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


The full results are listed in the Table. The Figure shows discrepancies between the timing of treatment in the 9 institutional protocols reviewed and the timing indicated in the 2019 guidelines (baseline, tier 1, or tier 2).


Timing of therapies in 9 different institutional protocols for pediatric traumatic brain injury compared with the timing indicated in the 2019 guidelines.

Interventions categorized as baseline care in the 2019 guidelines were included as a first-line treatment in the institutional protocols to various degrees.[8] Maintenance of normothermia and administration of antiepileptic drugs were categorized as baseline care at 100% of institutions. Other interventions were less frequently cited (see Table), including maintenance of volume status (89%), elevation of the head of the bed (89%), analgesia and sedation (78%), maintenance of a minimum blood hemoglobin level (44%), and coagulopathy management (0%).

Institutional protocols are most similar to the guidelines in the baseline tier and tier 1 and more variable in tier 2.

Of the tier 1 interventions in the 2019 guidelines, hypertonic saline was tier 1 in most protocols (89%).[8] Other interventions were included as tier 1 interventions less frequently (see Table), including cerebrospinal fluid drainage (44%), neuromuscular blockade (33%), maintenance of cerebral perfusion pressure (22%), and additional analgesia and sedation (22%).

Regarding the tier 2 interventions in the 2019 guidelines (see Table), barbiturate infusion was included most often as tier 2 in institutional protocols (89%).[8] Other tier 2 interventions included decompressive craniectomy (78%), induction of moderate hypothermia (56%), hyperventilation (44%), and repeat computed tomography of the head (33%).