Severe Pediatric Traumatic Brain Injury (TBI), PICU — ED Management — Clinical Pathway: Emergency, ICU and Inpatient

Traumatic Brain Injury (TBI) Clinical Pathway — Emergency Department and ICU

ED Management

Goals

  • Airway management
  • Avoid hypotension
  • Avoid hypoxemia
  • Evaluate and treat elevated ICP
  • Expedite time for definitive care

Assessments and Interventions

Assessment Intervention(s)
Airway & Breathing
  • Tracheal Intubation Recommendations:
  • Goals:
    • SpO2 > 92% and ≤ 98%
    • EtCO2: 30-34 mmHg
  • Comments
  • Etomidate lasts for approximately 8 minutes – consider that patients may need additional sedation but avoid hypotension
Neurologic
  • Signs of elevated ICP in the absence of an ICP monitor:
    • Focal neurological exam deficit (e.g. unilateral dilated pupil)
    • and/or
    • Hypertension
    • and/or
    • Bradycardia
    • and/or
    • Abnormal breathing
  • Consider the following interventions if concern for elevated ICP:
    • Hyperventilate to transiently lower EtCO2 to < 30 mmHg:
      • Monitor vital signs and/or abnormal portion of exam (e.g. pupil dilation) for signs of improvement.
      • Reassess the need for hyperventilation to avoid prolonged duration to avoid cerebral ischemia.
    • Hyperosmolar therapy:
    • Secondary sedation:
      • Consider Fentanyl, Ketamine and/or Midazolam based on the patient’s clinical status.
      • Administer the minimal amount needed to avoid hypotension.
    • If seizure symptoms present, consider anti-epileptic medications (Fosphenytoin or Levetiracetam)
Circulation
  • Maintain euvolemia
  • AVOID hypotension