Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children

Hengameh B. Pajer, MS; Anthony M. Asher, BA; Dennis Leung, MD; Randaline R. Barnett, MD; Benny L. Joyner Jr, MD, MPH; Carolyn S. Quinsey, MD


Am J Crit Care. 2021;30(5):402-406. 

In This Article

Abstract and Introduction


Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. Of 24 institutions identified and contacted, 10 did not respond and 5 did not have a pediatric TBI protocol. Pediatric TBI protocols were successfully collected from 9 institutions. These 9 protocols were separated into treatment tiers analogous to those in the 2019 Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies guidelines, and the intervention variables were identified and compared across the 9 institutions. First-line therapies were similar between institutions, including seizure prophylaxis, maintenance of normoglycemia and normothermia, and avoidance of hypoxia, hyponatremia, and hypotension. However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.


Traumatic brain injuries (TBIs) cause significant death and disability in children in the United States. The incidence of pediatric TBI has increased since the year 2000, with 837 000 cases of pediatric TBI, resulting in 23 000 hospitalizations and 2529 deaths in 2014.[1]

The Institute of Medicine defines guidelines as "statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."[2] (p3) Management of adult TBI relies on evidence-based guidelines that reduce mortality without compromising functional status at discharge.[3]

Little research has addressed severe TBI in children. Since 2003, 3 sets of guidelines for management of severe pediatric TBI have been published by the Brain Trauma Foundation with support of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Previous guidelines were based on adult and pediatric clinical studies,[4,5] but the 2019 guidelines considered only evidence from pediatric studies.[6] Adult severe TBI guidelines include level I and II recommendations whereas pediatric guidelines include mostly level III recommendations.[6,7] Despite published pediatric TBI guidelines, institutional protocols can differ significantly.

This study seeks to identify similarities and differences in institutional protocols for pediatric TBI at major trauma centers in the United States, with the goal of guiding future research and the development of standardized guidelines based on robust clinical evidence.