9.3 Pediatric Severe Traumatic Brain Injury (TBI Guidelines, CPP Optimization & Secondary Injury Prevention)

Pediatric Severe Traumatic Brain Injury

Clinical core. Stabilize oxygenation and circulation, document the neurologic exam before drugs obscure it, and identify lesions that need urgent neurosurgery. Brain Trauma Foundation (BTF) guidance for the PICU addresses severe pediatric TBI and uses a different set of treatment targets from prehospital shock screening.

Primary Injury and Secondary Injury

Primary injury occurs with the impact or acceleration. A contusion is bruised brain tissue at the impact site (coup) or opposite it (contrecoup). Rotational or acceleration forces may cause traumatic axonal injury at the gray–white junction, corpus callosum or brainstem. An early CT can underestimate this injury. If a stabilized child remains profoundly unresponsive with few explanatory CT findings, discuss MRI, including susceptibility-sensitive sequences for hemorrhagic shear lesions. MRI can also show nonhemorrhagic injury with other sequences.

In an infant, a subdural collection with extensive retinal hemorrhages or suspicious fractures raises concern for abusive head trauma. Evaluate the developmental history, reported mechanism, complete injury pattern and alternative causes with a multidisciplinary child protection team. The finding pattern alone cannot identify a specific mechanism. AAP technical report · ACR pediatric head trauma imaging criteria

Secondary injury evolves after the impact. Hypoxemia lowers arterial oxygen content, and hypotension or raised ICP can reduce cerebral blood flow. Ischemia limits ATP production. Failure of ion pumps promotes cellular swelling, and excess excitatory signaling can worsen calcium-mediated injury. Seizures and fever add metabolic demand. Early recognition and treatment of hypoxemia, hypotension, expanding hematoma and seizures reduces exposure to these insults. Pediatric cohort studies associate hypotension with worse outcomes and timely treatment with better outcomes. These studies cannot assign a fixed mortality multiplier to an individual episode. Pediatric resuscitation cohort

Assess Severity and Secure Oxygenation

Score eye, verbal and motor responses separately with the age-appropriate Glasgow Coma Scale (GCS). Eye opening ranges from spontaneous (4) to absent (1), with response to voice (3) or pressure (2) between them. Use a pediatric scale for preverbal responses, such as normal age-appropriate vocalization versus cry to pressure. Motor responses range from obeying commands or normal spontaneous movement in a young infant (6), to localizing (5), withdrawal (4), abnormal flexion (3), extension (2), and no response (1). Record confounders such as intubation, sedation, paralysis, shock and developmental baseline. Pediatric neurologic observations scale

A post-resuscitation GCS of 8 or less supports severe TBI and ordinarily warrants airway protection. Escalate earlier for loss of airway reflexes, failure of ventilation or oxygenation, or rapid neurologic decline. Preoxygenate, ventilate gently if necessary and restrict cervical motion. Prepare suction and rescue airway equipment. Correct shock while preparing the airway because induction and positive pressure can lower MAP. Pediatric ED protocols may use ketamine 1–2 mg/kg IV in a hemodynamically appropriate child and rocuronium 1.2 mg/kg IV. Adjust induction dosing for physiology and follow the local pathway. A pediatric severe-TBI observational study did not show an ICP rise after ketamine boluses given for sedation. It did not establish universal hemodynamic safety or compare induction strategies. Etomidate is another induction option for selected older children. The U.S. label gives 0.3 mg/kg IV as a usual individualized dose for patients older than 10 years and describes transient suppression of cortisol and aldosterone even after an induction dose. Routine fentanyl or lidocaine pretreatment is not required by BTF. After intubation, verify placement with continuous waveform capnography, compare with an arterial gas when available, maintain near-normal ventilation, and provide ongoing analgesia and sedation while paralysis persists. Pediatric ED RSI pathway · Pediatric emergency airway guidance · Pediatric ketamine study · Etomidate label

Maintain Perfusion and Identify Surgically Treatable Lesions

The PALS screening threshold for low systolic BP at ages 1–10 is $70 + (2 \times \text{age in years})$ mmHg. At age 6 this is 82 mmHg. The other screening cutoffs are below 60 mmHg for term neonates, below 70 mmHg for infants and below 90 mmHg above age 10. An SBP of 76 mmHg is already hypotensive even if the child later responds to resuscitation. Treat promptly. Evaluate hemorrhage, give blood early when hemorrhagic shock is likely, and titrate further support to measured perfusion. For suspected TBI, the separate 2023 BTF prehospital guideline favors targeting SBP at or above the age-specific 75th percentile. In the PICU, arterial pressure trends and, when available, measured ICP guide CPP-directed care. AHA PALS reference · BTF prehospital guideline

Obtain noncontrast head CT once resuscitation allows safe transport. A child with a new fixed pupil and a mass lesion needs immediate neurosurgical action. For a smaller epidural collection without a deficit, serial examination and imaging in a neurosurgical center can inform observation versus evacuation. The pediatric decision incorporates the child’s exam and trajectory as well as clot size, location and mass effect. A normal early CT (within six hours) does not rule out high ICP in a comatose child. BTF suggests ICP monitoring in severe pediatric TBI, treating to ICP below 20 mmHg, and maintaining a minimum CPP of 40 mmHg. A target of 40–50 mmHg is suggested, with infants toward the lower end and adolescents potentially at or above the upper end. After admission and initial follow-up, routine repeat CT beyond 24 hours solely for decisions about neurosurgical intervention is discouraged unless the exam worsens or ICP rises. If an invasive brain tissue oxygen monitor is used, BTF suggests a value above 10 mmHg, with insufficient evidence that placement improves outcomes. BTF pediatric severe TBI guideline · Pediatric epidural hematoma observation study

Seizures, Bleeding and Oxygen Delivery in the PICU

• Early seizures. BTF suggests prophylaxis to reduce clinical and electrographic seizures in the first seven days (Level III). A short prophylactic course through that window is typical when there are no seizures. Levetiracetam or phenytoin/fosphenytoin may be used according to the local pediatric pathway. BTF found insufficient evidence to favor levetiracetam over phenytoin on efficacy or toxicity. A documented seizure changes the question to treatment and follow-up. For unexplained depressed consciousness or suspected electrographic seizures, including when paralysis hides clinical activity, use continuous EEG when available. ACNS recommends at least 24 hours for most indications, with duration individualized to the clinical course and EEG. BTF · ACNS consensus
• Bleeding. Obtain platelet count, coagulation tests and fibrinogen. Viscoelastic testing, where available, can add information for component selection. Coordinate hemostatic resuscitation with hemorrhage control and the local trauma protocol. In a child with traumatic hemorrhagic shock, consider TXA within three hours under the local pediatric trauma protocol. Pediatric evidence is limited, and adult isolated head injury trial data do not establish routine TXA for isolated pediatric TBI. Pediatric trauma consensus · TIC-TOC pilot trial
• Anemia. In critically ill children with acute brain injury, TAXI allows consideration of red cell transfusion at hemoglobin 7–10 g/dL, accounting for bleeding, perfusion and clinical trajectory. It does not support using brain tissue oxygen alone to decide on transfusion. A trauma hemorrhage protocol addresses ongoing shock independently of this anemia decision. Pediatric TAXI consensus