Patrick M Kochanek1, Robert C Tasker2,3, Michael J Bell4, P David Adelson5, Nancy Carney6, Monica S Vavilala7, Nathan R Selden8, Susan L Bratton9, Gerald A Grant10, Niranjan Kissoon11, Karin E Reuter-Rice12, Mark S Wainwright13. 1. Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. 2. Department of Neurology and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA. 3. Harvard Medical School, Boston, MA. 4. Critical Care Medicine, Children's National Medical Center, Washington, DC. 5. Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ. 6. Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR. 7. Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, WA. 8. Department of Neurological Surgery, Oregon Health & Science University, Portland, OR. 9. University of Utah, Salt Lake City, UT. 10. Department of Neurosurgery, Stanford University, Stanford, CA. 11. Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada. 12. School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, NC. 13. Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA.
Abstract
OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
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