Pediatric Traumatic Brain Injury Guidelines
This effort represents the third edition of guidelines for management of pediatric severe traumatic brain injury from the Brain Trauma Foundation. Forty-eight studies are included that were not in the second edition (2012), though the level of evidence for most remains low. There are no Level I recommendations, and 3 Level II recommendations. Nine of the recommendations are new or significantly revised from the previous edition: Follow up CT scan is not recommended to rule out elevated intracranial pressure (ICP) in patients who have had previous normal scans. Bolus dosing of hypertonic saline (either 3% or 23.4%) is recommended for ICP control (Level 2 for 3% saline). Bolus infusions of midazolam or fentanyl are not recommended as part of multiple ICP-related therapies, as they increase the risk of cerebral hypoperfusion. Early seizure prophylaxis is recommended (in the first 7 days after TBI). Hypothermia (32-33 degrees C) is not recommended to control ICP (Level 2), but it is noted to be a suggestion. Enteral nutrition within 73 hours is recommended. Corticosteroid use as an agent to control elevated ICP is not recommended.
Along with these guidelines is a separate algorithm to provide guidance for clinicians caring for these patients. In the algorithm, steps that are evidence-based are clearly noted, while other components are based on consensus of expert opinion.