Approach to a Child with Traumatic Brain Injury (TBI)

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Initial Assessment and Stabilization (The ABCs)

The immediate priority in a child presenting with a traumatic brain injury (TBI) is the rapid assessment and stabilization of the airway, breathing, and circulation to prevent secondary brain injury from hypoxia and ischemia.
Airway (A): The airway must be secured while strictly maintaining cervical spine stabilization.
Endotracheal intubation is strongly indicated if the child has a Glasgow Coma Scale (GCS) score of $\leq$ 8, a rapidly declining GCS (drop of 3 or more), absent protective airway reflexes, apnea, or signs of impending brain herniation.
Intubation should be performed using cerebroprotective Drug-Assisted Intubation (DAI) to prevent a reflex spike in intracranial pressure (ICP).
Recommended premedications for DAI include intravenous lidocaine, thiopental (or etomidate for hemodynamically stable patients), and a short-acting non-depolarizing neuromuscular blocking agent (e.g., vecuronium or rocuronium).
Breathing (B): Supplemental oxygen should be administered immediately to treat or prevent hypoxia, targeting an oxygen saturation ( $S p O_{2}$ ) of > 92% and a $P a O_{2}$ between 80-120 mmHg.
Normoventilation is the strict physiological target; the arterial carbon dioxide ( $P a C O_{2}$ ) should be maintained between 35-40 mmHg.
Prophylactic hyperventilation is detrimental as it causes cerebral vasoconstriction and worsens ischemia; it is only indicated as a temporary rescue measure for acute signs of impending herniation.
Circulation (C): Maintaining euvolemia and a normal mean arterial pressure (MAP) is critical to ensure an adequate cerebral perfusion pressure (CPP).
Isotonic crystalloids (e.g., 0.9% Normal Saline) are the fluids of choice; hypotonic fluids (like 5% Dextrose in water) are absolutely contraindicated as they increase free water clearance into the brain, thereby exacerbating cerebral edema.
If circulatory failure or hypotension is present, fluid boluses (20 ml/kg of Normal Saline) should be given, followed by vasopressors if required, to target a MAP > 50th percentile for the child's age.

Neurological Evaluation and Monitoring

Once stabilized, a thorough neurological examination should be performed to establish a baseline and detect focal deficits or signs of herniation.
The depth of coma must be objectively quantified using the Modified Glasgow Coma Scale (mGCS).
Pupillary size, symmetry, and reactivity to light are critical surrogate markers for brainstem function and impending uncal herniation (e.g., a unilateral fixed and dilated pupil).
Cerebral Perfusion Pressure (CPP) Targets: CPP is calculated as MAP minus ICP ( $C P P = M A P - I C P$ ). The minimal acceptable CPP values to prevent cerebral ischemia are > 40-50 mmHg for infants and toddlers, and > 50-60 mmHg for older children.
Invasive ICP Monitoring: Placement of an invasive ICP monitor is indicated in patients with severe TBI (GCS 3-8 after resuscitation) who have an abnormal admission head CT, or a normal CT accompanied by motor posturing or hypotension.

Neuroimaging

A Non-Contrast Computed Tomography (NCCT) of the head is the primary and most rapid imaging modality of choice to detect surgically correctable lesions in the emergency setting.
The NCCT should be evaluated for the presence of epidural or subdural hematomas, intraparenchymal hemorrhage, midline shift, effacement of basilar cisterns, and loss of grey-white matter differentiation indicative of diffuse cerebral edema.

Stepwise Management of Raised Intracranial Pressure

The medical management of raised ICP in TBI is escalated through specific therapeutic tiers based on the clinical response and ICP monitoring.

Therapeutic Tier	Interventions and Clinical Targets
General Measures	Maintain head in midline position with 30° elevation (to facilitate venous drainage). Ensure cervical collar is not obstructing venous return.
Metabolic Control	Maintain normothermia ( $< 38^{\circ} C$ ); aggressively treat fever with antipyretics. Maintain blood glucose strictly between 80-120 mg/dL to prevent hyper- and hypoglycemic brain injury.
Sedation & Analgesia	Administer adequate sedation (e.g., Midazolam) and analgesia (e.g., Fentanyl) to blunt noxious stimuli. Use endotracheal lidocaine (1-2 mg/kg) prior to suctioning.
Seizure Prophylaxis	Prophylactic administration of antiepileptic drugs (Phenytoin or Levetiracetam) is recommended for 7 days in patients with severe TBI, parenchymal injury, or depressed skull fractures.
Tier 1: Osmotherapy	Hypertonic Saline (3% NaCl): Preferred agent, particularly in hypovolemia. Administer as a 5 ml/kg bolus over 30 mins, followed by an infusion (0.5-1.5 ml/kg/hr) targeting a serum sodium of 155-160 mEq/L. Mannitol (20%): Administer as a 0.5-1 g/kg bolus every 4-6 hours. Avoid continuous infusions. Contraindicated in hypotension or if serum osmolality $> 320$ mOsm/kg.
Tier 2 Therapies	Moderate Hyperventilation: Target $P a C O_{2}$ 28-34 mmHg. Strictly reserved only for acute impending herniation or acute neurological deterioration. Barbiturate Coma: Thiopentone or Pentobarbital infusion titrated to achieve burst suppression on EEG. Requires invasive hemodynamic monitoring due to profound myocardial depression.
Tier 3/Surgical	Decompressive Craniectomy: Indicated for medically refractory intracranial hypertension with diffuse swelling on CT, or for evacuation of mass lesions (hematomas).

Therapies to Avoid in Pediatric TBI

Corticosteroids: The use of steroids (e.g., dexamethasone) is absolutely contraindicated and not recommended in the management of severe TBI, as they have been shown to worsen outcomes and offer no benefit for traumatic cytotoxic edema.
Hypotonic Fluids: Fluids such as 5% Dextrose or 0.45% Saline must be strictly avoided.
Prophylactic Hyperventilation: Decreasing $P a C O_{2}$ routinely without signs of herniation induces severe cerebral vasoconstriction, causing secondary ischemic infarction.