Intensive Care Med (2006) 32:16061612
DOI 10.1007/s00134-006-0285-4
Kevin P. Morris
Robert J. Forsyth
Roger C. Parslow
Robert C. Tasker
Carol A. Hawley
UK Paediatric Traumatic Brain
Injury Study Group
Paediatric Intensive Care Society
Study Group
Received: 23 July 2005
Accepted: 20 June 2006
Published online: 28 July 2006
Springer-Verlag 2006
This study was supported by grants from
the Paediatric Intensive Care Society,
Birmingham Childrens Hospital Research
Foundation and the Warwick University
Research and Teaching Development Fund.
K. P. Morris (u)
Diana Princess of Wales Childrens
Hospital,
Steelhouse Lane, B4 6NH Birmingham, UK
e-mail: kevin.morris@bch.nhs.uk
Tel.: +44-121-3339673
Fax: +44-121-3339651
R. J. Forsyth
Sir James Spence Institute of Child Health,
Royal Victoria Infirmary, Child Health,
School of Clinical Medical Sciences,
NE1 4 lP Newcastle upon Tyne, UK
R. C. Parslow
Leeds Institute of Genetics, Health and
Therapeutics, University of Leeds,
Paediatric Epidemiology Group, Centre for
Epidemiology and Biostatistics,
30 Hyde Terrace, LS2 9JT Leeds, UK
R. C. Tasker
Addenbrookes Hospital, Cambridge
University Clinical School,
Hills Rd, CB2 2QQ Cambridge, UK
C. A. Hawley
Warwick Medical School, University of
Warwick, Division of Health in the
Community,
CV4 7AL Coventry, UK
PE D I A T R I C O R I G I N A L
Intracranial pressure complicating severe
traumatic brain injury in children:
monitoring and management
Abstract Objective: To identify (6% of cases); therefore cerebrospinal
factors associated with the use of in- fluid drainage is seldom used as
tracranial pressure (ICP) monitoring a first-line therapy for raised ICP.
and to establish which ICP-targetted Jugular venous bulb oximetry (4%),
therapies are being used in children brain microdialysis (< 1%) and brain
with severe traumatic brain injury tissue oxygen monitoring (< 1%)
(TBI) in the United Kingdom. To are rarely used in current practice.
evaluate current practice against re- Contrary to published guidelines,
cently published guidelines. Design moderate to severe hyperventilation
and setting: Prospective data col- is being used without monitoring for
lection of clinical and demographic cerebral ischaemia. Conclusions:
information from paediatric and adult There is an urgent need for greater
intensive care units in the UK and Ire- standardisation of practice across UK
land admitting children (< 16 years) centres admitting children with severe
with TBI between February 2001 TBI.
and August 2003. Results: Detailed
clinical information was obtained for Keywords Traumatic brain injury
501 children, with information on the Children Intensive care Intracranial
use of ICP monitoring available in pressure Treatment Monitoring
445. ICP monitoring was used in only
59% (75/127) of children presenting
with an emergency room Glasgow
Coma Scale of 8 or below. Large be-
tween centre variation was seen in the
use of ICP monitoring, independent
of severity of injury. There were 86
children who received ICP-targetted
therapies without ICP monitoring.
Wide between centre variation was
found in the use of ICP-targetted
therapies and in general aspects of
management, such as fluid restric-
tion, the use of muscle relaxants and
prophylactic anticonvulsants. Intra-
ventricular catheters are rarely placed

Introduction
The United Kingdom Paediatric Traumatic Brain Injury
(TBI) Study Group was established in 1999 with the
intention of promoting multi-centre interdisciplinary
research aimed at improving the outcome of children who
have suffered a head injury. As a first step it was decided
to conduct a prospective data collection across the UK
of children with TBI admitted to an intensive care unit.
This study had three purposes. First, the exercise would
test whether it is feasible to collect a large volume of
data through an organisation with strong commitment but
limited resources. Second, the information would provide
a unique epidemiological picture of severe TBI in children
and of contemporary practice across the UK, the first
such database of paediatric TBI in the UK. Third, the
results would be invaluable for informing future clinical
trials.
The need to prevent raised intracranial pressure
(ICP) is recognised as central to current intensive
care practice. Previous questionnaire surveys of both
adult and paediatric physicians have highlighted wide
variation in the use of ICP monitoring and in the
management of raised ICP [1, 2], but questionnaire
surveys are based on physician recall and do not nec-
essarily provide a true reflection of actual practice.
Prospective studies in adults with TBI have confirmed
considerable centre to centre variation [3]. We anal-
ysed data from the national database with the aim of
identifying factors that are associated with the use of
ICP monitoring and the secondary aim of establishing
which ICP-targetted therapies are being used in chil-
dren with severe TBI. We have related our findings to
the recommendations made in the recently published
Guidelines for the acute medical management of se-
vere traumatic brain injury in infants, children, and
adolescents [4].
Methods and materials
Detailed methods have been reported elsewhere [5]. In
summary, a clinician or nurse at each participating centre
provided anonymised data for each child under 16 years of
age admitted primarily for the management of a traumatic
brain injury to one of 28 participating paediatric intensive
care units (PICUs) in England, Wales, Scotland, Northern
Ireland and the Republic of Ireland over a rolling 12-month
period. In most centres this was 1 April 200131 March
2002. A total of 721 children were identified across the
data collection period. Detailed clinical abstracts were
returned on 501 children (69%), who form the basis for
this analysis. As a result of unknown data items, missing
data items and subgroup analysis the precise denominator
varied for individual analyses.
1607
Two clinical abstracts were prepared prospectively for
each child. The first detailed information available within
24 h of admission including demographics, mechanism
of injury, pre-admission management, Glasgow Coma
Score (GCS), surgical procedures and computed tomog-
raphy (CT) findings. A second abstract was prepared at
discharge from the intensive care unit and included data
on monitoring modalities, medical interventions, any
further surgical procedures and subsequent CT findings.
In addition we asked whether a patient was enrolled into
a trial and whether inclusion in the trial could affect the
data items being collected. We identified 44 children (9%)
as being enrolled in a research trial but in only 13 (3%)
was it felt that the responses given for this study could
be affected by inclusion in the trial. These cases were
therefore included in the analysis. Ethical approval for
data collection was obtained from the West Midlands
Multicentre Research Ethics Committee; approval was
additionally gained from the Local Research Ethics
Committee for each participating ICU.
In addition limited data on children under 16 years
admitted with TBI as the primary reason for admission
to 48 adult ICUs were obtained from the Intensive Care
National Audit Research Centre (ICNARC) for the period
1 April 200131 March 2002. A cross-check identified
children who were transferred from an adult ICU to
a PICU to avoid double-counting. No data relating to the
use of ICP monitoring or use of ICP-targetted therapies
was available for the group of children who were managed
exclusively in an adult ICU.
Data items used for this report were use of ICP
monitoring, mode of ICP monitoring, presence of
raised ICP, use of other modalities of brain monitoring
(microdialysis, jugular venous oximetry, brain tissue
oxygenation), use of invasive haemodynamic monitor-
ing (arterial line, central line) and the use of different
therapies. Raised ICP was defined as a level higher than
20 mmHg on more than 1 hourly recording at any point
during ICU stay. This threshold is consistent with the
United States guidelines [4]. ICP-targetted therapies were
classified as first- or second-tier therapies [4]. First-tier
therapies were mannitol, hypertonic saline, mild hyper-
ventilation (PaCO2 4.04.5 kPa) and cerebrospinal fluid
(CSF) drainage. Second-tier therapies were barbiturates,
hypothermia, moderate (3.53.9 kPa) or severe hyperven-
tilation (< 3.5 kPa). In addition we looked separately at
children undergoing decompressive craniectomy. General
therapeutic approaches were also included such as the use
of fluid restriction, artificial ventilation, muscle relaxants,
steroids, prophylactic anticonvulsants and inotropes or
vasopressors. Findings on cerebral CT were noted. CT
findings were defined as abnormal if they demonstrated
intracranial haemorrhage (extradural, subdural, subarach-
noid, intracerebral), diffuse axonal injury, or features of
1608

cerebral oedema (reduced grey/white differentiation, com- Results

pressed lateral ventricles or basal cisterns, midline shift).
In order to contrast the use of ICP targetted therapies
across different centres in comparable patients we defined
a severe TBI group to include children with GCS of
8 or below in the accident and emergency department
and those children requiring intubation and ventilation
pre-hospital or in the accident and emergency department
in whom no GCS was recordable.
For statistical analysis, ICP monitoring (yes/no) was
entered as the dependent variable in a random effects
logistic regression analysis with the following indepen-
dent variables: age, sex, emergency department GCS
score, pupil reactivity, CT abnormality, admitting centre,
and the need for a neurosurgical procedure within 24 h
of injury. A random effects model was used to allow
for variability between admitting centres. In a separate
multiple regression analysis ICU length of stay was
the dependent variable with the following independent
factors: emergency department GCS, age, sex, mechanism
of injury, pupil reactivity, CT abnormality, need for
a neurosurgical procedure within 24 h of injury, ICP
monitoring and development of raised ICP. Kaplan-Meier
survival plots were produced for ICU length of stay,
with Cox regression used to derive length of stay hazard
ratios for the groups: (a) ICP monitored and raised, (b)
ICP monitored but normal and (c) ICP not monitored.
All statistical analyses were performed using Stata
version 8.2.
Monitoring
ICP monitoring
Information relating to the use of ICP monitoring was
recorded in 445 cases. ICP monitoring was undertaken
in 45% of cases (199/445). ICP monitoring was more
common in those with an emergency room GCS of 8 or
below (59%, 75/127) than in those with GCS 912 (38%,
30/80) or GCS 1315 (22%, 22/98). The US guidelines
recommend that ICP monitoring be undertaken in all
children with an admission GCS of 8 or below. ICP moni-
toring was also more common in the group of children in
whom GCS could not be assessed accurately in accident
and emergency departments (51%, 72/140). This group
comprised children who were intubated or had received
sedation or muscle relaxants. ICP monitoring was more
common in those with an abnormal admission CT (56%,
156/282) than in those with a normal initial CT (26%,
43/163).
We found large between centre variation in the propor-
tion of cases undergoing ICP monitoring (7100% of cases
within each centre). This persisted when only the 212 cases
meeting the definition of severe TBI cases were analysed
(7100% of cases within each centre; Fig. 1). The random
effects logistic model confirmed a strong admitting cen-
tre effect on ICP monitoring rates (lr test 2 = 37.8, 1 df,

Fig. 1 Illustration of the

variation in use of ICP
monitoring, ICP therapies and
general therapies across 12
centres admitting more than ten
cases of severe TBI (n = 168).
For each centre the percentage
of patients in whom each
intervention was used is
calculated. The data are shown
as box plots, with the median
value representing practice at the
centre with the median use of
each intervention, and low and
high outliers representing
practice at centres with the
lowest and greatest use of each
intervention, respectively
 1609

Table 1 Random effects model for use of ICP monitoring (n = 331). Between centre variation in management of ICP
Glasgow Coma Score (GCS) refers to that measured in the accident and general management
and emergency department. Baseline categories for the analysis were
GCS 1315 and age 1014 years. In addition to the significance of
GCS, age and CT abnormality, a strong admitting centre effect was To allow for between-centre variation in the GCS thresh-
found ( = 0.293, likelihood ratio test p < 0.001, 2 = 37.8) (OR odds old for ICU admission this analysis was confined to severe
ratio, CI confidence interval) TBI cases in 12 centres admitting ten or more severe
cases and includes cases with and without ICP monitor-
OR p 95% CI ing (n = 168). Wide variation in every aspect of practice
GCS 8 4.67 0.000 2.0010.86 was evident (Fig. 1). Use of mannitol was recorded in 43%
GCS 912 2.20 0.09 0.885.49 (73/168) of cases, with considerable variation across cen-
GCS unrecordable 4.13 0.001 1.779.67 tres (range 777% of cases within each centre). Of these,
Age 1 year 0.08 0.001 0.020.36
Age 14 years 1.27 0.53 0.602.72 92% (155/168) were managed with some degree of hy-
Age 510 years 0.99 0.97 0.511.92 perventilation (range 50100% of cases within each cen-
Age > 14 years 0.62 0.47 0.172.24 tre), and 14% (24/168) barbiturate therapy (range 027%
CT abnormality 3.89 0.000 1.987.64 of cases within each centre). Fluid restriction was used in
Neurosurgical procedure 1.05 0.90 0.502.21 58% (98/168) of severe TBI cases, with considerable vari-
first 24 h
Pupil(s) unreactive 1.60 0.21 0.773.31 ation across centres (0100% of cases within each centre).
first 24 h The restriction was moderate (5175% of normal fluids) in
70% of these cases and severe (< 50% of normal fluids) in
30% of cases.

p < 0.001). Inter-centre variation accounted for 29% of the

overall variance in the model. In addition the model con-
firmed greater use of ICP monitoring in the group with
an emergency department GCS of 8 or below in those in
whom GCS could not be assessed in the emergency de-
partment, and those with abnormalities on CT. ICP mon-
itoring was used less in children below the age of 1 year
(Table 1).
There was considerable variation in the mode of
ICP monitoring reported, with the most common being
parenchymal catheter placement (50%, 100/198), followed
by subdural (29%, 57/198), extradural (15%, 30/198) and
intraventricular (6%, 11/198). Only two centres reported
use of intraventricular monitoring.
Multi-modality brain monitoring
Additional brain monitoring was undertaken infrequently;
jugular venous oximetry in 4% of cases (n = 20) in seven
centres, microdialysis in only two cases in one centre, and
brain tissue oxygenation monitoring in two cases in two
centres.
Invasive haemodynamic monitoring
Accurate assessment of cerebral perfusion pressure
requires invasive arterial pressure monitoring as well
as ICP monitoring. Invasive arterial pressure mon-
itoring was undertaken in 87% (390/450) of total
cases and 94% (200/212) of cases classified as se-
vere TBI. A central venous line was placed in 52%
(232/444) of total cases and 66% (139/212) of severe TBI
cases.
Management of raised ICP
Of the 199 children in whom ICP was monitored 98 (49%)
developed raised ICP. Complete data relating to ICP ther-
apies was available for 90 of the 98 cases. First-tier ther-
apies were used in 99% (89/90) of cases. Figure 2a shows
the frequency with which individual therapies and com-
binations of therapies were used. We did not specifically
collect data relating to the order with which therapies were
used. The US guidelines suggest that the initial ICP spe-
cific therapeutic intervention be CSF drainage when ven-
tricular access is available. CSF drainage was used in only
16% (14/90) of UK cases, and all cases received at least
one other first-tier therapy, suggesting that CSF drainage
is not being employed as a first-line therapy.
Hyperosmolar therapy is recommended as the next
line therapy in the US guidelines, with the choice between
mannitol and hypertonic saline left to the clinician.
Hyperosmolar therapy was used in 87% (78/90) of cases,
with mannitol use (78%, 70/90) exceeding hypertonic
saline use (36%, 32/90). Mild hyperventilation was used
in 83% (75/90) of cases, frequently in combination with
hyperosmolar therapy (72%, 65/90). Figure 2a suggests
that there is no consistency of practice with respect to
whether hyperosmolar therapy or mild hyperventilation is
employed as the first intervention.
Second-tier therapies were used in 54% (49/90) of
children with raised ICP (Table 2). The US guidelines do
not make recommendations concerning the order with
which these therapies should be employed. Barbiturates
were used in 36% (32/90) of cases, moderate or severe
hyperventilation in 27% (24/90), hypothermia in 24%
(22/90) and decompressive craniectomy in 10% (9/90).
Figure 2b shows the frequency with which individual
1610

therapies and combinations of therapies were used and

suggests a lack of consistency of practice in terms of the
order in which they are employed. Therapeutic hypother-
mia was employed in only six centres, most frequently
mild hypothermia (3436 C; 77%, 17/22) rather than
moderate hypothermia (3234 C; 23%, 5/22). Eight
of nine cases undergoing decompressive craniectomy
received at least one other second-tier therapy, suggesting
that decompressive craniectomy is being undertaken once
other therapies have been used.
For the purposes of this study raised ICP was recorded
when ICP was higher than 20 mmHg on more than
1 hourly recording at any point during ICU stay. There
were 101 children in whom ICP was monitored who did
not fulfil this definition. Complete data relating to ICP
therapies were available for 87 of these 101 cases. First-
tier therapies were used in 51% (44/87) of cases in this
group and second-tier therapies in 12% (10/87; Table 2),
suggesting that a proportion of these children may have
experienced raised ICP of insufficient duration to meet
the definition. Alternatively centres may be employing
these therapies at an ICP threshold below 20 mmHg, as
suggested by an earlier survey [2].

Use of ICP-targetted therapies without ICP monitoring

ICP was not monitored in 246 children. Despite this first-

tier therapies were used in 86 children (35%) and second-
tier in 21 (9%; Table 2).

ICU length of stay

Independent risk factors for longer length of stay were

Fig. 2 Venn diagrams showing the use of first-tier ICP-targetted ther-
apies in 89 children with raised ICP and complete data relating to
use of first-tier therapies (a) and the use of second-tier ICP-targetted
therapies in 49 children with raised ICP and complete data relating
to use of second-tier therapies (b)
GCS score below 8 (p = 0.005) or unrecordable GCS
(p = 0.001), abnormal CT (p < 0.001), fixed pupil(s)
(p < 0.001), and raised ICP (p < 0.001). In addition pa-
tients with a normal ICP on monitoring also had a longer
length of stay than those in whom ICP was not monitored

Table 2 Use of ICP-targetted ICP monitoring No ICP monitoring

therapies in children undergoing (n = 246)
ICP monitoring, with and ICP raised (n = 90) ICP not raised (n = 87)
without raised ICP, and in n % n % n %
children in whom ICP
monitoring was not instituted. First-tier ICP therapies
Only cases with complete data CSF drainage 14 16 2 2 1 0.4
relating to ICP therapies have Mannitol 70 78 21 24 35 14
been included Hypertonic saline 32 36 4 5 13 5
Mild hyperventilation 75 83 28 32 64 26
Second-tier ICP therapies
Barbiturates 32 36 1 1 2 1
Hypothermia 22 24 2 2 2 1
Moderate, severe 24 27 7 8 17 7
hyperventilation

Fig. 3 Kaplan Meier plots for time to discharge from ICU by ICP
monitoring status and whether or not ICP was raised. Deaths are
excluded. Using Cox regression both the high-ICP group (hazard ra-
tio 0.26, p < 0.001) and the normal-ICP group (hazard ratio 0.60,
p < 0.001) had a longer length of ICU stay than the unmonitored
group
(p = 0.001; Fig. 3). Fall as the mechanism of injury was
associated with a shorter length of stay (p = 0.04).
Discussion
This study highlights the large variation in practice that
exists across UK units admitting children with severe TBI.
Variation is evident with respect to ICP monitoring, use of
ICP-targetted therapies and areas of general management.
Of particular concern is the use of ICP-targetted therapies
in 86 children without ICP monitoring. The data were col-
lected before publication of the US guidelines [4], the first
published paediatric TBI guidelines. It is possible that pub-
lication of the guidelines will have resulted in a greater
standardisation of approach, although certain areas of man-
agement such as fluid restriction and use of prophylactic
anticonvulsants are not covered within the guidelines.
Previous studies have shown that institutional varia-
tions in practice can have an effect on outcome of patients
with severe TBI. Bulger et al. [6] compared the manage-
ment and outcomes of 182 adult patients with severe TBI
admitted to 33 US trauma centres. They defined aggres-
sive centres as those who instituted ICP monitoring in
more than 50% of patients with a GCS below 8 and abnor-
mal CT findings. Management at an aggressive centre was
associated with a significant reduction in the risk of mortal-
ity and a shorter hospital length of stay for survivors. Til-
ford et al. [7] compared management and outcomes of 477
children with an admitting diagnosis of head trauma admit-
ted to three US paediatric trauma centres. They found sig-
nificant variation in the use of muscle relaxants, anticon-
vulsants, induced hypothermia, and ICP monitoring across
1611
the three centres, with the use of anticonvulsants associated
with a reduced risk of mortality.
Just over one-half of children with severe TBI un-
derwent ICP monitoring, with large between centre
differences. TBI guidelines recommend intra-ventricular
catheter placement as the most accurate, low cost, reliable
method of ICP monitoring, with the additional benefit
of allowing CSF drainage [4, 8]. We found a very low
reported use of ventricular catheters and a higher than
expected reported use of subdural and extradural catheter
positions, methods that have been shown to be less accu-
rate than parenchymal or ventricular placement [9, 10]. It
was not possible to check the accuracy of reporting, and
therefore we cannot rule out the possibility that parenchy-
mal devices were in some cases described as subdural.
The greater ICU length of stay associated with ICP
monitoring could reflect the selective use of ICP monitor-
ing in more severely injured children. However, the rela-
tionship between ICP monitor use and ICU length of stay
persists after controlling for markers of injury severity and
the presence of raised ICP. This suggests that ICP mon-
itoring in less severely injured children may at times be
unnecessarily delaying discharge from ICU. Robust crite-
ria are needed for the prospective identification of children
at significant risk of developing raised ICP.
The management of raised ICP was found to be broadly
consistent with US guidelines, although it is not possi-
ble to be confident about the order with which therapies
are being used. The data would support the survey find-
ings of Segal et al. [2], with hyperventilation used in some
units as first line therapy ahead of hyperosmolar therapy.
As a result of the infrequent use of ventricular catheters
CSF drainage was rarely used and was never used as the
sole ICP therapy. This suggests that some centres selec-
tively place ventricular catheters in patients who demon-
strate refractory intracranial hypertension. The US guide-
lines recommend that monitoring for cerebral ischaemia,
such as jugular venous bulb oximetry, be used if aggres-
sive hyperventilation is employed to lower ICP; 75% of
UK cases underwent moderate or severe hyperventilation
without such monitoring. A small randomised controlled
trial has suggested benefit for early decompressive craniec-
tomy in children with raised ICP following TBI [11]. De-
compressive craniectomy was undertaken only on nine oc-
casions across the UK over the 1-year period of this study
and appeared to be used later in patients with raised ICP
despite first- and second-tier therapies.
This study shows that it is feasible to collect a large
volume of data through an organisation with strong com-
mitment but limited resources. The study was inexpensive,
as centres were offered minimal funding, and its success
depended upon the commitment of the participants. Nev-
ertheless the data returned were generally of high quality
with regard to completeness of information. More than
90% of potential observations were completed, and data
checking revealed few recordings outside specified ranges
1612

or showing obvious inconsistencies requiring referral back
to the investigator for clarification. A limitation of the
study was that no attempt could be made to confirm the
accuracy of the data by comparison with original case
records, as this process is extremely expensive in time
and personnel. In addition our findings relate to those
cases in which a detailed clinical abstract was completed,
representing only 69% of the total cases admitted to
participating units. Only two PICUs that admit children
with TBI did not participate in the study. We think it
unlikely that inclusion of additional cases from these
centres would have altered the key conclusions of the
study. A further limitation of the study was the reliance on
intermittent hourly recording of ICP to define a group with
raised ICP. It is conceivable that a number of additional
children experienced ICP readings above 20 mmHg that
were not captured on the hourly chart recordings.
Conclusions
There is a need for greater standardisation of practice
across UK centres admitting children with severe TBI.
Less variation in management could have a beneficial
effect on outcomes and would be essential, to reduce
between centre heterogeneity, before embarking on
multicentre trials.
Acknowledgements. We are grateful to all the staff of PICUs who
completed data collection forms, to Dr. Kathy Rowan of ICNARC
for supplying data on paediatric admissions to adult ICUs, and to
Naveed Hussain, Helen Sherry and Neil Hallworth for database de-
sign, data entry and preliminary data processing. The UK Paediatric
Traumatic Brain Injury Study Steering Group consists of: K. Morris
(Chair), R. Appleton, M. Crouchman, R. Forsyth, C. Hawley,
M. Marsh, P. May, P. McKinney, J. Middleton, R. Parslow, J. Punt,
T. Ralph and R. Tasker. Participating centres and investigators were:
Addenbrookes Hospital (R. Tasker), Alder Hey Childrens Hospital
(R. Sarginson), Antrim Hospital (A. Ferguson), Beaumont Hospital,
Dublin (E. Keane), Birmingham Childrens Hospital (K. Morris),
Bristol Childrens Hospital (J. Fraser), City General Hospital,
Stoke (J. Alexander), Derriford Hospital, Plymouth (S. Fergu-
son), Great Ormond St. Hospital (M. Kenny, D. Lutman), Guys
Hospital (A. Durward), Hull Royal Infirmary (H. Klonin), John
Radcliffe Hospital (A. Shefler, C. Killick), Kings College Hospital
(D. Prior, l. Edwards, Y. Egberongbe), Leeds General Infirmary
(T. Chater, M. Darowski), Leicester Royal Infirmary (P. Barry),
Queens Medical Centre, Nottingham (P. Khandelwal), James Cook
University Hospital (A. Robinson), Newcastle General Hospital
(R. Forsyth), Royal Belfast Hospital for Sick Children (B. Taylor),
Royal Berkshire Hospital (A. Maunganidze), Royal Devon & Exeter
Hospital (J. Purday), Royal Hospital for Sick Children, Edinburgh
(M. Lo, D. Simpson), Royal Hospital for Sick Children, Glasgow
(P. Cullen), Royal London Hospital (P. Withington), Royal Manch-
ester Childrens Hospital (D. Stewart, M. Samuels), Royal Preston
Hospital (P. Tomlin), Sandwell Hospital (J. Bellin), Sheffield
Childrens Hospital (T. Ralph), Southampton General Hospital
(C. Boyles), Southern General Hospital, Glasgow (D. Snaddon,
A. Wagstaff), St. Georges Hospital (S. Skellett), University Hospital
of Wales (M. Gajraj), Walsgrave Hospital (M. Christie), Walton
Centre for Neurosurgery (E. Wright).

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