complexity and variability between the relationship of ICP and cerebral blood
flow, the Monro-Kellie doctrine provides a reasonable basic explanation of
intracranial dynamics.
Figure 5: ICP and volume relationship: Initially the ICP remains unchanged with increasing
volumes due to compensation mechanisms, however at elevated ICP’s, small volume increases
cause a significant change in pressure.
Interventions are therefore tailored to decrease CSF and/or hyperemia, while
ensuring adequate oxygenation and blood flow and preventing secondary brain
injury. Secondary damage includes both the evolution of damage within the
brain leading to edema, ischemia, and necrosis and secondary insults such as
hypotension and hypoxia which further exacerbate damage, elevate ICP or
decreased CPP.
Figure 6 and Figure 7 published in the first edition of the guidelines for
pediatric TBI provides an algorithm for the management of pediatric TBI.^17
Initial trauma management in the emergency department begins with the ATLS
(Advanced Trauma Life Support) protocol of Airway, Breathing, Circulation,
Disability and Exposure. Physical exam with Glasgow Coma Score (GCS)