Pediatric Traumatic Brain Injury Management

Initial Assessment and Classification

The American Academy of Pediatrics and other medical societies recommend assessing severity immediately using the Glasgow Coma Scale (GCS), focusing on the motor response component, along with pupillary size and reactivity 1, 2, 3
Age, initial GCS score, and pupillary examination are key prognostic factors validated in large cohort studies 1, 2
The GCS should be classified as: Severe (GCS ≤8), Moderate (GCS 9-13), and Mild (GCS 14-15) 4, 5

The American College of Surgeons recommends securing the airway and ensuring adequate oxygenation to prevent hypoxemia, which significantly increases mortality and worsens neurological outcomes 4, 5
Maintaining normocapnia with PaCO₂ between 35-40 mmHg is crucial 4, 5
Avoiding prolonged hyperventilation is essential, as it causes cerebral ischemia 5, 6

The Brain Trauma Foundation recommends obtaining an urgent CT scan of the head in all pediatric TBI patients to identify surgical lesions and guide management 4, 5
Immediate neurosurgical consultation is necessary for depressed skull fractures, open skull fractures with CSF leak or brain tissue exposure, expanding intracranial lesions, and epidural hematoma with mass effect 4

The Neurocritical Care Society recommends implementing ICP monitoring in severe TBI (GCS ≤8) with abnormal CT findings 7, 5
Target ICP should be <20 mmHg, as values of 20-40 mmHg are associated with increased mortality risk 5

The Centers for Disease Control and Prevention (CDC) recommends providing comprehensive discharge instructions, including warning signs of deterioration, expected symptom course, and instructions for monitoring postconcussive symptoms 8, 9
A gradual return to activity is recommended, with close monitoring of symptom number and severity 8, 9

Never delay neuroimaging in patients with a history of lucid interval, even if currently stable 4
Never use hypotonic fluids that worsen cerebral edema 5, 6
Never employ prolonged hyperventilation, as it causes cerebral ischemia 5, 6
Never allow hypotension in TBI patients, even with hemorrhagic shock elsewhere 4, 5, 6
Never assume stability in patients who appear well after initial injury—deterioration can be sudden 4
Never prescribe complete rest beyond the first few days in mild TBI, as this may delay recovery 8, 9