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Object: The aim of this study was to evaluate physician agreement with published recommendations and guidelines for the management of severe traumatic brain injury (TBI) in children and to identify markers associated with physician responses matching published guidelines., Methods: An Internet survey was created based on recommendations and guidelines published in 2003 and was sent to US physicians and neurosurgeons caring for pediatric patients with severe TBI. Agreement with each recommendation was tabulated. Characteristics of the surveyed physicians and their institutions were compared to identify markers of conformity with first-tier recommendations (intracranial pressure [ICP] treatment threshold, monitoring cerebral perfusion pressure, use of sedation/neuromuscular blockade, and use of hyperosmolar therapy)., Results: One hundred ninety-four US physicians responded: 36 neurosurgeons and 158 nonsurgeons. Overall, physician responses matched most recommendations more than 60% of the time. The serum osmolality threshold of hypertonic saline, use of prophylactic hyperventilation, and differences in ICP thresholds based on a child's age comprised the recommendations with the least agreement. No physician variable was linked to increased agreement with first-tier recommendations., Conclusions: Overall, physician responses coincided with the published guidelines and recommendations. Examples of variable conformance most likely reflect the paucity of available data and lack of randomized controlled trials in the field of severe TBI.