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semirigid cervical collar or inline manual stabilization. If intubation is
determined to be necessary, endotracheal intubation is the preferred method.
Evaluation by a neurosurgeon is preferred prior to intubation with
neuromuscular blockade, but there should not be any delay in obtaining an
advanced airway. Patients should be preoxygenated, and lidocaine should
be utilized as a pretreatment medication. Atropine is no longer considered
to be standard of care for pediatric rapid sequence intubation, and special
consideration must be taken with this population as it can mask bradycardia
secondary to increased ICP. Lidocaine at 1 to 2 mg/kg of weight with a
maximum of 100 mg is used to prevent potential increased ICP by blunting
airway reflexes. Rapid sequence intubation includes administration of
medications for sedation and paralysis. Sedative medications should be
used to decrease airway responses and keep the patient comfortable. (Refer
to Chapter 8 Airway .) Preferred medications for the child in whom a head
injury is suspected include etomidate and midazolam. Etomidate has
minimal cardiovascular effects and is used effectively in patients with
hemodynamic instability, thus providing neuroprotection. The typical dose
of etomidate is 0.3 mg/kg of weight. Midazolam has minimal effects on
systemic arterial pressure with typical dosage of 0.1 to 0.3 mg/kg of weight.
Neuromuscular blockade and paralysis may be achieved with rocuronium at
doses of 0.6 to 1.2 mg/kg of weight or succinylcholine at doses of 1 to 2
mg/kg of weight. There is no available outcome data regarding the use of
sedatives and paralytic medications in children with ciTBI, and their use
should be tailored to the individual patient.
Noninvasive maneuvers also should be standard management to decrease
ICP. The head of the bed should be elevated to 30 degrees, the head should
be kept in a neutral position while maintaining cervical spine
immobilization, ventilation to maintain PaCO2 at 35 to 40 mm Hg,
continuous sedation infusion to prevent complications after intubation and
agitation. There is no evidence to support or refute the use of brain
oxygenation monitoring, transcranial Doppler, cerebral microdialysis or

near-infrared spectroscopy (NIRS) in conjunction with ICP monitoring.
Aggressive hyperventilation should not be the standard as an initial therapy;
however, it may be necessary acutely for refractory intracranial
hypertension and to prevent cerebral herniation.