The primary goal in treating any pediatric patient with severe traumatic brain injury (TBI) is the prevention of secondary insults such as hypotension, hypoxia, and cerebral edema. Despite the publication of guidelines, significant variations in the treatment of severe TBI continue to exist, especially in regards to intracranial pressure (ICP)-guided therapy. This variability in treatment results mainly from a paucity of data from which to create standards and from the heterogeneity inherent in pediatric TBI. The approach to management of severe TBI based on the published guidelines should be focused on ICP control, which should ultimately improve cerebral perfusion pressure. After identifying and surgically evacuating expanding hematomas, the first-tier treatment approach requires placing an ICP monitor. This is accompanied by medical management of elevated ICP, initially with simple maneuvers such as elevating the head of the bed to improve venous drainage, instituting sedation and analgesia to decrease metabolic demands of the brain, and draining cerebrospinal fluid. If these measures fail, then further first-tier interventions include hyperosmolar therapy to decrease cerebral edema and controlled ventilation to decrease cerebral blood volume. For elevations of ICP resistant to first-tier therapies, treatment escalates to second-tier therapy, which includes more aggressive measures such as placing jugular catheters to measure cerebral oxygenation with moderate hyperventilation, placing lumbar drains to remove more cerebrospinal fluid, administering high-dose barbiturates to suppress cerebral electrical activity, inducing hypothermia as a protective measure, and performing decompressive craniectomy to open the cranial vault. To properly execute these interventions, appropriate neuromonitoring is essential, starting from standard physiological parameters such as ICP, mean arterial blood pressure, and temperature. Additional modalities of neurologic monitoring are becoming more readily available and can provide additional clinically useful information about the pediatric patient with TBI; these include cerebral oxygenation, continuous electroencephalography, noninvasive blood flow monitoring, and advanced neuroimaging.