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

Materials and Methods

We surveyed the websites of all pediatric hospitals affiliated with academic institutions with a pediatric critical care fellowship and contacted any faculty member with available contact information to review their pediatric TBI protocols. The survey and initial emails occurred a month after the publication of the 2019 guidelines. A follow-up email was sent 2 weeks later for those who did not respond to the original email. The authors waited 2 additional weeks for responses. In total, we contacted 24 institutions and reviewed 9 protocols. Of the 15 remaining institutions, 10 did not reply or publish their protocols online, and 5 did not have an institutional protocol.

Each institutional protocol was divided into 3 stepwise treatment tiers (baseline care, tier 1, and tier 2) analogous to the 2019 guidelines.[8] The 2019 guidelines delineate 8 baseline interventions that all pediatric patients with TBI should undergo. Tier 1 interventions for the 2019 guidelines include 6 interventions housed under 3 categories: intracranial pressure (ICP) regulation, cerebral perfusion pressure maintenance, and brain tissue partial pressure of oxygen maintenance. The 6 interventions categorized as tier 2 in the 2019 guidelines are implemented after the first-tier interventions for ICP management fail. These protocols are designed for patients with a score less than 8 on the Glasgow Coma Scale, so we assumed that all of the patients would be receiving mechanical ventilator support. We also did not include maintenance of brain tissue partial pressure of oxygen and advanced neuromonitoring in our analysis given that these are not available or used universally.

We then compared each institution's protocol with the 2019 guidelines, noting the inclusion or exclusion of different interventions from the 2019 protocol, along with the treatment tier for each intervention.