Pediatric Severe Traumatic Brain Injury Guidelines

These updated guidelines on brain trauma in infants, children and adolescents help in determining our approach to brain trauma. The article does note that while progress has been made, overall the level of evidence informing these guidelines remains low. There is a need for quality randomized trials. With that in mind, the guidelines and evidence level include:

Use of ICP monitoring suggested (III)

If brain tissue oxygenation (PbrO2) used, keep > 10 mm Hg (III)

Excluding elevated ICP from a normal initial (0–6 hr after injury) CT examination of the brain is not suggested in comatose pediatric patients (III)

Routine repeat CT scan after 24 hours is not suggested for decisions about neurosurgical intervention, unless there is either evidence of neurologic deterioration or increasing ICP (III)

ICP target < 20 mm Hg suggested (III)

CPP minimum target 40 mm Hg (40-50 suggested) (III)

Bolus Hypertonic Saline (HTS) (3%) is recommended for intracranial hypertension. Recommended 2 to 5 mL/kg over 10–20 minutes (II)

Continuous infusion HTS is suggested in patients with intracranial hypertension. Suggested 3% saline between 0.1 and 1.0 mL/kg of body weight per hour, administered on a sliding scale. The minimum dose needed to maintain ICP less than 20 mm Hg is suggested (III)

Bolus of 23.4% HTS is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a maximum of 30 mL (III)

Avoid bolus administration of midazolam and/or fentanyl during ICP crises due to risks of cerebral hypoperfusion (III)

Prophylactic seizure treatment is suggested to reduce the occurrence of early (within 7 d) seizures (III)

Hyperventilation to a PaCO2 less than 30 mm Hg in the initial 48 hours not recommended. If used for refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischemia is suggested (III)

Prophylactic moderate (32–33°C) hypothermia is not recommended over normothermia (II)

Moderate (32–33°C) hypothermia is suggested for ICP control, with slow rewarding 0.5-1° per 12 – 24 h (III)

High-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management (III)

Decompressive craniectomy (DC) is suggested to treat refractory neurologic deterioration, herniation, or intracranial hypertension (III)

Decompressive craniectomy is suggested to treat refractory neurologic deterioration, herniation, or refractory intracranial hypertension (III)

Use of an immune-modulating diet is not recommended (II)

Initiation of early enteral nutritional support (within 72 hr from injury) is suggested (III)

The use of corticosteroids is not suggested to improve outcome or reduce ICP (III)

Full evidence link

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