Traumatic Brain Injury (TBI) Clinical Pathway – Emergency Department and PICU

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

Goals and Metrics
Provider Resources
Child with Severe TBI
Glasgow Coma Scale (GCS) consistently ≤ 8 and not improving
Trauma Alert as per Protocol, Notify Neurosurgery
 
Within 20 mins
of arrival
 
 
 
Exclusion Criteria
Non-traumatic brain injury
e.g., anoxic brain injury from cardiac arrest
Acute ED Management
 
 
  • ATLS protocol
  • Avoid hypotension
  • Avoid hypoxia, wean supplemental O2 to goal SpO2 ≥ 92%
  • Avoid hypercarbia or hypocarbia
    (unless concern for brain herniation)
  • Goal normocarbia
    • Arterial CO2 35–39 mmHg
    • End tidal CO2 30–34 mmHg
  • Avoid hyperthermia
 
 
Emergent Head CT
 
 
 
 
  • Immediate Neurosurgical Management
  • OR Now as indicated
 
 
 
Within 1–6 hrs
of PICU arrival
 
Admit to PICU
 
 

Non-Invasive Neuromonitoring, All Patients

  • Assess hourly
    • GCS
    • Pupillometer
    • Serial Neurologic Assessment Pediatrics (SNAP)
  • Continuous
 
 

Main Goals

  • Maintain:
    • ICP < 20 mmHg
      Arterial CO2 35–39 mmHg
      EtCO2 30–34 mmHg
    • Cerebral perfusion pressure (CPP)
      • < 6 yrs ~ 45–55 mmHg
      • ≥ 6 yrs > 60 mmHg
    • Targeted MAP
    • Brain oxygenation (PbtO2) ≥ 20 mmHg
    • Normothermia, euglycemia
  • Call PICU fellow/APP for any value out of range ≥ 5 min

Invasive Neuromonitoring per Neurosurgery
Brain Invasive Intracranial Pressure (ICP)
Brain Tissue Oxygen (PbtO2)

Escalation of Therapies
Treating Elevated ICP ≥ 20 mmHg
Treating Decreased PbtO2 < 20 mmHg

 
 

PICU Parameters

 
 
Normal ICP × 48 hrs
De-escalate Invasive Monitoring