Paeds · acute-care-resuscitation-and-toxicology
Initial stabilisation of major paediatric head injury
Also known as Paediatric traumatic brain injury · Severe paediatric head injury · Paediatric major trauma with brain injury · Neuroprotection in paediatric TBI · Raised ICP in head-injured child
A fellowship approach to the initial stabilisation of a child with major traumatic brain injury. Run the primary survey with cervical spine protection, intubate for GCS of 8 or below, oxygenate and ventilate to normocapnia, avoid hypotension with isotonic fluid, treat raised intracranial pressure with hyperosmolar therapy and 30-degree head-up positioning, give early seizure prophylaxis, obtain urgent CT, and escalate to neurosurgery and retrieval before local support is exceeded.
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Target exams
Red flags
- Glasgow Coma Scale of 8 or below, or a deteriorating conscious level after head injury: secure the definitive airway now
- Unilateral or dilated pupil, Cushing triad of hypertension with bradycardia, or decerebrate posture: impending herniation from raised intracranial pressure
- Hypoxia (oxygen saturation below 90 percent) or hypotension: each doubles mortality after severe traumatic brain injury
- Open or depressed skull fracture, signs of basal skull fracture, or cerebrospinal fluid leak: neurosurgical emergency
- Post-traumatic seizure or a new focal neurological deficit in a head-injured child
- Suspicion of abusive head trauma in an infant: stabilise first, then activate safeguarding in parallel
- A child needing monitoring, imaging, or neurosurgical care unavailable locally: call retrieval early
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute Care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Acute care
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people
- General Paediatrics: Assumes the role of Acute Paediatric Team Leader
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 2: Interprofessional and Team Communication
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
Major paediatric head injury is traumatic brain injury severe enough to threaten the brain through either the primary mechanical damage at impact or the cascade of secondary injury that follows. The initial stabilisation is built around one principle: the primary injury has already happened and cannot be undone, but the secondary injury is preventable. Hypoxia, hypotension, hypercapnia, raised intracranial pressure, fever, seizure and hyperglycaemia each worsen outcome, and each is treatable from moment child arrives. [1] [11]
The stabilisation method is the ABCDE primary survey adapted for trauma: cervical spine control is added to Airway, and a rapid neurological assessment is woven through Disability. The defining rule is the same as any primary survey: treat each life threat as you find it, then reassess from A. The difference is that in head injury, every action has a cerebral price. Intubation, ventilation, fluid, sedation and positioning all change intracranial pressure, cerebral perfusion and oxygen delivery, so each intervention is chosen with the brain in mind. [1] [8]
[1] [7]Neuroprotection is not a separate protocol bolted onto resuscitation. It is the organising principle that shapes every decision in the primary survey: which fluid, which ventilation target, which position, which drug for induction, and when to image. A child with a Glasgow Coma Scale of 8 or below needs a definitive airway, and that airway is best secured with a neuro-friendly rapid sequence technique that avoids both hypoxia and the surge in intracranial pressure that rough laryngoscopy can cause. [1] [11]
The neuroprotective primary survey
- 1
Cervical spine and Airway
Apply manual in-line stabilisation, fit a correctly sized hard collar, and assess whether the airway is open and protected. Intubate for GCS 8 or below, or for loss of airway reflexes.
- 2
Breathing and ventilation
Give high-flow oxygen to correct hypoxia, then ventilate to normocapnia. Target oxygen saturation at least 94 percent and a partial pressure of carbon dioxide in the normal range. Avoid prophylactic hyperventilation.
- 3
Circulation and perfusion
Control external bleeding, gain access, and treat hypotension with isotonic crystalloid boluses. Avoid hypotonic fluids. Maintain a systolic blood pressure appropriate for age.
- 4
Disability and neuroprotection
Check GCS, pupils, glucose and posture. Position the head 30 degrees up and midline. Treat clinical or radiological raised intracranial pressure with hyperosmolar therapy and give seizure prophylaxis in high-risk cases.
- 5
Exposure and urgent imaging
Expose for other injuries while keeping the child warm. Arrange urgent CT of the head and cervical spine when stable enough to scan. Call neurosurgery and retrieval early.
References12ShowHide
- [1]Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition Pediatric critical care medicine, 2012.PMID 22217782
- [2]Kochanek PM, Adelson PD, Rosario BL, et al. Comparison of Intracranial Pressure Measurements Before and After Hypertonic Saline or Mannitol Treatment in Children With Severe Traumatic Brain Injury JAMA network open, 2022.PMID 35267036
- [3]Chong SL, Zhu Y, Wang Q, et al. Clinical Outcomes of Hypertonic Saline vs Mannitol Treatment Among Children With Traumatic Brain Injury JAMA network open, 2025.PMID 40067302
- [4]Afridi A, Bacha Z, Sajjad F, et al. Therapeutic comparison of hypertonic saline and mannitol in pediatric intracranial hypertension: a systematic review and meta-analysis Child's nervous system, 2025.PMID 41420712
- [5]Laws JC, Vance EH, Betters KA, et al. Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury Critical care medicine, 2023.PMID 36825892
- [6]Pajer HB, Asher AM, Leung D, et al. Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children American journal of critical care, 2021.PMID 34467382
- [7]Erickson SL, Killien EY, Wainwright M, et al. Mean Arterial Pressure and Discharge Outcomes in Severe Pediatric Traumatic Brain Injury Neurocritical care, 2021.PMID 33108627
- [8]Mai G, Lee JH, Caporal P, et al. Prehospital and emergency management of pediatric traumatic brain injury: a multicenter site survey Journal of neurosurgery Pediatrics, 2023.PMID 38716719
- [9]Lele AV, Vavilala MS Cerebral Autoregulation-guided Management of Adult and Pediatric Traumatic Brain Injury Journal of neurosurgical anesthesiology, 2023.PMID 37523326
- [10]Gaither JB, Spaite DW, Bobrow BJ, et al. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids) Annals of emergency medicine, 2021.PMID 33187749
- [11]de Carvalho Panzeri Carlotti AP, do Amaral VH, de Carvalho Canela Balzi AP, et al. Management of severe traumatic brain injury in pediatric patients: an evidence-based approach Neurological sciences, 2025.PMID 39476094
- [12]Agrawal S, Abecasis F, Jalloh I Neuromonitoring in Children with Traumatic Brain Injury Neurocritical care, 2024.PMID 37386341