Emergency Department and PICU Clinical Pathway for Children
with Severe Traumatic Brain Injury (TBI)
Patient with Traumatic Brain Injury (TBI)
(Admit via ED/Transport)
Notify Neurosurgery - Trauma Alert as per Protocol
(Admit via ED/Transport)
Notify Neurosurgery - Trauma Alert as per Protocol
Acute ED Management
GCS ≤ 8
ED Management
ED Management
Within 30 minutes
of arrival
of arrival
- ATLS protocol
- AVOID hypotension
- Avoid hypoxia – wean supplemental
O2 to SpO2 > 92 and < 98% - Avoid hypercarbia or hypocarbia
(unless concern for brain herniation) - Goal normocarbia – arterial CO2 of 35-39 mm Hg or end tidal CO2 of 30-34 mm Hg
- Avoid hyperthermia
Acute Radiology/OR Management
STAT Head CT
Immediate Neurosurgical Management in OR
Acute Critical Care Management
Within 1-6 hours
of PICU arrival
of PICU arrival
Admit to PICU
cEEG Monitoring (CT/MRI Compatible)
x 48 Hours Minimum
Consult Neurology – Order Seizure Action Plan
x 48 Hours Minimum
Consult Neurology – Order Seizure Action Plan
Interventions for Treating Elevated ICP &
Physiologic Monitoring Parameters
Physiologic Monitoring Parameters
Main Goals
- ICP < 20 via normocarbia
(arterial CO2 35-39; EtCO2 30-34) - Cerebral perfusion pressure
(CPP > 40) - Avoid hypotension
- Adequate brain oxygenation
(PbtO2 ≥ 15 - ≤ 35 mmHg) - Maintain normothermia, avoid hypoglycemia
> 5 minutes
ICP Monitoring:
PICU Parameters:
- Vital Signs, Clinical Goals for Physiologic Monitoring
- Sedation Recommendations
- Lab Monitoring Parameters
- Additional Considerations (Nutrition, Temperature Regulation, PT/OT, Skin Care)
Normal ICP x 48 hours:
De-escalate Invasive Monitoring
De-escalate Invasive Monitoring
Posted: July 2015
Revised: August 2022
Authors: J. Huh, MD; K. Agarwal, RN; J. Lavelle, MD; T. Kilbaugh, MD; A. Donoghue, MD; D. Perks, CRNP; K. Resendiz Trujano, PharmD; S. Chen, MD
Revised: August 2022
Authors: J. Huh, MD; K. Agarwal, RN; J. Lavelle, MD; T. Kilbaugh, MD; A. Donoghue, MD; D. Perks, CRNP; K. Resendiz Trujano, PharmD; S. Chen, MD