Severe Pediatric Traumatic Brain Injury (TBI), PICU — Treating Elevated ICP — Clinical Pathway: Emergency, ICU and Inpatient

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

Treating Elevated ICP – Escalation of Therapy

For elevated ICP in the absence of noxious stimuli, regardless of the monitor that is in place, the following actions should be taken to achieve a goal of ICP < 20.

ICP > 20 for > 5 minutes
Call PICU Fellow/CRNP to notify Neurosurgery and Trauma to:
  • Adjust HOB (from 30° C)
  • and/or
  • Loosen C-collar to promote venous drainage
If NO resolution after 5 minutes
  • Provide adequate sedation & analgesia
    (use the lowest dose to achieve effect;
    AVOID HYPOTENSION)
If NO resolution after 5 minutes, call back PICU Fellow/CRNP and
  • Consider 3% hypertonic saline bolus: 5 mL/kg*
    • *Max: 5 mL/kg (or 500 mL/dose); may repeat PRN. 3% hypertonic saline is preferred. If unavailable mannitol may be used, but monitor for osmotic diuresis and treat hypotension.
  • Consider starting a continuous IV 3% saline infusion at 0.1 ml/kg/hr and titrate to effect up to 1 ml/kg/hr
If NO resolution after 5 minutes, call back PICU Fellow/CRNP to notify Neurosurgery and
  • Consider neuromuscular blockade and continuous EEG monitoring
  • If EVD in place, consider CSF drainage
  • Repeat Head CT (portable if unstable)
  • PICU Attending to notify Neurosurgery Attending to consider early decompressive craniectomy if the patient now needs to be:
    1. Hyperventilated to lower arterial paCO2 to 28-34 mm Hg
    2. Initiated on high-dose Pentobarbital for burst suppression on cEEG
      Start continuous IV infusion at 1 mg/kg/hour — may need to titrate up depending on response
      Bolus dose: 3-5 mg/kg IV (low dose recommended to avoid hypotension)
      Order/begin continuous IV Phenylephrine or Epinephrine infusion when starting Pentobarbital continuous infusion
    3. Consider the benefits and risk of targeted temperature management, 32-34°C
      PICU Thermoregulation Clinical Pathway