What are the management strategies for pediatric traumatic brain injury (TBI) in children?

Pediatric Traumatic Brain Injury Management

Severity Classification and Initial Assessment

Immediately classify TBI severity using the Glasgow Coma Scale (GCS): Severe (GCS ≤8), Moderate (GCS 9-13), or Mild (GCS 14-15), with particular attention to motor response and pupillary examination as these are the strongest predictors of neurological outcome. 1

• The initial GCS score, pupillary reactivity, and CT findings determine prognosis and guide the intensity of intervention 2
• Age-dependent considerations apply: children <4 years have worse recovery rates, while children ≥6-8 years use adult-like ICP thresholds 1, 3

Immediate Resuscitation: Prevent Secondary Brain Injury

The three critical, evidence-based priorities are: (1) avoid hypoxemia by maintaining SaO₂ >95%, (2) prevent hypotension at all costs—never allow low blood pressure even with hemorrhagic shock elsewhere, and (3) maintain normocapnia with PaCO₂ 35-40 mmHg. 1, 2, 3

• Combined hypotension and hypoxemia carries 75% mortality—these are the most modifiable factors affecting outcome 2
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2
• Intubation prior to hospital arrival has increased from 35% to 94% in recent years, reflecting recognition of airway protection importance 4

Urgent Neuroimaging and Neurosurgical Consultation

Obtain non-contrast CT of the head and cervical spine immediately in all severe TBI patients to identify surgical lesions. 1

• Immediate neurosurgical consultation is required for: depressed skull fractures, open fractures with CSF leak, epidural hematoma with mass effect, and any expanding lesion causing midline shift 1
• Invisible basal cisterns on initial CT strongly predict bad outcome 4

Intracranial Pressure Monitoring and Management

Implement ICP monitoring in severe TBI (GCS ≤8) with abnormal CT findings, targeting ICP <20 mmHg in children ≥6-8 years; consider lower thresholds in younger children as physiologic ICP is age-dependent. 1, 2

• ICP monitoring is indicated in 26 of severe TBI patients and moderate-to-severe intracranial hypertension significantly predicts bad outcome 4
• Treatment escalation for elevated ICP includes: hyperosmolar therapy, cerebrospinal fluid drainage, temperature control, sedation/analgesia, and ultimately barbiturate coma or decompressive craniectomy 5, 6

Specific Therapeutic Interventions

Decompressive Craniectomy

Perform decompressive craniectomy for neurologic deterioration, herniation, or intracranial hypertension refractory to medical management. 5

Nutrition

Initiate early enteral nutritional support within 72 hours of injury to decrease mortality and improve outcomes; do NOT use immune-modulating diets. 5

Seizure Prophylaxis

Provide antiseizure prophylaxis in the acute phase, though specific agent selection requires local protocol development. 6

Corticosteroids

Do NOT use corticosteroids—they do not improve outcomes or reduce ICP (except for patients requiring chronic steroid replacement, those with adrenal suppression, or hypothalamic-pituitary axis injury). 5

Hypothermia

Prophylactic hypothermia does NOT improve overall outcomes, though it may be effective for ICP control as a second-tier intervention when other measures fail. 5

Barbiturate Coma

Reserve high-dose barbiturate therapy for refractory intracranial hypertension, with mandatory cardiovascular support to maintain cerebral perfusion pressure as cardiorespiratory instability is common. 5, 6

Special Pediatric Considerations

Maintain high suspicion for non-accidental trauma (inflicted injury) in children <2 years old. 1

• Monitor renal function closely when using mannitol 1
• The developing brain is uniquely vulnerable: only 51% achieve good recovery after moderate-severe TBI, with 48% demonstrating moderate disability at long-term follow-up 2

Mild TBI (Concussion) Management

For mild TBI, implement strict physical and cognitive rest for the first 3 days—this includes keeping the child home from school, limiting screen time and reading, and avoiding all sports and physical exertion. 7

• Immediate rest improves recovery by 4.6 days compared to delayed rest 7
• After 3 days, begin gradual return to activity: light cognitive activity → light aerobic activity → school reintegration → sport-specific exercise 7
• If symptoms worsen at any stage, return to the previous level for 24 hours before attempting progression 7
• Arrange follow-up within 3-5 days to reassess symptoms, with earlier follow-up if symptoms worsen, new symptoms develop, sleep disturbances persist, or symptoms continue beyond 2 weeks 7
• Return to full activity only when: symptom-free at rest for ≥24 hours, symptom-free with increasing physical exertion, and returned to premorbid school performance 7

Long-Term Outcomes and Follow-Up

For moderate-severe TBI, expect approximately 50% good recovery, 25-30% moderate disability, and 20-25% severe disability or death. 2

• Processing speed deficits, attention problems, and executive dysfunction persist long-term and interfere with academic performance 2
• Academic decline is common with significantly lower grade-point averages compared to peers 2
• MRI (not CT) is the most sensitive modality for detecting chronic sequelae years post-injury if unexplained cognitive or neurologic deficits persist 2
• Comprehensive neuropsychological testing should document cognitive deficits objectively 2
• Multidisciplinary evaluation including neuropsychology, psychiatry, and rehabilitation specialists is essential for persistent symptoms 2
• Educational supports under federal statutes are frequently required 2

Critical Pitfalls to Avoid

• Never allow hypotension or hypoxemia—these are the most preventable causes of secondary brain injury 2, 3
• Do not use corticosteroids for neuroprotection 5
• Do not use prophylactic hypothermia for overall outcome improvement 5
• Do not delay neurosurgical consultation when surgical lesions are present 1
• Do not underestimate long-term cognitive sequelae—the developing brain remains vulnerable for years after injury 2