provide an
updated review of the literature in relation to the
physiological effects of essential nursing interventions or
care (e.g. endotracheal suctioning, turning or any hygiene
interventions) in children with severe TBI in the intensive
care unit.
Background
The paediatric intensive care management of children
with TBI has become more aggressive and goal directed,
focusing on maintaining high CPP and avoiding hypoxia,
with the increasing use of invasive ICP monitoring in
children (Keenan and Bratton, 2006). There is increasing
evidence to suggest that this goal-directed therapy, with
the avoidance of hypotension in particular, has a positive
effect on patient outcome (Kokoska et al, 1998; Adelson
et al, 2003; Frampton et al, 2004). Recent research (Carter
et al, 2008) has further added to the knowledge that per-
sistent raised ICP relates to poor patient outcomes in
children.
Nursing interventions and care are essential activities
carried out to reduce morbidity associated with critical
illness. These activities, which include regular turning to
prevent pressure ulcer development and endotracheal suc-
tioning to prevent secretion retention, atelectasis and an
occluded endotracheal tube, promote recovery from criti-
cal illness and minimize the effects of invasive medical
therapies. However, the physiological effects of these
interventions have been shown to produce some adverse
British Journal of Neuroscience Nursing
effects in this patient group, such as, intracranial hyper-
tension, reduced cerebral perfusion pressure, hypoxaemia
and bradycardia (Mitchell et al, 1981; Fisher et al, 1982;
Parsons and Shogan, 1984; Parsons and Wilson, 1984;
Parsons et al, 1985; Garradd and Bullock, 1986; Lee,
1989; Ersson et al, 1990; Campbell, 1991; Rudy et al,
1991; Crosby and Parsons, 1992; Paratz and Burns, 1993;
Jones, 1995; Brucia and Rudy, 1996; Kerr et al, 1998;
Gemma et al, 2002). The performance of any interven-
tions needs to be considered in light of the child’s stabil-
ity, but these activities are essential, and the intensive care
nurse must decide the best method, the appropriate tim-
ing, and how to best minimize the adverse effects.
Literature search strategy
An initial search was undertaken in October 2005, and
updated in May 2006, January 2007 and January 2008, to
answer the following clinical question:
■ In children with severe head injury in intensive care,
what are the effects of essential intensive care nursing
interventions (e.g. endotracheal suction, turning and
hygiene interventions) on intracranial and cerebral
perfusion pressure?
A number of databases—Cochrane Library, MedLine
(1966-current), CINAHL (1982-current), PubMed,
Proquest and Science Direct—were searched using the
following keywords/terms: pediatric head injury (US),
Abstract
Paediatric intensive care nurses managing children with severe traumatic
brain injury often face the dilemma of performing essential nursing
interventions in children with unstable physiology. Although these
interventions are essential, they can produce considerable physiological
instability to the child’s cerebrovascular parameters. This article provides an
updated review of the literature in relation to the physiological effects of
essential nursing interventions and cares in children with severe traumatic
brain injury in the intensive care unit. It also highlights implications for
practice and gives recommendations for future research.
Key words
n Nursing: management n Intensive care n Brain injuries n Paediatric nursing
Accepted for publication following double-blind peer review 4 March 2008.
April 2008 Vol 4 No 4 151
clinical
paediatric head injury (UK), or traumatic brain injury, or
brain injury and intensive care, to identify the appropriate
patient group. Additionally, the following keywords were
searched: suctioning, endotracheal suctioning, respiratory
physiotherapy, nursing activities, nursing cares, nursing
interventions, turning, moving, repositioning, log-rolling,
washing, hygiene interventions, eye care, and mouth care
(as the interventions) and intracranial pressure or cerebral
perfusion pressure (as the outcome measure).
Reference lists from key articles were followed up, and
the UK National Research Register was searched for com-
pleted but unpublished research with key terms: head
injuries, intracranial pressure, nursing cares and intensive
care. The search was limited to published articles (not
abstracts) as full details of the study could not be
reviewed. Non-UK PhD theses were excluded as they
could not be obtained and only English-language articles
were included (as no translation was possible). The author
reviewed all the papers using a critiquing framework as
described by Parahoo (1997:360) and the QUOROM
method of reviewing literature for meta-analyses (Moher
et al, 1999).
The search results yielded 28 articles, but as only arti-
cles which met the following criteria were included, this
review is based on 18 articles:
■ Experimental, quasi-experimental or observational
research designs, where one of the nursing interventions
(previously cited) was analysed as the main aim or part
of the aim of the study. Respiratory physiotherapy was
included as this also related to the suctioning
procedure
■ The research was in children or adults (not pre-term
infants) with head injury or raised ICP. Adult papers
were included because the number of purely paediatric
papers was limited, and because older children (in the
author’s experience, most paediatric head injuries are
not infants) are physiologically more like adults than
neonates
■ The study was in mechanically ventilated intensive
care patients.
The exclusion criteria were:
■ Descriptive and case study designs with no inferential
data analysis
■ Articles older than 1980, as neurological monitoring
was very limited, and the intensive care management
was markedly different from current practice.
The effects of repositioning, moving
or turning
There are five research papers on this topic and only two
involve children. Three of the five studies demonstrated
significant ICP rises with repositioning (Parsons and
Wilson, 1984; Lee, 1989; Jones, 1995), but the study
involving 13 children (Hobdell et al, 1989) and another in
adults (Muwaswes, 1984) found no significant change in
ICP with turning or changing head position. By 5 minutes
post-intervention Jones (1995) found that ICP was still
elevated from baseline in 50% of these adults, however
152 British Journal of Neuroscience Nursing
Parsons and Wilson (1984), found that this rise in ICP was
transient and showed recovery towards baseline by 1 and
5 minutes. Muwaswes (1984) found that recovery times
varied from patient to patient but were related to the
degree of initial increase in ICP.
Evidence on this topic is inconclusive, and it is surpris-
ing that Hobdell et al (1989) produced contradictory
results in the paediatric sample. However, this study had
significant limitations, using children with varying pathol-
ogies requiring ICP monitoring and different ICP meas-
urement devices.
Effects of ‘planned rest periods’
between nursing interventions
Normal practice in unstable critically ill children is ‘a
minimal handling’ approach, where all nursing cares are
clustered together at one time and then the child is left
for up to eight hours (without being handled). However,
there has been some suggestion that this method of care
delivery may not be the most appropriate in severe head
injured children, as this ‘care cluster’ can produce more
sustained and persistent raised ICP than ‘spacing out’ the
cares over a longer period (Yanko and Mitcho, 2001).
There have only been two studies on this topic, neither
able to demonstrate any significance with planned rest
periods. Bruya (1981) found no difference between
groups in a randomized controlled trial in 20 adult inten-
sive care patients with ICP monitoring in situ. The con-
trol group received no planned rest periods, with the
treatment group having 10-minute rest periods between
interventions. The researcher acknowledged that 10-
minute rest intervals were too short and that the sample
size was small.
Hugo (1987) found similar results in her experimental
study of 23 head-injured patients (both adults and chil-
dren) and found no statistical difference between having
and not having planned rest periods. The treatment group
had a 30-minute rest period before each intervention,
compared to normal ward routine (the control) of
10–20 minutes. The author acknowledged that the study
was underpowered, and it was possible that rest period
length may not have been sufficiently different between
the two groups. It was also noted that there was no statis-
tical significance between baseline ICP and recovery time.
Mitchell et al (1981) in their study on positioning noted
that there was a cumulative increase in ICP in activities
that were spaced 15 minutes apart, but no cumulative
effect was seen when activities were spaced one hour
apart, suggesting that in both of these studies rest periods
were too short.
Effects of hygiene interventions
Only one study has specifically examined this. Parsons et
al (1985) studied the effect of various hygiene interven-
tions (oral hygiene, body hygiene and urinary catheter
care) on cerebrovascular parameters of 19 severe closed-
head injured adults. It was found that all three interven-
tions produced significant mean increases in all physio-
April 2008 Vol 4 No 4

logical parameters (P<0.005) when compared to baseline.
However, all these elevations retuned to baseline within
1 minute after intervention. It was concluded that hygiene
interventions can be safely performed in this group of
patients.
Effects of endotracheal suctioning
There has been more research on endotracheal suctioning
(Figure 1) than other aspects of care covered in the
review. There are six adult research papers, one mixed
a d u l t /
paediatric paper and one specific study in paediatrics.
Fisher et al (1982), in an experimental study involving
nine children (9 months–12 years) with raised ICP, found
that ICP rose by an average of 5mmHg during
endotracheal suctioning (ETS) compared to a non-ETS
period, with no change in CPP. He found two thirds of the
children coughed during ETS (despite neuromuscular
blockade), but their ICP rises remained similar to non-
coughing children.
In the studies that specifically examined ETS and man-
ual hyperinflation in head injured patients (Parsons and
Shogan, 1984; Campbell, 1991; Rudy et al, 1991; Crosby
and Parsons, 1992; Kerr et al, 1998; Gemma et al, 2002),
all demonstrated that ETS produced statistically signifi-
cant elevations in ICP compared to baseline. Earlier
Figure 1. A nurse undertaking endotracheal suctioning.
British Journal of Neuroscience Nursing April 2008
clinical
researchers (Campbell, 1991; Rudy et al, 1991; Crosby
and Parsons, 1992) describe a classic ‘stair step’ pattern in
response to ETS and manual hyperinflation which increas-
es with successive treatments. However, Brucia and Rudy
(1996) noted that even suction catheter insertion alone
(without the application of negative pressure) significantly
increased ICP and CPP in severely brain injured adults.
The suctioning component of the procedure exacerbated
the ICP rise.
In terms of recovery time from ETS, there are contrast-
ing results. Parsons and Shogan (1984) found no signifi-
cant ICP changes at 1 minute post-ETS compared to
baseline. This is contradicted by Rudy et al (1991), how-
ever, who found that 76% of patients had not regained
their baseline ICP values by 1 minute, 42% had not by
5 minutes, and 25% had not by 9 minutes. Kerr et al
(1998) also found prolonged recovery times in 20% of
patients who had not recovered their baseline ICP by
15 minutes post-ETS.
Crosby and Parsons (1992) also found that patients with
higher baseline ICPs (>7.1–9.3 mmHg) had higher ICPs
in the recovery phase. In contrast to Fisher et al’s (1982)
early study in children, Gemma et al (2002) in a study of
17 head injured adults (with baseline ICPs 15–20 mmHg)
noted that six patients (in 20 episodes) coughed or moved
during ETS. Their ICP rise was more pronounced than in
ALISON TOWNLEY
Vol 4 No 4 153
clinical
patients who were more sedated and did not cough.
Similarly Kerr et al (1998), in a large experimental study
of 71 head injured adults comparing different drug
treatments with ETS, found that patients treated with no
sedative drugs displayed the classic ‘stair step’ ICP
increase pattern with ETS. Those treated with opiates and
neuromuscular blockade showed a flat response to ETS,
with little change in ICP, demonstrating the effectiveness
of levels of sedation and paralysis on patient’s response
to ETS.
In terms of changes to CPP, most studies (Rudy et al,
1991; Crosby and Parsons, 1992; Brucia and Rudy,
1996; Gemma et al, 2002) report some significant peak
CPP changes with ETS; however, these are mixed, with
both reductions and increases in CPP in the same sam-
ple. CPP either reduced as a result of increased ICP or
increased as a result of increased mean arterial pressure
(or a balance between the two variables). This appeared
to relate to whether patients were able to generate an
increase in mean arterial pressure in response to ETS.
None of these studies report patients on inotropic sup-
port. Most studies (Rudy et al, 1991; Crosby and
Parsons, 1992; Brucia and Rudy, 1996; Gemma et al,
2002) report that CPP values recovered rapidly, with
virtually all recovered by 5 minutes.
The studies examining the effect of respiratory physio-
therapy on ICP (Garradd and Bullock, 1986; Ersson et al,
1990; Paratz and Burns, 1993) found that a full treatment
produced a significant increase in ICP, but Garradd and
Bullock (1986) found that in chemically paralysed
patients, this was considerably less, until near the end of
the treatment (lasting 17 minutes), by which time the ICP
rise was the same as the non-paralysed patients.
Discussion
This review demonstrates that the evidence remains
inconclusive in relation to the effects of many essential
nursing care interventions in head injured patients, and
especially in children, as the paediatric data is extremely
limited. There are contradictory results in many of the
studies with regard to recovery time after interventions
and even whether there are significant changes in the
cerebrovascular parameters. Neither Hugo (1987) nor
Bruya (1981) could demonstrate any difference in their
Key Points
■ Essential nursing cares, although important in optimizing patient care
and preventing complications associated with critical illness, may
cause physiological instability in severe head injured patients
■ Little evidence exists on the effect of these essential cares on children
in intensive care
■ The paediatric intensive care nurse needs further good quality
evidence to assist in delivering best practice to this group of
vulnerable children
154 British Journal of Neuroscience Nursing
examinations of the effect of manipulating the time
between intervention activities. Some of this incon-
clusiveness in the literature may be the result of the weak-
nesses in many of these studies in terms of:
■ Inconsistent ICP device measurement (which has been
shown to affect the primary outcome measure ICP)
■ Mixed sample of intracranial pathology
■ Mixed adults and children in the groups
■ Very small sample sizes
■ Weak research design
■ Lack of account or acknowledgement of known
confounding variables affecting ICP (the effect of
sedation level, neuromuscular blockade or the use of
barbiturates) or CPP (the effect of inotropes to
augment this)
■ The baseline ICP of the samples does not reflect the
current reality of children in paediatric intensive care
after a traumatic brain injury.
Some samples of patients with raised ICP (not all were
head injuries) were severely ill (with high baseline ICP)
and others not, which will have an effect on the patient’s
response and also on medical therapies. Without this, data
presented or accounted for in the results, makes compara-
bility or validity of the results difficult to interpret. It is
apparent that there is a need to control for the above vari-
ables and study the effect of nursing interventions sepa-
rately on the ICP and CPP, specifically in children after
traumatic brain injury.
Implications for nursing practice
The lack of strong paediatric evidence on which to guide
nursing practice has resulted in huge variations in paedi-
atric intensive care nursing practice nationally (Tume,
2007) and has made nursing practice in this area reliant
largely on intuition rather than evidence. The develop-
ment of some evidence-based nursing guidelines for pae-
diatric TBI management are possible, but only with weak
Class 2 and some Class 3 evidence (Adelson et al, 2003).
There is currently insufficient evidence to help the inten-
sive care nurse solve the dilemma about how and when to
perform these essential nursing cares in severe head
injured children, to produce minimal physiological insta-
bility. The only conclusion that can be drawn from the
literature, so far, is that endotracheal suctioning does pro-
duce considerable adverse effects in this patient group and
so should only be undertaken as clinically required.
Conclusions
The literature suggests that some essential nursing care
interventions do affect the physiological stability of chil-
dren with severe traumatic brain injury in intensive care.
However, the degree to which this occurs remains unclear,
as does which care interventions produce the most adverse
effects. Children with severe TBI (despite being frequent-
ly older children) are still not ‘little adults’ and they
should not be analysed as part of an adult sample. More
good quality, observational research is urgently needed,
specifically in children with severe TBI. This will pave
April 2008 Vol 4 No 4

the way for future experimental studies, which can ulti-
mately generate Class 1 evidence. This will then provide
the basis for the development of strong evidence-based
guidelines for practice. Currently, much of paediatric
intensive care nursing practice in the field of TBI is based
on intuition, rather than evidence, and this can only be
addressed through further research.
Acknowledgment: Figure 1 is reproduced with kind permission of
Alison Townley.
Conflict of interest: None declared.
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