Pediatric TBI Algorithms: First-Tier & Second-Tier (Fig 82.13 & 82.14)

📋 Fig 82.13 — First-Tier Therapies for Severe Pediatric TBI

🩺 ICP-Directed First-Tier Algorithm

Baseline Care (All patients):

• HOB 30°, midline head position

• Controlled ventilation (PaCO2 35-40 mm Hg)

• Sedation/analgesia (fentanyl, midazolam, propofol)

• Normothermia (avoid fever)

• Isotonic fluids, euvolemia, treat hypotension

• Seizure prophylaxis (fosphenytoin or levetiracetam)

ICP Monitoring (EVD or parenchymal)
Target ICP <20 mm Hg

└─ ICP elevated (>20 mm Hg) → First-Tier Therapies:

▸ CSF drainage via EVD (if ventricular catheter)

▸ Osmolar therapy: Hypertonic saline (3%) 2-5 mL/kg bolus OR Mannitol 0.25-1 g/kg

▸ Optimize sedation, add neuromuscular blockade if needed

▸ Maintain CPP targets (age-dependent: 2-6y ≥50, 7-10y ≥55, 11-16y ≥65 mm Hg)

✚ Reassess frequently. If ICP refractory → proceed to Second-Tier (Fig 82.14)

📋 Fig 82.14 — Second-Tier Therapies for Refractory Intracranial Hypertension

ICP remains >20 mm Hg despite FIRST-TIER therapies

Second-Tier Options (in no specific order):

▸ Pentobarbital infusion: Load 5-10 mg/kg over 30 min, then 5 mg/kg q1h x 3, maintenance 1-5 mg/kg/hr. Monitor BP, EEG.

▸ Decompressive craniectomy: Surgical removal of bone flap to allow brain swelling.

▸ Mild hypothermia (32-34°C): Induce and maintain with surface cooling. Slow rewarming. (Controversial, Level III evidence)

▸ Hyperventilation (PaCO2 25-30 mm Hg): Reserved for brief use or herniation. Avoid prolonged use.

▸ High-dose barbiturates (alternative to pentobarbital)

└─ Continuous monitoring: ICP, CPP, EEG (for burst suppression), arterial line

▸ Consider repeat CT to rule out surgical lesion

Combinations of second-tier therapies often required. Discuss with neurosurgery and PICU team.