University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
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Last updated March 7, 2019 8:21 AM

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Head Injury

ICP and Cerebral perfusion pressure

Keep ICP < 20 mmHg

Maintain CPP:

CPP > 45-60 mmHg, Age < 10 yrs

CPP > 50-70 mmHg, Age > 10 yrs


Indications of ICP monitoring: These are suggestions only

Severe TBI GCS < 8 with abnormal admission head CT (haematoma, contusion, cerebral oedema and/or compressed brain cisterns).

Severe TBI GCS < 8 with normal admission head CT if two of the following features

Maintenance of Normal CPP

Cerebral perfusion pressure = Mean Arterial Pressure - ICP


Give volume if low CVP or clinically indicated
Start on noradrenaline infusion


Algorithm for maintaining CPP


Raised ICP

Is there an easily correctable or transient cause?


These should be excluded and corrected before proceeding with further treatment.

Emergency Management of Increased ICP


This is intended as a guide only. In some cases, it may be appropriate to tolerate higher ICP and maintain appropriate CPP rather than starting on thiopentone.

Algorithm for emergency management raised ICP


General Managment


Fluid Management





The Use of Hypothermia for TBI should not be adopted outside a clinical trial



1. Li M, Chen T, Chen S, et al.: Comparison of equimolar doses of mannitol and hepertonic saline for the treatment of elevated intracranial pressure after traumatic brain injury. Medicine 2015;94(17):e736.
2. Beca J, McSharry B, Erickson S, et al.: Hypothermia for traumatic brain injury in children – A phase II randomized controlled trial. Critical Care Medicine 2015;43(7): 1458-66.
3. Adelson PD, Wisniewski SR, Beca J, et al.: Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomized controlled trial. Lancet Neurol 2013;12:546-53.
4. Kochanek PM, Adelson PD, Ashwal S, et al.: Guidelines for the Acute Medical Management
of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition. Pediatric Critical Care Medicine 2012; 13:1–2.
5. Brain Trauma Foundation: Guidelines for the Management of Severe Traumatic Brain Injury 3ed edition. Journal of Neurotrauma 2007, 24(supplement 1).
6. Brody RA, Touger-Decker R: Evidence-Based Approach to the Nutritional Management of Head Injury. Top Clin Nutr 2008, 23(1):3-12.
7. Carlson AP, Schermer CR et al: Retrospective evaluation of anemia and transfusion in traumatic brain injury.[see comment]. Journal of Trauma-Injury Infection & Critical Care 2006, 61(3):567-571.
8. Christian E, Zada G et al: A review of selective hypothermia in the management of traumatic brain injury. Neurosurgical Focus 2008, 25(4):E9.
9. Claire Battison BHPJDA, MD; Catriona Graham, MSc; Thomas Petty: Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intracranial pressure after brain injury. Crit Care Med 2005, 33(1).
10. Clifton GL, Miller ER et al: Lack of Effect of Induction of Hypothermia after Acute Brain Injury. [Article]. New England Journal of Medicine February 2001, 344(8):556-563.
11. Collaborators Ct: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004, 364:1321-1328.
12. Figaji AA, Fieggen AG et al: Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in a child with traumatic brain swelling. Childs Nervous System 2007, 23(11):1331-1335.
13. Figaji AA, Zwane E et al: Pressure autoregulation, intracranial pressure, and brain tissue oxygenation in children with severe traumatic brain injury. Journal of Neurosurgery: Pediatrics 2009, 4(5):420-428.
14. Ginsberg MD: Fluid resuscitation in traumatic brain injury. Critical Care Medicine 2008, 36(2):661-662.
15. Guy L. Clifton MERM, PhD, RN; Sung C. Choi, PhD; Harvey S. Levin, PhD: Fluid thresholds and outcome from severe brain injury. Crit Care Med 2002, 30( 4).
16. Hutchison JS, Ward RE et al: Hypothermia therapy after traumatic brain injury in children. New England Journal of Medicine 2008, 358(23):2447-2456.
17. Jagannathan J, Okonkwo DO et al: Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up. Journal of Neurosurgery 2007, 106(4 Suppl):268-275.
18. Josan VA, Sgouros S: Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury. Childs Nervous System 2006, 22(10):1268-1274.
19. Li H, Lu G et al: Protective effect of moderate hypothermia on severe traumatic brain injury in children. Journal of Neurotrauma 2009, 26(11):1905-1909.
20. P. David Adelson, Susan L. Bratton et al: Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med 2003, 4(3 Suppl).
21. Ruf B, Heckmann M et al: Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study.[see comment]. Critical Care (London, England) 2003, 7(6):R133-138.
22. Rutigliano D, Egnor MR et al: Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure. Journal of Pediatric Surgery 2006, 41(1):83-87; discussion 83-87.
23. Sahuquillo J, Arikan F: Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database of Systematic Reviews 2006(1):CD003983.
24. Sookplung P, Vavilala MS: What is new in pediatric traumatic brain injury? Current Opinion in Anaesthesiology 2009, 22(5):572-578.
25. Tuettenberg J, Czabanka M et al: Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. Journal of Neurosurgery 2009, 110(6):1200-1208.
26. Tyagi R, Donaldson K et al: Hypertonic saline: a clinical review. Neurosurgical Review 2007, 30(4):277-289; discussion 289-290.
27. Utter GH, Sena MJ: Evaluating anemia as a risk factor for worse neurologic outcome after traumatic brain injury (TBI).[comment]. Journal of Trauma-Injury Infection & Critical Care 2007, 62(4):1065-1066; author reply 1066.
28. Vespa P. M. , R. NM et al: Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. Journal of Neurosurgery 1999, 91(5):750.
29. Vialet R, Albanese J et al: Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Critical Care Medicine 2003, 31(6):1683-1687.
30. Zygun DA, Nortje J et al: The effect of red blood cell transfusion on cerebral oxygenation and metabolism after severe traumatic brain injury.[see comment]. Critical Care Medicine 2009, 37(3):1074-1078.


Dr Rim Alsamsam January 2016, to be reviewed January 2019.