Initial stabilisation of major paediatric head injury — formative SAQs

1. Airway management

A Glasgow Coma Scale of 8 or below is the threshold for definitive airway protection, because the child cannot reliably protect the airway or maintain adequate ventilation. I intubate using rapid sequence induction with preoxygenation, a neuro-friendly induction agent that avoids hypotension, and a muscle relaxant. I avoid coughing, bucking and prolonged laryngoscopy because each raises intracranial pressure. I confirm tube placement with waveform capnography immediately and secure the tube before transport. Manual in-line cervical stabilisation is maintained throughout. ^[1]

2. Ventilation target

The ventilation target is normocapnia: I aim for a partial pressure of carbon dioxide in the normal range for age, guided by waveform capnography and confirmed by blood gas. Prophylactic hyperventilation is contraindicated because lowering the partial pressure of carbon dioxide below the normal range causes cerebral vasoconstriction, reduces cerebral blood flow, and risks cerebral ischaemia. I reserve temporary mild hyperventilation for the acute signs of impending herniation, such as a unilateral dilated pupil, while hyperosmolar therapy and neurosurgical escalation are prepared. ^[1]

3. Fluid strategy

I give isotonic crystalloid, such as 0.9 percent saline or a balanced solution, in aliquots of approximately 10 mL per kilogram, reassessing after each. I avoid hypotonic fluids because hyponatraemia worsens cerebral oedema. Even a single episode of hypotension after severe traumatic brain injury is associated with a doubling of mortality, so I maintain an age-appropriate systolic blood pressure aggressively. If shock persists despite fluid resuscitation, I consider blood products and vasoactive support and escalate to critical care. ^{[1] [7]}

4. Disability assessment and positioning

I record the Glasgow Coma Scale score, the time and the trend. I check pupils for size and reactivity and look for abnormal posture. I check bedside glucose immediately because hypoglycaemia worsens outcome and is immediately treatable; I correct any dangerous low now. I position the head of the bed 30 degrees up and keep the head midline, with the cervical spine protected, because this promotes jugular venous drainage and reduces intracranial pressure without compromising cerebral perfusion, provided the child is normovolaemic. ^[1]

5. Imaging and referral timing

I arrange urgent CT of the head and cervical spine once the child is stable enough for transport to the scanner. I never send an unstable child to CT without monitoring, escort and a rescue plan. I call neurosurgery and retrieval at the point of recognising severe traumatic brain injury, in parallel with resuscitation, not after the CT confirms an operable lesion. Early referral allows planning for transfer, operating theatre readiness and ongoing intensive care. ^{[8] [11]}