Emergency Department and PICU Clinical Pathway for Children
with Severe Traumatic Brain Injury (TBI)

Patient with Traumatic Brain Injury (TBI)
(Admit via ED/Transport)
Notify Neurosurgery - Trauma Alert as per Protocol
Acute ED Management
GCS ≤ 8
ED Management
Within 30 minutes
of arrival
  • ATLS protocol
  • AVOID hypotension
  • Avoid hypoxia – wean supplemental
    O2 to SpO2 > 92 and < 98%
  • Avoid hypercarbia or hypocarbia
    (unless concern for brain herniation)
  • Goal normocarbia – arterial CO2 of 35-39 mm Hg or end tidal CO2 of 30-34 mm Hg
  • Avoid hyperthermia
Acute Radiology/OR Management
Immediate Neurosurgical Management in OR
Acute Critical Care Management
Within 1-6 hours
of PICU arrival
Admit to PICU
cEEG Monitoring (CT/MRI Compatible)
x 48 Hours Minimum
Consult Neurology – Order Seizure Action Plan
Interventions for Treating Elevated ICP &
Physiologic Monitoring Parameters
Main Goals
  • ICP < 20 via normocarbia
    (arterial CO2 35-39; EtCO2 30-34)
  • Cerebral perfusion pressure
    (CPP > 40)
  • Avoid hypotension
  • Adequate brain oxygenation
    (PbtO2 ≥ 15 - ≤ 35 mmHg)
  • Maintain normothermia, avoid hypoglycemia
Call PICU fellow/CRNP if any of these values are out of range for
> 5 minutes
Normal ICP x 48 hours:
De-escalate Invasive Monitoring
Posted: July 2015
Revised: August 2022
Authors: J. Huh, MD; K. Agarwal, RN; J. Lavelle, MD; T. Kilbaugh, MD; A. Donoghue, MD; D. Perks, CRNP; K. Resendiz Trujano, PharmD; S. Chen, MD