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Pediatric traumatic brain injury: beyond the guidelines
1Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA. kochanekpm@ccm.upmc.edu
Insights
Guidelines for severe traumatic brain injury in children focus on managing intracranial hypertension. New developments include optimizing cerebral perfusion pressure and considering hypothermia or decompressive craniectomy.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma management
- Intensive care unit (ICU) protocols
Background:
- First guidelines for severe traumatic brain injury (TBI) in children were established in 2003.
- Initial management prioritizes preventing secondary insults like hypotension and hypoxemia.
- Intracranial hypertension is a primary therapeutic target in pediatric TBI.
Purpose of the Study:
- To review established and emerging therapies for managing intracranial hypertension in pediatric TBI patients.
- To discuss advancements in the critical pathway for TBI management.
- To highlight new developments in optimizing cerebral perfusion pressure (CPP).
Main Methods:
- Synopsis of the established critical pathway for TBI management.
- Review of first- and second-tier therapies for intracranial hypertension.
- Discussion of emerging therapeutic modalities.
Main Results:
- The critical pathway emphasizes limiting intracranial hypertension and optimizing CPP.
- Emerging evidence supports mild-moderate hypothermia as a therapeutic option.
- Decompressive craniectomy is also supported by emerging evidence.
Conclusions:
- Contemporary management of pediatric TBI centers on controlling intracranial pressure.
- A refined understanding of optimal CPP targets is crucial for therapy.
- Hypothermia and decompressive craniectomy represent significant advancements in TBI treatment.
Abstract:
In 2003, a multidisciplinary group of physicians formulated the first guidelines for the management of severe traumatic brain injury in infants and children. Initial treatment of these patients is focused on stabilization to prevent the occurrence of secondary insults such as hypotension and hypoxemia. However, this article focuses on the established and emerging therapies used in the intensive care unit management of intracranial hypertension--which represents the key target for contemporary therapy of this condition. A critical pathway for the treatment of this condition was established within the guidelines, and this pathway is appropriately focused on limiting intracranial hypertension and optimizing cerebral perfusion during the intensive care unit phase. This includes first- and second-tier therapies. This article contains a brief synopsis of this critical pathway and discusses important new developments for the management of this condition. Key new developments include a better understanding of the optimal cerebral perfusion pressure target for intracranial pressure-directed therapy, with emerging evidence supporting the use of two therapeutic modalities, mild-moderate hypothermia and decompressive craniectomy.
