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Updated: Jul 7, 2026
Controlled Cortical Impact Model for Traumatic Brain Injury
Published on: August 5, 2014
Management of critically ill children with traumatic brain injury
Gilles A Orliaguet1, Philippe G Meyer, Thomas Baugnon
1Département d'Anesthésie - Réanimation et SAMU de Paris, Hôpital Necker Enfants Malades, France. gilles.orliaguet@nck.ap-hop-paris.fr
Insights
Effective management of pediatric traumatic brain injury (TBI) involves assessing brain and extra-cranial injuries, preventing secondary brain insults (SBI), and optimizing cerebral perfusion pressure (CPP). Treatment focuses on resuscitation and ICP management.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Neurosurgery
- Trauma Surgery
Background:
- Severe traumatic brain injury (TBI) in children necessitates comprehensive management beyond brain lesions.
- Extra-cranial injuries and secondary brain insults (SBI) significantly impact outcomes.
- Pediatric trauma centers are ideal for managing severe TBI cases.
Purpose of the Study:
- To outline the critical management strategies for children with severe TBI.
- To emphasize the prevention of secondary brain insults (SBI).
- To detail the monitoring and optimization of cerebral perfusion pressure (CPP).
Main Methods:
- Initial assessment includes clinical examination, transcranial Doppler ultrasonography, and body CT scans.
- Monitoring and optimizing cerebral perfusion pressure (CPP = Mean Arterial Blood Pressure - Intracranial Pressure).
- Implementation of general resuscitation maneuvers and tiered ICP-specific treatments.
Main Results:
- Neurosurgical intervention is rarely needed, primarily for compressive hematomas.
- Preventing SBI through managing hypotension, hypoxia, hypercarbia, anemia, and hyperglycemia is crucial.
- Tiered treatments for intracranial hypertension include CSF drainage, osmotic therapy, hyperventilation, barbiturates, hypothermia, and decompressive craniectomy.
Conclusions:
- Optimal management of pediatric TBI requires a multi-faceted approach addressing primary injury and secondary insults.
- Close monitoring and timely intervention to maintain adequate CPP are vital.
- A stepwise approach to managing intracranial hypertension is essential for improving outcomes.
Abstract:
The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra-cranial injuries. Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans-cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure - intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age-related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation-analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first-tier ICP-specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second-tier therapy (profound hyperventilation with P(a)CO(2) < 35 mmHg, high-dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan.
