Previous reports have shown that the implementation of Brain Trauma Foundation guidelines for management of traumatic brain injury in adults has been associated with significant reduction in mortality and neurological disability. To compare two-cohorts on the clinical outcome in the management of children with TBI in the tertiary-care pediatric intensive care unit before and after the implementation of BTF guidelines, 34 children (age from 1 month to 14 years) with acute traumatic brain injury admitted in Pediatric Intensive Care Unit of AKUH from January 2000 to December 2007 were identified from electronic database. Twenty patients (Group I) were treated with traditional treatment before the implementation of BTF guidelines and 14 patients (Group II) treated with BTF guidelines as multidisciplinary team approach with special emphasis on initial prompt resuscitation to avoid hypoxia, hypotension, and maximize the cerebral oxygenation by reducing intracranial pressure, and optimize cerebral perfusion. We compared the mortality, Glasgow Outcome Scale (GOS) and length of stay (LOS) between two cohorts. Patients in two groups were similar with respect to age, gender, mode of injury, Glasgow Coma Scale and neurosurgical procedure before admission in PICU. Implementation of BTF guidelines was associated with a marked reduction in mortality from 40 % to 0% (relative risk 2.6; 95% confidence interval 1.3 -5.2; p<0.007) and decreased in the LOS (relative risk 2.2; 95% confidence interval 1.4-3.3; p<0.002). The absolute risk reduction of mortality is 0.4 Adherence to BTF guidelines in management of children with acute TBI was very effective. It can be successfully implemented in other regional hospitals.