The “Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents” were published on June 6 as special supplements to Pediatric Critical Care Medicine, Critical Care Medicine and the Journal of Trauma. I have copied for my readers some of the researcher’s suggestions.
Pediatric patients with traumatic brain injury should be treated in a pediatric trauma center or, failing that, a level I or II adult trauma center with pediatric trauma services. Transfers should be made as efficiently as possible — a previous treatment protocol for adult head traumas resulted in increased transfer times in one state.
Hypoxia must be treated appropriately; however, there is no evidence to support endotracheal intubation vs. bag-mask ventilation during transfer to the hospital.
The sensitivity of ventricular catheters, external gauge transducers, or catheter tip pressure transducers in monitoring intracranial pressure appears equal. Subarachnoid, subdural, epidural, and externally placed monitors are less accurate.
The routine use of sedation and neuromuscular blockade in severe pediatric traumatic brain injury is not supported by any scientific evidence.
Cerebrospinal fluid drainage via ventriculostomy is a first-line option for refractory elevated intracranial pressure.
Mannitol or hypertonic saline are both acceptable agents for lowering intracranial pressure.
Hyperventilation should only be used as a second-line method to reduce refractory intracranial pressure.
High-dose barbiturates may also be employed in the treatment of refractory increased intracranial pressure. Patients receiving this therapy require extremely close monitoring for hypotension.
Hyperthermia has been postulated to increase secondary mechanisms of brain injury in adults. Therefore, hyperthermia should be avoided in younger patients. Hypothermia, on the other hand, may be beneficial, and when intracranial hypertension is refractory, the authors recommend that it be considered, despite a lack of evidence.
Decompressive craniectomy also may be considered to improve refractory intracranial pressure. Surgical interventions may be more successful in patients with reversible brain insults.
There is no evidence to recommend steroid therapy in children with traumatic brain injury.
Although research has not directly addressed outcomes in pediatric patients with traumatic brain injury, nutritional support should be strongly considered with a goal of replacing 130%-160% of resting metabolism expenditure.