Care of children with acute brain injury is evolving from mere observation to active intervention that requires intensive care units focused on the nervous system primarily and other organs secondarily. The physical examination supplemented by neuroimaging, invasive monitoring, and an improved understanding of the mechanisms of injury allows for the development of rational therapies. This paper reviews common bedside controversies in care, including initial assessments and outcomes, as well as the prevention of secondary injury through the maintenance of brain oxygen and energy and the treatment of cerebral edema. The advantages and disadvantages of frequently utilized techniques are identified.