Pediatric traumatic brain injury

Guidelines for the management of severe traumatic brain injury in infants, children, and adolescents.

The second edition of guidelines for acute medical management of Traumatic Brain Injury in infant, children and adolescent was published by Brain trauma foundation in 2012. Almost 8 years ago in 2003 the first edition of these guidelines was published.

Major changes are in Hyperosmolar therapy: Use of 3% saline in preference ("should be considered for treatment"). The targets of serum osmolarity with regards to mannitol therapy are discarded. Details about inducing moderate hypothermia are included. Etomidate to control severe intracranial hypertension and use of prophylactic phenytoin to reduce incidence of early post-traumatic seizures are also emphasized. 

These are the major excerpts from guidelines, in short. 

Icp monitoring	Level II  There are insufficient data to support a level II recommendation for this topic. Level III Use of intracranial pressure (ICP)monitoring may be considered in infants and children with severe traumatic braininjury (TBI)
Threshold for treating Intracranial hypertension	Level III Treatment of intracranial pressure (ICP) may be considered at a threshold of 20 mm Hg. Cerebral perfusion pressure threshold
Cerebral perfusion pressure threshold	Level III A minimum cerebral perfusion pressure (CPP) of 40 mm Hg may be considered in children with traumatic brain injury(TBI). A CPP threshold 40–50 mm Hg may be considered. There may be age-specific thresholds with infants at the lower end and adolescents at the upper end of this range.
Advanced neuromonitoring	Level III If brain oxygenation monitoring is used, maintenance of partial pressure of brain tissue oxygen (PbtO2) 10 mm Hg may be considered. Neuroimaging (repeat CT)
Neuroimaging (repeat CT)	Level III In the absence of neurologic deterioration or increasing intracranial pressure  (ICP), obtaining a routine repeat CT scan 24 hrs after  the admission and initial follow-up study may not be indicated for decisions about neurosurgical intervention.
Hyperosmolar therapy	Level II Hypertonic saline should be considered for the treatment of severe pediatric traumatic brain injury (TBI) associated with intracranial hypertension. Effective doses for acute use range between 6.5 and 10 mL/kg. Level III Hypertonic saline should be considered for the treatment of severe pediatric TBI associated with intracranial hypertension. 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 intracranial pressure (ICP) 20 mm Hg should be used. Serum osmolarity should be maintained 360 mOsm/L.
Temperature control	Level II Moderate hypothermia (32–33°C) beginning early after severe traumatic brain injury (TBI) for only 24 hrs’ duration should be avoided. Moderate hypothermia (32–33°C) beginning within 8 hrs after severe TBI for up to 48 hrs’ duration should be considered to reduce intracranial hypertension. If hypothermia is induced for any indication, rewarming at a rate of > 0.5°C/hr should be avoided. Level III Moderate hypothermia (32–33°C) beginning early after severe TBI for 48 hrs, duration may be considered.
CSF  drainage	Level III Cerebrospinal fluid (CSF) drainage through an external ventricular drain may be considered in the management of increased intracranial pressure (ICP) in children with severe traumatic brain injury (TBI). Level III    The addition of a lumbar drain may be considered in the case of refractory intracranial hypertension with a functioning external ventricular drain, open basal cisterns, and no evidence of a mass lesion or shift on imaging studies.
Use of Barbiturates.	Level III High-dose barbiturate therapy may be considered in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management. When high-dose barbiturate therapy is used to treat refractory intracranial hypertension, continuous arterial blood pressure monitoring and cardiovascular support to maintain adequate cerebral perfusion pressure are required.