Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – supportive care

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ACUTE
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all patients
1st line – 

supportive care

Patients often require supportive care to maintain their cardiovascular status. Interventions may include oxygen via a mask or endotracheal tube and infusions of intravenous fluids. Blood glucose levels should also be monitored.

Plus – child protection services and social work evaluation

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ACUTE
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all patients
Plus – 

child protection services and social work evaluation

Treatment recommended for ALL patients in selected patient group

It is important to consult with a hospital child protection team and social work services as soon as possible when a case of potential child abuse is identified.[1][22] If there are other children in the home, child protection services may remove those children from exposure to the offending carer. Local policy should be referred to when informing legal authorities.

The accurate diagnosis of abuse is important to protect the patient and other children from ongoing abuse, and to avoid accusations of abuse in cases where medical findings may be explained by underlying medical disorders (e.g., coagulation defects, metabolic disease, or infection).

Medical evaluation may involve testing for osteogenesis imperfecta or glutaric aciduria type I.[32][33][34]

Plus – CPR per protocol

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ACUTE
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all patients
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with apnoea or bradycardic arrest
Plus – 

CPR per protocol

Treatment recommended for ALL patients in selected patient group

Medical providers are directed to treatment recommendations for both basic and advanced paediatric life support.[59][63][64]​​​​

In patients with severe cardiorespiratory compromise, CPR may be indicated.

Plus – anticonvulsive therapy

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ACUTE
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all patients
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with seizure
Plus – 

anticonvulsive therapy

Treatment recommended for ALL patients in selected patient group

Basic guidelines are followed for stabilisation of infants with unexplained seizures.[65]

For patients with hypoglycaemia, intravenous glucose should be administered as soon as possible.[60]

If the seizures persist beyond 5 minutes then a benzodiazepine is recommended.[60]

An alternative anticonvulsant may be required if the seizures continue despite benzodiazepine administration. In refractory cases, induction of a coma may be required.[60]

Plus – neurosurgery consultation ± ICP monitoring ± ICP-lowering regimen

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ACUTE
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all patients
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with increased intracranial pressure (ICP) ± cerebral oedema
Plus – 

neurosurgery consultation ± ICP monitoring ± ICP-lowering regimen

Treatment recommended for ALL patients in selected patient group

Raised ICP is clinically suggested by irritability, vomiting, and tense fontanelles. International consensus statements on the management of increased ICP should be followed.[61][66]​​​​

Patients with paediatric Glasgow Coma Scale scores of ≤8 may need to have ICP monitoring. Monitoring can be done by ventriculostomy, subarachnoid bolt, or intraparenchymal ICP monitor.[61]​​

Primary options that can be used to lower ICP include raising the head of the bed to 30°, or using the reverse Trendelenburg position if spinal instability or injury is present. Analgesics and sedation can be useful, as pain and agitation can increase the ICP.[61]​​

When ventricular access is available, cerebrospinal fluid drainage should be considered.[61]​​

Secondary treatment options to lower ICP include neurosurgery and/or medical options - including barbiturate infusion, late moderate hypothermia, induced hyperventilation, and higher levels of hyperosmolar therapy.[61]​​

If hypotension is a contributory factor, vasopressors may be beneficial.

Plus – observation ± surgery

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ACUTE
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all patients
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with subdural haemorrhage
Plus – 

observation ± surgery

Treatment recommended for ALL patients in selected patient group

While acute, small, non-expansile haematomas may not warrant acute surgical intervention, they may be associated with other intracranial haematomas requiring either increased intracranial pressure management or surgical evacuation. In a small group of patients, small subdural haematomas may cause significant cerebral oedema and neurological deterioration. For this reason, clinical symptoms and signs, in conjunction with size, influence the management of subdural haematomas.

Surgery is indicated for an acute subdural haematoma that is expanding and/or causing neurological signs and symptoms. The decision of what type of surgery to perform depends on the radiographic appearance of the haematoma and the surgeon's preference.

Surgical options include burr hole craniotomy, where at least 2 burr holes are made and the clot is irrigated out using saline irrigation and suction; trauma craniotomy, which involves standard frontotemporoparietal craniotomy, durotomy and removal of the clot; and hemicraniectomy, which involves a large frontotemporoparietal craniotomy, durotomy, and removal of the clot without replacement of the bone flap.

Hemicraniectomy and duraplasty is frequently performed when there is considerable cerebral swelling and/or other intraparenchymal lesions.

Plus – antibiotics

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ACUTE
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all patients
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with fever or other signs of sepsis
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Appropriate antibiotic administration typically precedes identification of a specific pathogen.

When choosing empirical therapy, the suspected source of infection or causative organism, local resistance patterns, and the patient's immune status need to be considered.

Once culture and sensitivity results are known, antibiotics should be adjusted if required. See  Sepsis in Children (Treatment algorithm)

Plus – blood transfusion

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ACUTE
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all patients
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with anaemia
Plus – 

blood transfusion

Treatment recommended for ALL patients in selected patient group

Red cell transfusions should be given to ameliorate cardiovascular or respiratory symptoms, for severe anaemia (Hb <100 g/L [10 g/dL]), or for clinical signs of cardiovascular instability such as tachycardia.[67]

Plus – correction of coagulopathy

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ACUTE
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all patients
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with coagulopathy
Plus – 

correction of coagulopathy

Treatment recommended for ALL patients in selected patient group

Many patients with severe head injury present in a state of disseminated intravascular coagulopathy and require normalisation of their coagulation profile. All patients should have serial prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalised ratio, platelet and fibrinogen levels.

Correction of coagulopathy can include fresh frozen plasma for abnormal bleeding function (aPTT, PT, fibrinogen) and platelets for severe thrombocytopenia.[62]

Plus – sub-specialty consultation/referral

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ACUTE
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all patients
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with associated injury and signs of physical abuse
Plus – 

sub-specialty consultation/referral

Treatment recommended for ALL patients in selected patient group

It is critical to involve the ophthalmology service in the evaluation of retinal haemorrhages.[13]

Emergency evaluation is required in those with skull fracture, with urgent referral to a neurosurgeon.

If skeletal trauma is evident, stabilisation of spinal injury and/or associated fractures with immediate orthopaedic consultation is necessary in accordance with trauma guidelines.[68]

Emergency evaluation is required in those with signs of abdominal injury, with urgent referral to a paediatric surgeon.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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