title: Initial observations of combination barbiturate coma and decompressive craniectomy for the management of severe pediatric traumatic brain injury.
abstract: OBJECTIVE
  In the pediatric population, treatment of severely injured children presenting with low Glasgow Coma Score (GCS) and fixed and dilated pupils is controversial. The combination of barbiturate coma and decompressive craniectomy as an aggressive means of controlling intracranial pressure is limited to few studies. In the present series, we report our experience with aggressive combination therapy resulting in good outcomes in pediatric patients with severe traumatic brain injury (TBI).
  
  
  METHODS
  Six TBI patients, aged <18 years, either presented with or deteriorated to a GCS <5 with fixed and dilated pupils and CT evidence of surgical lesions with brain edema. Despite hyperventilation, anesthesia, and mannitol, intracranial pressures remained elevated and all patients underwent decompressive craniectomy and external ventricular drainage and were subsequently placed into barbiturate coma for 72 h.
  
  
  RESULTS
  One patient died and 1 patient remained vegetative. Two patients had excellent recoveries (GOS 5/Rankin 1 or 0, no cognitive deficits) and 2 patients had good recoveries (GOS 4/Rankin 1, mild cognitive deficits).
  
  
  CONCLUSIONS
  Combination of barbiturate coma with decompressive craniectomy and external ventricular drainage led to good outcomes in a small group of pediatric patients with severe TBI. Based on this series we recommend further investigation into aggressive combination management.
authors.affiliation: Department of Neurosurgery, Mount Sinai Hospital, Rush Medical College, University of Illinois College of Medicine, Chicago, IL 60608, USA. rpglick@hotmail.com
authors.forename: Roberta P
authors.initials: RP
authors.lastname: Glick
authors.forename: Alexander
authors.initials: A
authors.lastname: Ksendzovsky
authors.forename: John
authors.initials: J
authors.lastname: Greesh
authors.forename: Patti
authors.initials: P
authors.lastname: Raksin
mesh_terms: D000293:Adolescent; D001463:Barbiturates / Q000008:administration & dosage*; D001930:Brain Injuries / Q000175:diagnosis* / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003128:Coma / Q000139:chemically induced; D003131:Combined Modality Therapy; D056424:Decompressive Craniectomy / Q000379:methods; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D012720:Severity of Illness Index
chemical_list: D001463:Barbiturates; C032232:barbituric acid