Document Type

Presentation

Publication Date

Fall 10-5-2026

Abstract

Background: Traumatic brain injury (TBI) is the leading cause of death and disability for pediatric patients. Approximately 5.4 million children globally sustain a TBI, with 45,500 deaths annually. Severe TBls (8 on the Glasgow Coma Scale) account for the majority of these fatalities. Patients also experience significant disability and have lifelong effects on health and development.

Method: We performed a structured review of contemporary pediatric severe TBl guidance, including the Brain Trauma Foundation guidelines1, institutional clinical pathways2, and relevant peer-reviewed literature3-8_ Recommendations were compared across key domains including initial stabilization and imaging, neuromonitoring, intracranial pressure (ICP) and cerebral perfusion pressure targets, seizure prophylaxis, hyperosmolar therapy, cerebrospinal fluid drainage, and surgical escalation. Agreement and discordance were identified and used to develop an evidence-informed management algorithm for an urban Level II pediatric trauma center.

Results: Most recommendations were supported by Level Ill evidence, yet substantial agreement existed across major guidance sources. Consistent recommendations included early non-contrast head computed tomography; ICP monitoring in patients with severe TBI; avoidance of hypotension, hypoxemia, fever, and other secondary insults; protocolized sedation and analgesia; early seizure prophylaxis; and stepwise treatment of intracranial hypertension. Hypertonic saline was consistently supported for elevated ICP, while cerebrospinal fluid drainage and decompressive craniectomy were reserved for persistent intracranial hypertension. Greater variability exists in advanced neuromonitoring, specific cerebral perfusion pressure targets, indications and timing for repeat or magnetic resonance imaging, and thresholds for escalation of therapy. These findings informed a tiered institutional algorithm incorporating initial neuroprotective care, monitoring goals, sequential ICP-directed interventions, and criteria for neurosurgical escalation.

Conclusions: Despite predominantly low-level evidence, current pediatric severe TBI guidance demonstrates sufficient consensus to support standardized management while highlighting areas requiring clinical judgment. Translating this evidence into a tiered institutional pathway provides a practical framework to reduce unwarranted variation and standardize escalation of care for children with severe TBI.

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