What are the recommended steps for rapid assessment (airway, breathing, circulation [ABCs]), neurological exam with pediatric Glasgow Coma Scale (pGCS), indications for emergent non‑contrast head computed tomography (CT), and management of intracranial pressure (ICP), seizure prophylaxis, and cerebral perfusion pressure (CPP) in a child or adolescent with suspected traumatic brain injury?

Pediatric Traumatic Brain Injury: Rapid Assessment and Management

Immediate Airway, Breathing, and Circulation (ABCs)

Secure the airway immediately in any child with a Glasgow Coma Scale (GCS) ≤8 or clinical signs of raised intracranial pressure, using rapid-sequence intubation with cervical spine precautions. 1

Airway Management

• Intubate children with GCS ≤8, deteriorating consciousness, or signs of impending herniation to protect the airway and prevent aspiration 1
• Apply cervical spine immobilization during intubation using jaw thrust without head tilt 1
• Progressive drowsiness with vomiting signals deteriorating neurological status and imminent loss of airway reflexes—secure the airway before obtaining imaging 1

Breathing and Ventilation

• Target normocapnia (PaCO₂ 35–40 mmHg) to prevent secondary brain injury; avoid rapid rises in CO₂ during initiation of mechanical ventilation as this exacerbates intracranial hypertension 1, 2
• Reserve hyperventilation only for imminent herniation; otherwise maintain normocapnia to avoid cerebral vasoconstriction and ischemia 1, 2
• Ensure adequate oxygenation—avoid hypoxemia as it is a critical contributor to secondary brain injury 3

Circulation

• Maintain systolic blood pressure >110 mmHg in school-age children to ensure adequate cerebral perfusion 1
• Avoid post-traumatic arterial hypotension—this is one of three evidence-based measures critical to preventing secondary brain injury 3

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Neurological Examination with Pediatric Glasgow Coma Scale

Use the pediatric GCS immediately to stratify injury severity and guide management decisions. 4, 5

Risk Stratification by pGCS and Clinical Features

High-Risk (requires immediate CT and likely ICU admission):

• GCS ≤14 or altered mental status (4.3% risk of clinically important traumatic brain injury) 4, 5
• Signs of basilar skull fracture (Battle sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) 4, 5
• Palpable skull fracture in children <2 years (4.4% risk) 5
• Post-traumatic seizures 4
• Focal neurological deficits 4

Intermediate-Risk (consider CT vs. observation):

• Children ≥2 years: GCS 15 with normal mental status but history of loss of consciousness, vomiting, severe headache, or severe mechanism of injury (0.8% risk) 4, 5
• **Children <2 years:** GCS 15 with normal mental status but loss of consciousness >5 seconds, severe mechanism, or not acting normally per parent (0.9% risk) 4, 5

Very Low-Risk (observation without CT):

• GCS 15, normal mental status, no loss of consciousness, no vomiting, no severe mechanism, no severe headache, no basilar skull fracture signs (<0.05% risk; sensitivity >96%, NPV 99.9%) 4, 5

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Indications for Emergent Non-Contrast Head CT

Obtain immediate non-contrast head CT for all high-risk patients; consider CT versus observation for intermediate-risk patients based on clinical trajectory. 4, 5

Mandatory CT Indications

• GCS ≤14 4, 5
• Altered mental status or deteriorating consciousness 4, 1, 5
• Signs of basilar skull fracture 4, 5
• Palpable skull fracture (especially in infants <2 years) 5
• Post-traumatic seizures 4
• Focal neurological deficits 4

CT Consideration for Intermediate-Risk Features

• Vomiting (especially if persistent or worsening during observation) 4
• Loss of consciousness 4
• Severe headache 4
• Severe mechanism (high-speed MVC, fall >3 feet/5 stairs) 4
• Multiple intermediate-risk factors coexisting 4

Observation Strategy to Reduce Unnecessary CT

• Each additional hour of ED observation is associated with decreased CT utilization without delaying diagnosis of significant injury 4
• Monitor for 4–6 hours with hourly neurological reassessment 4
• Proceed to CT if symptoms worsen, vomiting persists, or new neurological signs emerge 4

CT Protocol Specifications

• Use pediatric-specific, reduced-dose protocols following ALARA principles, tailored to patient size 4, 2
• Perform multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 4
• Do not use skull radiographs—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma 2, 4, 5
• Do not use MRI acutely—longer acquisition times and potential need for sedation make it impractical in the emergency setting, though it may be useful later for suspected non-accidental trauma 2, 5

Radiation Risk Counseling

• Discuss both the immediate injury risk (4.3% for high-risk features) and the small lifetime cancer risk from CT with families to support informed decision-making 4, 2
• The immediate risk of missing a clinically important injury in high-risk patients is 40- to 400-fold higher than the lifetime cancer risk from a single CT 4

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Intracranial Pressure (ICP) Management

Maintain cerebral perfusion pressure (CPP) and prevent secondary brain injury through meticulous ICP control. 2, 6

ICP Monitoring Indications

• Severe TBI (GCS ≤8) with abnormal CT findings 6, 7
• Consider in children with normal CT but two or more of: age <40 years, motor posturing, systolic BP <90 mmHg 6

First-Tier ICP Management

• Elevate head of bed 30 degrees with head midline to optimize venous drainage 6
• Maintain normocapnia (PaCO₂ 35–40 mmHg)—hyperventilation only for acute herniation 2, 1, 6
• Ensure adequate sedation and analgesia to reduce metabolic demand 6
• Maintain normothermia—treat fever aggressively as hyperthermia worsens secondary injury 7
• Administer hyperosmolar therapy (3% hypertonic saline or mannitol) for elevated ICP 7
• Drain CSF if external ventricular drain is in place 6

Second-Tier ICP Management (if first-tier fails)

• Barbiturate coma (pentobarbital) for refractory ICP elevation 7
• Decompressive craniectomy for medically refractory intracranial hypertension 7
• Moderate hypothermia (32–34°C) may be considered, though evidence in pediatrics is limited 7

CPP Targets

• Maintain age-appropriate CPP: generally >40–50 mmHg in younger children, >50–60 mmHg in adolescents 2, 6
• Use vasopressors if needed to maintain adequate mean arterial pressure (MAP) 6

Transcranial Doppler Utility

• Use TCD to assess cerebral blood flow velocity and pulsatility index (PI) as part of initial assessment 2
• Diastolic velocity <20 cm/s and PI >1.4 indicate poor brain perfusion and warrant immediate therapeutic measures 2

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Seizure Prophylaxis

Do not routinely administer prophylactic antiepileptic drugs (AEDs) for seizure prevention in pediatric TBI. 7

Updated 2012 Guideline Recommendations

• Prophylactic AEDs are not recommended to prevent late post-traumatic seizures (occurring >7 days after injury) 7
• Early seizures (within 7 days) occur in 2.4% of mild TBI and up to 28–83% of severe TBI 4
• Treat acute post-traumatic seizures when they occur, but do not give prophylaxis to prevent them 7

When to Treat Seizures

• Administer benzodiazepines (lorazepam, midazolam) for active seizure activity 6
• Load with phenytoin or levetiracetam if seizures persist or recur 6
• Obtain immediate CT if post-traumatic seizure occurs, as this is a high-risk feature for intracranial injury 4

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Other Critical Management Considerations

Glucose Management

• Avoid hyperglycemia—maintain normoglycemia as elevated glucose worsens neurological outcomes 7

Corticosteroids

• Do not administer corticosteroids—they are not recommended and may increase mortality 7

Referral to Specialized Center

• Transfer all severe TBI patients (GCS ≤8) to a specialized trauma center with neurosurgical capabilities and pediatric expertise 2, 3
• Management by an experienced multidisciplinary team at a center with specialized equipment improves survival and neurological outcomes 2, 3

Discharge Instructions for Low-Risk Patients

• Provide written warning signs: persistent/worsening vomiting, excessive sleepiness, seizures, worsening headache, unsteady gait, unequal pupils 4, 5
• Instruct parents to seek immediate care if any red-flag symptoms develop 4, 5
• Counsel on cognitive and physical rest, expected symptom course, and follow-up 5

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Common Pitfalls to Avoid

• Do not delay airway management to obtain imaging—secure the airway first in any child with GCS ≤8 or deteriorating consciousness 1
• Do not rely on skull radiographs—they miss half of intracranial injuries and cannot evaluate brain parenchyma 2, 4, 5
• Do not obtain CT in very low-risk patients who meet all PECARN criteria—this exposes them to unnecessary radiation 4
• Do not use MRI in the acute setting for deteriorating patients—CT is faster and does not require sedation 2, 1, 5
• Do not hyperventilate routinely—reserve it only for imminent herniation, as it causes cerebral vasoconstriction and ischemia 2, 1, 6
• Do not give prophylactic antiepileptic drugs—they do not prevent late seizures and are not recommended 7
• Do not administer corticosteroids—they worsen outcomes in TBI 7