Traumatic Brain Injury, Paediatrics (012)

Objectives

• To provide a consistent approach to TBI within PICU

• To minimise the incidence of secondary brain injury within PICU

Scope

This guideline is intended for all healthcare professionals caring for traumatic brain injury patients within the Paediatric Intensive Care Unit at the Royal Hospital for Children, Glasgow.

Audience

All medical, nursing and allied professionals caring for patients who have traumatic brain injury should be familiar with the protocol.

NOTE: extradural haematomas can be an imminently life-threatening neurosurgical emergency. They require immediate neurosurgical referral for possible emergency surgery. The following guidelines do not apply to extradural haematomas.

Introduction

Traumatic Brain injury (TBI) is a major source of mortality amongst older children. Public health measures have had the biggest impact on reduction in mortality and morbidity in recent years (safety helmets, seatbelts, speed reduction). 

The intensive care management of these injuries focuses on preventing secondary injury and being alert to a surgically remediable event. This includes mitigating clinical factors that may increase brain injury. There is good evidence that it is beneficial to avoid hypotension; hypoxaemia; hyperthermia; and hyperglycaemia. While evidence for benefit in lowering of ICP is more limited, raised ICP and brain swelling are known to be harmful. Therefore, in some patients with TBI (particularly those with GCS<8 and an abnormal CT) a direct monitor for ICP may be placed.

Maintaining the cerebral perfusion pressure (CPP) is also thought to be beneficial, although detailed discussion is beyond the scope of this guideline.

CPP = MAP - ICP

This formula is only accurate when both the ICP and MAP are directly measured. See below for age-related values. Some patients may benefit from a strategy primarily focused on reducing ICP, whereas others may benefit from a strategy focused on maintaining CPP, depending on autoregulatory status.

Preventing secondary brain injury starts with good basic intensive care and attention to detail - sedate and minimise oxygen demand, employ minimal handling to prevent surges in ICP, oxygenate well, maintain blood pressure (therefore keeping CPP adequate), treat pyrexia, and avoid hypoglycaemia.

Hyperventilation with the aim of achieving a low pCO2 reduces ICP, but achieves this via cerebral vasoconstriction and therefore may cause cerebral ischaemia. A more conservative approach is now taken aiming for a low-normal pCO2 (4.5-5 kPa), and only resorting to hyperventilation in emergencies, such as impending cerebral herniation, or as a bridge to imminent surgery. Judicious use of inotropes to maintain and support CPP is important. There is some evidence that noradrenaline is superior to dopamine. However, it is more important to maintain CPP than differentiate between agents.

If the above basic management fails, other steps may be taken to control ICP. Hypertonic saline and mannitol (osmotic diuretics) are both highly effective at reducing ICP quickly, with hypertonic saline now being the first choice and the only advice within this guideline for reducing ICP that is supported by level 2 evidence.

If the ICP is difficult to control, an external ventricular drain (EVD) can be placed by the neurosurgeons in selected cases.. If an EVD is present then one response to raised ICP is to drain 5-10mL of CSF and allow the ICP to normalise. (See EVD guideline).

The evidence for all subsequent therapeutic measures to reduce ICP and prevent secondary brain injury is patchy at best. There was great hope on the basis of animal, neonatal and adult data that therapeutic hypothermia may minimise secondary brain injury. Cooling appears to improve survival and function in both neonatal encephalopathy and post-cardiac arrest in adults. However randomised controlled trial (RCT) evidence in paediatrics to date has found no benefit to routine prophylactic cooling in patients with traumatic brain injury. Moderate cooling (32-34oC) as a secondary intervention can be considered if ICP remains problematic after osmotic diuretics are given. If actively cooling, paralysis should be commenced to prevent shivering which increases ICP and oxygen demand.

Thiopental coma is an advanced treatment when ICP is refractory to treatment, but needs to be considered and undertaken carefully. Thiopental infusion will lead to a fall in blood pressure and measures must be in place to avoid this (eg. noradrenaline). CFAM monitoring or EEG should be used in conjunction with thiopental coma aiming for a reduction in ICP primarily or burst suppression. Thiopental is a particularly toxic substance which has a long half-life. An irritating side-effect of thiopental is that it may induce fixed dilated pupils. This removes one of the key areas of brain function assessment when paralysed and sedated. Brain stem testing cannot be performed until thiopental levels have fallen. A Cochrane Review concluded that barbiturate therapy did not improve outcome in head injury.

Decompressive craniectomy is a surgical treatment which literally allows the rigid box of the skull to be opened. This allows room for the brain to swell and therefore reduces ICP. Evidence from the RESCUEicp trial (exclusive of children) shows a small mortality benefit, but at the cost of an increase in severely disabled survivors (including outcomes such as persistent vegetative state) However, children may well have better potential for neurological recovery after craniectomy than adults. Decompressive craniectomy may have a place in well- selected cases. ICP dose burden (ie longer periods of time with high ICP) is harmful, and so there is some expert opinion that outcomes may be improved if decompressive craniectomy is performed early.

Intensive Care - Standard Operating Procedure (SOP) General PICU Management

The general aims of PICU management of children with severe head injuries are to meticulously maintain adequate oxygenation of the arterial blood, achieve a blood pressure that will perfuse the brain and an intracranial pressure of less than 20mmHg. It is also necessary to bear in mind continually the possibility of the development of an intracranial lesion that may require surgery.

1. General Measures

  • Elevate head of bed to 30o. *if no whole spine precautions; patients with cervical spine precautions only may still be placed head-up; seek advice from neurosurgery
  • Head kept midline & in the neutral position (neither flexed or extended).
  • Cervical collar not impeding cerebral venous return.
  • Place gastric tube; this may need to be orogastric if there is an anterior basal skull fracture; seek advice from neurosurgery
  • Meticulous attention to pressure areas. (A pressure-relieving mattress must not be used in any patient in which there are concerns regarding spinal injury).
  • Adequate drainage of urine (increased intra-abdominal pressure will ↑ ICP).
  • Cooling blanket in place if need is anticipated.

2. Airway, Breathing with C-spine control

Consider the possibility of cervical spine injury

Oral ETT placed. (Avoid nasal route as may have basal skull fracture). The aim of ventilation is to maintain adequate oxygenation with low normocapnia.

PaO2 >10 -13kPa PaCO2 4.5- 5 kPa

This should be achieved at the lowest possible PIP and PEEP (<5mmHg). 

Some literature suggest there may be a place for Pressure Regulated Volume Controlled Mode of ventilation (ie SIMV Autoflow, rather than BIPAP). Continuous measurement of end-tidal pCO2 and reaction to changes is more important than mode of ventilation.

Arterial gases should be performed at least 4-6 hourly in the first few days of admission. A change in end-tidal pCO2 or rise in ICP should result in a repeat gas.

Endotracheal suctioning (ETS) may produce significant (usually transient) rises in ICP. It remains necessary, but should be minimised and sedation boluses, such as of fentanyl, should be considered pre-suction. See Child BNF for dosing.

C-spine – ensure correct collar placement and careful moving and handling as per APLS guidelines. Log-roll –no straight lifting. Seek advice from neurosurgery about spinal precautions. See separate moving and handling guideline.

3. Circulation

Hypotension should be considered an emergency

If adequate filling alone fails to produce an adequate blood pressure then judicious use of inotropic support will be necessary. Consider noradrenaline / vasopressin / adrenaline to titrate to BP. Arterial and central venous catheters will generally be placed to allow continual monitoring of arterial and CVP. Transducers will be levelled to the right atrium. Femoral lines are preferred in view of less disruption to cerebral venous return. Aim for a CVP 6-10mmHg.

Fluids: 0.9% sodium chloride (75-100% calculated maintenance). Glucose should be withheld from the IV solution if the serum glucose is above 10 mmol/l. When serum glucose reaches the normal range the IV solution should be changed to glucose 5%/ sodium chloride 0.9%.

Glucose: if low blood sugar is found treat quickly and ensure followed up carefully. For blood sugar ≤3.0, Give 2ml/kg of 10% glucose and repeat sugar at 30 mins and 1 hour minimum. If blood sugar falls to 3.0-4.0 recheck regularly (1 hourly) to ensure it does not drop below 3.0. If hypoglycaemia occurs when on IV fluids containing 5% glucose, or borderline (3.0-4.0) hypoglycaemia persists, change IV fluids to 10% glucose/0.9% sodium chloride.

Electrolytes: Hyponatraemia may produce further brain swelling in this context. particularly if syndrome of inappropriate ADH (SIADH) occurs, therefore target:

[Na] at >140mmol/l and a serum osmolality of >280mOsm

Cerebral perfusion pressure: maintaining an optimal Cerebral Perfusion Pressure (CPP) is recommended, as well as controlling the ICP.

CPP = MAP – ICP

Age

Treatment Threshold for ICP

Target CPP values

<2 years

>20mmHg

>45mmHg

2-6 years

>20mmHg

>55mmHg

7-12 years

>20mmHg

>60mmHg

>12 years

>20mmHg

>65mmHg

Agree target ICP and CPP for intervention for each individual patient with intensivist and neurosurgeon.

4. Disability

Neuro-observations must be performed regularly – every 30 minutes if an ICP monitor is not in-situ. 2 hourly if ICP monitor in place. Any changes should be alerted to a doctor.

ICP monitoring – If present be alert to changes. See separate ICP monitoring guideline.

If elevation of ICP is >20mmHg for >5min then move on to CONTROL ICP ALGORITHM

Analgesia and Sedation

Patients should receive an infusion of narcotic (morphine or fentanyl) and midazolam. Inadequate sedation should be a first consideration for raised ICP. Once adequately sedated, a muscle relaxant may be added as required as a bolus or as an infusion, to prevent coughing on suction. If cooled, paralysis should be delivered as a continuous infusion to prevent shivering and its associated metabolic demands.

NB. If using propofol in older children do not exceed >48 hours to minimise risk of propofol infusion syndrome.

Seizures

Patients have a high risk of seizures which can be difficult to recognise in a sedated +/- paralysed child. Seizures increase ICP substantially, therefore a prophylactic approach has been adopted. Regular levetiracetam (typically 20mg/kg BD dosing is recommended by the neurology team) or phenytoin should be considered in all patients and continued for the first 7 days as a minimum.

When seizures do occur, treat as per status epilepticus guidelines, with benzodiazepine bolus as first line treatment. Seek Neurosurgical and neurology advice early. CFAM monitoring may be required to monitor brain activity.

5. Temperature Management

  • Core (rectal or bladder) temperature should be monitored continually in these children. The aim should be to maintain a temperature of 36.5 -37°C using paracetamol and cooling blanket if necessary.
  • If the child is therapeutically cooled for raised ICP then they must NOT be allowed to shiver. Continuous paralysis should be commenced.
  • Where possible place a second cooling blanket on top of the patient.
  • If the temperature is slow to fall consider use of cold packs, take care to monitor for cold injury, rotate frequently.
  • Be vigilant against pressure areas on cooling blankets.
  • Once target temperature reached remove 2nd blanket and ice packs.
  • If on phenytoin during hypothermia, monitor drug levels regularly during the hypothermic period and the re-warming period to minimise toxicity.

When re-warming after hypothermia:

  • Rewarm slowly, by 0.5oC-1oC every 12-24 hours by setting the blanket temp up 0.5 OC every 12 hours.
  • Be vigilant that the patient does not re-warm faster.

6. Nutrition

  • Enteral feeding should be considered early and should follow standard nutrition guidelines. Starting enteral feed within 72 hours may improve outcomes.
  • Gastric protection if nil by mouth with Omeprazole
  • Regular laxatives/aperients are started early to avoid straining. 

7. Other

Eye Care

  • Standard eye care treatment, see separate Eye care in PICU guideline.
  • If paralysed ensure eyes are well lubricated and closed over.
  • Beware ophthalmic assessment: long-acting dilating agents are contraindicated as these mask pupillary response and render us unable to evaluate brain injury

Nursing Care

  • Handling and suctioning should be performed separately. Ensuring adequate time has passed to allow ICP to settle. Both procedures are the highest risk of increased ICP, *consider extra sedation before suctioning or handling.
  • Plan carefully – required to do 12 hourly log rolls ensure enough staff and done as quickly as possible
  • Plan carefully – ETT suction as clinically indicated, required 2 person procedure. Ensure ET patency especially of patient is paralysed and sedated. Again do as quickly as possible and give extra sedation before procedure.
  • Skin care/wash at least 12 hourly and ensure under neck collar to prevent maintain skin hygiene and prevent sores.
  • Mouth care, see separate Oral hygiene for the highly dependent or critically ill infant or child
  • Meticulous regular catheter care
  • Reposition probed 4 hourly or more frequent to ensure skin integrity
  • Pressure relief aids where possible – seek physio and tissue viability advice if needed

N.B no nasal suctioning in case of basal skull fracture.

Infection and Sepsis

  • Blood, urine and BBAL cultures if pyrexial. N.B: BBAL – same care as suctioning – eg sedation bolus pre-procedure.
  • If EVD in situ monitor CSF for signs of infection – consult Medical and Neurosurgical Teams if any changes to CSF and patient, see separate – See separate EVD guideline. 

Laboratory Tests

  • Morning bloods: Daily U &E’s, FBC, clotting including serum osmolality.
  • 8 hourly U&E’s in first 3 days or if remains unstable.
  • Art gases- 4-6 hourly
  • If the child becomes polyuric consider diabetes insipidus– if urine output >5ml/kg/hr for >3 hours record specific gravity, send U&E’s and paired blood and urine for osmolality- See separate Diabetes Insipidus guideline

Haemoglobin top-up threshold

  • Maintain a minimum haemoglobin of 8g/dL.

DVT prophylaxis

  • Consider use of Low molecular weight heparin (enoxaparin) – discuss with neurosurgeon.

Steroids

  • Routine corticosteroids are contraindicated as they do not improve outcome, and there is evidence of harm.
  • However, if indicated for other reasons (eg concerns about Addison’s or required for refractory hypotension etc) then they can be used.

Neck Immobilisation

In the case of a patient who has no known radiological injury to the cervical spine and who is well sedated and immobile (paralysed), the purpose of the cervical collar is to serve as a warning of a potential neck lesion. The initial hard collar should be exchanged for a suitably sized long–term collar (eg. Miami J or Aspen). The collar should be left in situ but should be left open except when the patient is being moved to scan etc. or log rolled. The head should still be protected with sandbags either side. A sign should be placed above the bed declaring “ C-spine not cleared” .The collar must not be allowed to obstruct venous return or become a source of pressure necrosis. The collar MUST be fastened up again when the child is moved, log rolled, woken up, or when the paralysis is discontinued.

However, cervical spine immobilisation can be removed on a case-by-case basis – please discuss with neurosurgery.

KEY POINTS

  • Good oxygenation at all times
  • Avoid / Treat aggressively any drops in Cerebral Perfusion Pressure
  • If these measures fail to control ICP: if ICP is >20mmHg for >5min then move on to CONTROL ICP ALGORITHM

Raised ICP Management Algorithm

Treatment threshold is a sustained ICP rise above target limit for > 5 minutes.

At all times:

  • Review physiological parameters and ensure goals are met
  • Reconsider extracranial causes of raised ICP
  • Consider CT scan to characterise changes to intracranial pathology
  • Re-evaluate surgical options
  • Reconsider escalation to senior clinicians / neurosurgery depending on clinical context

Tier Zero Therapy (Fundamental Care)

  • Optimise sedation +/- neuromuscular blockage - sedation bolus should be used with caution as may reduce BP and so CPP
  • Head up 30 ° head midline, no obvious venous obstruction, loosen collar if on
  • Keep CPP >45 if 0-2; >55 if 2-6; >60 if 7-12; >65 if >12yrs
  • SpO2 > 96%; PaO2 >10-13kPa : PaCO2 4.5-5.0 kPa
  • Temp < 37 degrees
  • Confirm no evidence of seizure activity – treat if present. Consider seizure prophylaxis (typically 20mg/kg BD levetiracetam for minimum 7 days – discuss with neurology)
  • Check for clinical features of herniation eg pupillary changes, hypertension and bradycardia

If features of herniation go to impending herniation treatment plan and → Consider mass lesion – CT scan & Neurosurgical Opinion

↓

Tier One Therapy – If ICP remains raised for >5 mins

  •  In patients with EVD remove CSF – open for 5 minutes initially.

Osmotherapy

  • 1st line: Hypertonic saline (2.7% or 3%) Bolus 3ml/kg over 5 mins, or infusion of 0.1 -1ml/kg/hour titrated to lowest rate to control ICP (Consider mannitol instead if serum Na >155)
  • 2nd line: Mannitol 5g/kg (for 20% mannitol this is 2.5ml/kg) over 15 minutes repeat as needed until plasma osmolality 320 mOsm. Beware prolonged significant diuresis – may require additional fluids to prevent hypotension. Beware rebound intracranial hypertension with prolonged use. Osmotic therapy becomes less effective further away from injury

↓

ICP STILL RAISED

Tier Two Therapy 

  • Consider further CSF drainage ( by EVD ), or EVD insertion if not present
  • Hypertonic saline infusion (2.7% or 3%) if not already started - 0.1-1ml/kg/hr titrated to lowest rate to control ICP
  • Hyperventilation down to Pa CO2 4 - 4.5kPa
  • Titrated hypothermia: reduce core temp by 1oC at a time, reassessing ICP with each 1oC drop, to minimum 32-34oC, maintain for 48hours. See Temperature Management above.
  • Consider raising CPP into age-specific target range using inotrope infusion to maintain systemic hypertension, depending on autoregulatory status
  • Consider neuromuscular blockade (bolus or infusion)

↓

ICP STILL RAISED / Impending cerebral herniation?

  • Urgent neurosurgical consult and CT scan
  • Consider trial of Thiopental* - see response to bolus dose (consider smaller 1-2mg/kg bolus initially, increasing up to a max total of 4mg/kg if BP remains acceptable); if effective in reducing ICP →start infusion ( 3-5 mg/kg/hr). Titrate infusion rate to ICP and to CFAM response.
  • Consider decompressive craniectomy
  • Consider further doses of hypertonic saline or mannitol
  • Consider hyperventilation to PaCO2 4.0kPa

*Thiopental is a potent and toxic drug. It acts on GABA A and offers cerebral protection. It should be used with caution, using the smallest dose possible and titrated to effect, aiming to lower ICP. CFAM monitoring should always be used, with the aim of inducing burst suppression. It often leads to a fall in BP so inotropes are usually needed to maintain adequate BP and CPP. Thiopental accumulates over time as it undergoes zero-order kinetics. Levels need to be checked prior to being able to perform brain stem testing and can take a prolonged period to fall. Also be aware that it may induce fixed dilated pupils. Alternatively, propofol infusion can be considered in older children but consider carefully propofol syndrome.

NB. Thiopental can reduce the life-span of gas machine cartridges – if a patient is on a thiopental infusion all samples from that patient should be run through the same gas machine. The gas machine should be labelled thiopental. It can continue to be used for other patients.

The above is intended as a guide. It may be more appropriate in individual cases to tolerate a mildly elevated ICP (eg. 25mmHg) rather than proceed to second tier therapies.

 

Drug Doses

Unless specified in the guideline above, all drug doses should be as per BNFc.

Editorial Information

Last reviewed: 24/10/2025

Next review date: 31/10/2028

Author(s): Dr Anne McGettrick (PICU Consultant).

Version: 3

Author email(s): Anne.McGettrick2@nhs.scot.

Co-Author(s): Lorraine Moore (clinical nurse educator), Mr Michael Canty (neurosurgeon), Emma Harley (PICU ST7 trainee), Nicola Wilson (PICU Pharmacist)              .

Approved By: Paediatric Clinical Effectiveness & Risk Committee

Document Id: 12

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Evidence method

The guidelines have been constructed after consultation with standard textbooks, PubMed and Google Scholar searches (traumatic brain injury, head injury, mannitol, hypertonic saline, hypothermia, thiopentone, decompressive craniectomy). 

It incorporates the published Brain Injury Guidelines published in PCCM supplement 2003. It includes world expert opinion of the management of TBI as discussed at the World Paediatric Intensive Care Conference, Sydney 2011 and local expert opinion from the fields of neurosurgery, intensive care, neurology, nursing and pharmacy.

The best available levels of evidence were used to construct these guidelines.