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


In general, institutional protocols are most similar to the guidelines in the baseline tier and tier 1 and more variable in tier 2 (see Figure). The differences in the institutional protocols could contribute to differences in outcomes in pediatric TBI patients. For example, hyperventilation reduces ICP by inducing cerebral vasoconstriction, thereby lowering cerebral blood flow.[9] The reduction in cerebral blood flow can lead to ischemia, especially in children.[10] The 2019 guidelines endorse use of hyperventilation only in the case of impending herniation when other attempts to lower ICP have failed.[6] Despite the adverse ramifications of early hyperventilation, it is included as a baseline therapy in 2 institutions and as a tier 1 therapy in 2 institutions. The protocols may not have been updated and thus may not represent current practice at those institutions. It is also possible that institutions are relying on outdated treatment paradigms in their protocols.

Neuromuscular blockade was included in the 2019 tier 1 algorithm because it could optimize patient-ventilator interaction and prevent shivering, ultimately reducing ICP. The 2019 guidelines also recommend drainage of cerebrospinal fluid as a tier 1 therapy. Neuromuscular blockade and cerebrospinal fluid drainage were included as tier 1 interventions in 3 and 4 protocols, respectively, but both were also considered baseline care and tier 2 therapy at some institutions. These differences illustrate stylistic differences between institutions and demonstrate lack of consensus about the proper time to initiate these therapies. Further research should be directed at identifying the optimal timing of these interventions.

Maintenance of a minimum blood hemoglobin level is a baseline intervention in the 2019 guidelines, supported by findings in 6 published protocols that propose a target hemoglobin level of 7 to 12 g/dL. Treatment of coagulopathy is also included as a baseline intervention. Previous research supports normalization of international normalized ratio to reduce bleeding complications;[11] however, recent work suggests that overresuscitation with plasma after TBI in children may worsen coagulopathy and should be used only for active bleeding or titrated with respect to results of thromboelastography.[12] Fresh frozen plasma is the most common blood component used to treat coagulopathies; however, it expands the patient's intravascular volume, which may be disadvantageous in children.[13] For this reason, guidelines suggest reserving fresh frozen plasma for use during active bleeding.[14] Prothrombin complex concentrate has been postulated as a good alternative for fresh frozen plasma because of the much lower volumes needed; however, publications regarding its use in pediatric trauma patients are minimal.[15]