Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

Karin Reuter-Rice, PhD, CPNP-AC; Elise Christoferson, BA


Am J Crit Care. 2020;29(1):e13-e18. 

In This Article

Abstract and Introduction


Background: Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes.

Objectives: To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI.

Methods and Results: After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article.

Conclusions: The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.


Traumatic brain injury (TBI) is a major cause of mortality in the United States, accounting for 30% of all injury-related deaths.[1] In addition, the health care burden of TBIs continues to increase; about 2.8 million TBI-related emergency department visits, hospitalizations, and deaths occurred in the United States in 2013.[1] More specifically, approximately 56 800 TBI-related deaths occurred in 2014, including 2529 deaths of children.[2] Of those children living with moderate to severe TBI, more than 61% experience a disability.[3]

The use of intensive care management protocols focused on intracranial pressure (ICP) measurement and medical/surgical treatment of intracranial hypertension are critical to prevent secondary injury.[4] Secondary injury results from a pathophysiological cascade of events that reduces perfusion of surviving neural tissue, oxygen and metabolite delivery, and clearance of metabolic waste and toxins, ultimately leading to intracranial hypertension, further focal ischemic injury, brainstem compression, and, if untreated, death.[5–7]

"Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines,"[8] published in Pediatric Critical Care Medicine in 2018, provides updated evidence-based recommendations applicable to the management of children with severe TBI in the intensive care unit (ICU) and directly addresses some of the previous gaps in the pediatric TBI literature. As the number of children who arrive in the ICU with severe TBI continues to increase and because neurocritical care is provided in ICUs, it is vital that critical care providers be aware of the most current practice recommendations. Therefore, in this article, we describe the process behind the development of the third edition guidelines and focus on the highlighted new evidence and recommended best practice approaches for a child with a severe TBI.

These updated guidelines provide the most up-to-date evidence-based practice recommendations for children with severe traumatic brain injury.