Pediatric Severe Traumatic Brain Injury Clinical Practice Guidelines (2019)

Brain Trauma Foundation

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 26, 2019

Updated Brain Trauma Foundation guidelines for treating severe traumatic brain injury in infants, children, and adolescents were published in 2019 in the journal of Pediatric Critical Care Medicine.[1]


Intracranial pressure (ICP) monitoring is recommended.

Advanced neuromonitoring (brain oxygenation) should be reserved for patients with no contraindications to invasive neuromonitoring and patients who are not brain dead.


Targeting a threshold of < 20 mm Hg in ICP treatment is recommended.

Maintaining a minimum cerebral perfusion pressure (CPP) of 40 mm Hg is recommended.


Bolus hyperosmolar therapy (HTS) of 3% saline is recommended for patients with ICP. The recommended effective doses range from 2 to 5 mL/kg over 10 to 20 minutes.

For refractory ICP, a bolus of 23.4% HTS is recommended.

Avoiding bolus administration of midazolam and/or fentanyl during ICP crises is recommended due to risks of cerebral hypoperfusion.

Draining cerebrospinal fluid (CSF) through an external ventricular drain (EVD) is recommended for managing increased ICP.

Prophylactic treatment is recommended for reducing occurrence of early (within 7 days) posttraumatic seizures (PTSs).

Moderate (32–33°C) hypothermia is recommended for controlling ICP, but is not recommended over normothermia for improving overall outcomes.

In hemodynamically stable patients with refractory ICP, high-dose barbiturate therapy is recommended.

Decompressive craniectomy (DC) is recommended for treating neurologic deterioration, herniation, or intracranial hypertension refractory to medical management.

Initiating early enteral nutritional support (within 72 hours from injury) is recommended for decreasing mortality and improving outcomes.

Corticosteroids are not recommended for ICP.

For more Clinical Practice Guidelines, go to Guidelines.

For more information, go to Head Trauma.


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