Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary

Pediatr Crit Care Med. 2019 Mar;20(3):280-289. doi: 10.1097/PCC.0000000000001736.


Objectives: The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients.

Methods and main results: This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology.

Conclusions: New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Algorithms
  • Barbiturates / administration & dosage
  • Brain / physiopathology
  • Brain Injuries, Traumatic / complications
  • Brain Injuries, Traumatic / therapy*
  • Cerebrovascular Circulation / physiology
  • Child
  • Child, Preschool
  • Clinical Protocols / standards*
  • Decompressive Craniectomy / methods
  • Glasgow Coma Scale
  • Humans
  • Hypothermia, Induced / methods
  • Infant
  • Intracranial Hypertension / etiology
  • Intracranial Hypertension / therapy
  • Practice Guidelines as Topic*
  • Respiration, Artificial / methods


  • Barbiturates
  • barbituric acid