Management of Pediatric Severe Traumatic Brain Injury
Recommendations
MONITORING
To Improve Overall Outcomes
Use of intracranial pressure (ICP) monitoring is suggested.
(Level III, C)Advanced Neuromonitoring
To Improve Overall Outcome
If brain tissue oxygenation (Pbro2) monitoring is used, maintaining a level greater than 10 mm Hg is suggested.
(Level III, C)THRESHOLDS
Thresholds for Treatment of Intracranial Hypertension
To Improve Overall Outcomes
Treatment of ICP targeting a threshold of less than 20 mm Hg is suggested.
(Level III, C)Thresholds for cerebral perfusion pressure (CPP)
To Improve Overall Outcomes
Treatment to maintain a CPP at a minimum of 40 mm Hg is suggested.
(Level III, C)A CPP target between 40 and 50 mm Hg is suggested to ensure that the minimum value of 40 mm Hg is not breached. There may be age-specific thresholds with infants at the lower end and adolescents at or above the upper end of this range.
(Level III, C)TREATMENTS
Hyperosmolar Therapy
For ICP Control
Bolus hypertonic saline (HTS) (3%) is recommended in patients with intracranial hypertension. Recommended effective doses for acute use range between 2 and 5 mL/kg over 10–20 minutes.
(Level II, C)For ICP Control
Continuous infusion HTS is suggested in patients with intracranial hypertension. Suggested effective doses as a continuous infusion of 3% saline range 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.
(Level III, C)Bolus of 23.4% HTS is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a maximum of 30 mL.
(Level III, C)Safety Recommendation (applies to all recommendations for this topic).
In the context of multiple ICP-related therapies, avoiding sustained (>72 hr) serum sodium greater than 170 mEq/L is suggested to avoid complications of thrombocytopenia and anemia, whereas avoiding a sustained serum sodium greater than 160 mEq/L is suggested to avoid the complication of deep vein thrombosis (DVT).
Analgesics, Sedatives, and NMB
For ICP Control
With use of multiple ICP-related therapies, as well as appropriate use of analgesia and sedation in routine ICU care, avoiding bolus administration of midazolam and/or fentanyl during ICP crises is suggested due to risks of cerebral hypoperfusion.
(Level III, C)Note 2. Based on guidance from the U.S. Food and Drug Administration, prolonged continuous infusion of propofol for either sedation or the management of refractory intracranial hypertension is not recommended.
Cerebrospinal Fluid (CSF) Drainage
For ICP Control
CSF drainage through an EVD is suggested to manage increased ICP.
(Level III, C)Seizure Prophylaxis
For Seizure Prevention (Clinical and Subclinical)
Prophylactic treatment is suggested to reduce the occurrence of early (within 7 d) PTSs.
(Level III, C)Ventilation Therapies
To Improve Overall Outcomes
Prophylactic severe hyperventilation to a Paco2 less than 30 mm Hg in the initial 48 hours after injury is not suggested.
(Level III, C)If hyperventilation is used in the management of refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischemia is suggested.
(Level III, C)Temperature Control/Hypothermia
To Improve Overall Outcomes
Prophylactic moderate (32–33°C) hypothermia is not recommended over normothermia to improve overall outcomes.
(Level II, B)For ICP Control
Moderate (32–33°C) hypothermia is suggested for ICP control.
(Level III, B)Safety Recommendation 2. If phenytoin is used during hypothermia, monitoring and dosing adjusted to minimize toxicity, especially during the rewarming period, are suggested.
BARBITURATES
For ICP Control
High-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management.
(Level III, C)Safety Recommendation. When high-dose barbiturate therapy is used to treat refractory intracranial hypertension, continuous arterial blood pressure monitoring and cardiovascular support to maintain adequate CPP are required because cardiorespiratory instability is common among patients treated with barbiturate coma.
Decompressive Craniectomy
For ICP Control
Decompressive craniectomy (DC) is suggested to treat neurologic deterioration, herniation, or intracranial hypertension refractory to medical management (MM).
(Level III, C)Nutrition
To Improve Overall Outcomes
Use of an immune-modulating diet is not recommended.
(Level II, C)To Improve Overall Outcomes
Initiation of early enteral nutritional support (within 72 hr from injury) is suggested to decrease mortality and improve outcomes.
(Level III, C)Corticosteroids
To Improve Overall Outcomes
The use of corticosteroids is not suggested to improve outcome or reduce ICP.
(Level III, C)Note: This recommendation is not intended to circumvent use of replacement corticosteroids for patients needing chronic steroid replacement therapy, those with adrenal suppression, and those with injury to the hypothalamic-pituitary steroid axis.
Recommendation Grading
Overview
Title
Management of Pediatric Severe Traumatic Brain Injury
Authoring Organization
Brain Trauma Foundation
Publication Month/Year
March 1, 2019
Last Updated Month/Year
June 13, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Child, Infant
Health Care Settings
Emergency care, Operating and recovery room, Outpatient
Intended Users
Paramedic emt, nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D000070642 - Brain Injuries, Traumatic
Keywords
critical care, concussion, traumatic brain injury
Source Citation
Kochanek, Patrick M. MD, MCCM1; Tasker, Robert C. MA, MD, FRCP2; Carney, Nancy PhD3; Totten, Annette M. PhD4; Adelson, P. David MD, FACS, FAAP, FAANS5; Selden, Nathan R. MD, PhD, FACS, FAAP6; Davis-O’Reilly, Cynthia BS7; Hart, Erica L. MST8; Bell, Michael J. MD9; Bratton, Susan L. MD, MPH, FAAP10; Grant, Gerald A. MD11; Kissoon, Niranjan MD, FRCP(C), FAAP, MCCM, FACPE12; Reuter-Rice, Karin E. PhD, CPNP-AC, FCCM, FAAN13; Vavilala, Monica S. MD14; Wainwright, Mark S. MD, PhD15 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Pediatric Critical Care Medicine: March 2019 - Volume 20 - Issue 3S - p S1-S82 doi: 10.1097/PCC.0000000000001735