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

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

Vital Signs and Clinical Goals for Physiologic Monitoring

Age-related Blood Pressure Targets — Mean Arterial Pressure (MAP)

Age Target MAP (mmHg) Comments
0 to 30 days > 40 These MAP targets are minimum thresholds. MAPs should be adjusted and monitored based on cerebral perfusion pressure (CPP) targets.
31 days to < 1 year > 45
≥ 1 year to < 6 years > 50
≥ 6 to < 13 years > 60
≥ 13 years > 65

Clinical Goals for Physiologic Monitoring

Mechanisms Goals Interventions Mechanisms
Intracranial Pressure (ICP) < 20 mmHg   See Treating Elevated ICP – Escalation of Therapy
Cerebral Perfusion Pressure (CPP) < 6 yrs: 45-55 mmHg
≥ 6 yrs: 50-60 mmHg		 CPP = MAP - ICP If disrupted Cerebral Blood Flood (CBF) auto-regulation, CBF thresholds may be different; Licox® monitor may help
Brain PbtO2 ≥ 15 to < 35 mmHg ≤ 10 mmHg: Cerebral ischemia
≥ 35 mmHg: Cerebral hyperemia		 See Licox Monitoring
Avoid frequent and/or prolonged brain tissue desaturation episodes
SpO2 ≥ 92 to ≤ 98% Max FiO2: 55%
Blood Pressure — MAP Age-related
(see above)		 AVOID hypotension
Arterial monitoring preferred		 Preferred vasopressors:
Phenylephrine or Epinephrine
Central Venous Pressure (CVP) 5-10 mmHg    
Brain/Core Temperature Controlled normothermia (37°C)
  • Recommend esophageal temp probe. If concern for facial fractures, place temp-monitoring Foley catheter
    • Esophageal temperature probe and temperature-sensing foley are both NOT MRI compatible
  • Contact PICU fellow/CRNP for temp ≥ 38.0°C
  • See PICU/PCU Thermoregulation Pathway
  • Acetaminophen
  • Environmental adjustments
  • Daily reassessment of the need for targeted temperature management
  • Patients developing an infection may not mount a fever
  • Shivering may need to be treated with sedation, neuromuscular blockade
  • Avoid NSAIDs due to increased bleeding risk
Hemoglobin ≥ 8 g/dL   Transfuse pRBCs if needed
Urine Output Within normal parameters
  • Temperature monitoring Foley catheter, if concern for facial fractures
    • Foley temperature probe is not MRI compatible
 Reassess need for Foley daily
paCO2 (Arterial) or EtCO2 paCO2 35-39 mmHg EtCO2 30-34 mmHg For normal ICP (< 20) with low brain PbtO2 (< 15), tolerate a higher paCO2 If concern for herniation/refractory elevated ICP, hyperventilate to arterial paCO2 28-34 or EtCO2
< 30 mmHg transiently