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If the above measures are not adequate to control ICP, hyperosmolar
therapy may be necessary to control cerebral perfusion pressure. Hypertonic
(3%) saline may be used in the acute setting with bolus doses of 6 to 10
mL/kg of weight. Continuous infusions of hypertonic saline may be
necessary to maintain ICP less than 20 mm Hg with doses starting at 0.1
mL/kg of weight that may need to be increased incrementally to 1.0 mL/kg
of weight per hour, titrated to keep target serum sodium levels between 145
and 155 mEq/L. Serum osmolarity should be monitored and maintained at
less than 360 mOsm/L. In conjunction with hyperosmolar therapy,
externalization of CSF drainage by placement of a ventricular catheter may
be necessary to monitor and adjust ICP to maintain ICP <20 mm Hg.
Depending on the stability of the patient, decompressive craniectomy may
be necessary, especially for the evacuation of intracranial hematomas.
Craniectomy is necessary for large hematomas associated with neurologic
compromise or impending cerebral herniation. The timing of surgical
intervention depends on the severity of the injury and stability of the patient
and should be executed in collaboration with neurosurgery.
Other therapeutic adjuncts include the routine use of acetaminophen to
maintain a core temperature of 36°C to 37°C and the initiation of
antiseizure prophylaxis with levetiracetam at loading doses of 60 mg/kg of
weight (maximum of 4,500 mg) and continuing maintenance therapy within
12 hours at 30 mg/kg/day.
Medications that are not routinely recommended in children with ciTBI
include steroids. The use of corticosteroids has not been shown to either
improve neurologic outcome or decrease ICP. When used in spinal cord
injuries, there is anecdotal evidence that it may worsen outcomes for
patients with ciTBI.
Head trauma has been recognized as a common cause of posttraumatic
hydrocephalus. As management schemes for neurotrauma have improved
over recent years, more patients are surviving severe head traumas with
hydrocephalus occurring as a delayed complication. About 4% of patients

develop posttraumatic hydrocephalus requiring surgical CSF diversion.
Specific Brain Injury Patterns
The spectrum of brain injury patterns ranges in severity from mild and
isolated to diffuse with associated hemorrhages. The continuum of injury is