Table 3 Routine admission orders for patients with severe closed head injuries

• Admit to pediatric intensive care unit, or trauma ICU.

• Vitals per protocol with continuous BP, ICP and CPP monitoring and neurological checks every hour.

• Bed in 20 degrees reverse Trendelenburg position until spine clearance, and then head of bed elevated at 30 degrees.

• Cervical collar in place at all times (but avoid compression of jugular venous outflow); log roll every 1-2 hours for skin care.

• Diet: NPO except medications.

• IVF: 0.9 NS with appropriate KCL at maintenance rate for body surface area (account for insensible losses due to mechanical ventilation).

• Dilantin: appropriate loading and maintenance doses by weight if indicated.

• Sedation, analgesia and pharmacological paralysis according to ICU head-injury protocol. The overall plan for sedation level depends on stability of ICP management in each patient.

• Laboratory studies: serum sodium, glucose and osmolarity every 12 hours (every 6 hours if mannitol is given frequently). Dilantin level after 4th maintenance dose.

• Other laboratory studies ordered as indicated by critical-care team.

BP = blood pressure; CCP = cerbral perfussion pressure; ICP = intracranial pressure;

ICV = intensive care unit; IVF = intravenous fluids; KCL = potassium chloride; NPO

= nothing by mouth; NS = normal saline

Serum sodium, glucose and osmolarity should be measured at least every 12 hours for the first 48 hours. The critical care team should institute enteral feedings via a naso-jejunal tube or isotonic intravenous hyperalimentation within 24 hours of injury. Nutrition, physical therapy and physiatry consultation should be obtained by the second hospital day. Daily counseling by nursing and critical-care staff and the neurosurgeon and the use of written counseling materials are helpful for the families of head-injured children.

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