Severe Traumatic Brain Injury in Childhood—Guidelines

Abstract

Source: Carney NA, Chesnut R, Kochanek PM, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. J Trauma. 2003;54(suppl):S235–S310.Evidence-based guidelines for the management of severe head injury among adults first appeared in 1995 at the initiative of the Brain Trauma Foundation, the American Association of Neurological Surgeons, and the Joint Section on Neurotrauma and Critical Care. Skeptics initially viewed this effort (“The Guidelines” in neurosurgical conversation) as an academic edifice built on a foundation of weak clinical research, but although there has been no dispute about the need for more and better research, the Guidelines have, nevertheless, moved the practice of trauma care forward. The Guidelines have spotlighted important research questions, stimulated examination of practice variation in traumatic brain injury (TBI) care, and discouraged antiquated and potentially harmful interventions such as dehydration, steroid administration, and indiscriminate hyperventilation. There is even some evidence that compliance with the Guidelines has improved outcomes.1Guidelines for the management of severe TBI in childhood have now appeared. Unlike the earlier general document, these guidelines are the product of a genuinely multidisciplinary undertaking that reflected the perspectives of pediatric emergency physicians and intensivists as well as neurosurgeons. They have been endorsed by a variety of national and international specialty societies representing critical care, pediatric critical care, pediatric neurology, pediatric neurosurgery, and trauma surgery. For the widest possible dissemination, they have been published simultaneously in Critical Care Medicine, Pediatric Critical Care Medicine, and the Journal of Trauma.2,3 Treatment recommendations were labeled “Options,” “Guidelines,” and “Standards” in order of increasing confidence provided by increasing quality of the supporting evidence. No recommendations rose to the level of Standards because of the lack of large, properly designed, prospective, randomized, controlled trials—an eloquent commentary on the scientific underpinnings of contemporary practice.This substantial piece of work cannot be summarized briefly. The literature on a broad spectrum of topics was reviewed, ranging from various aspects of pre-hospital care and resuscitation, through many issues in intensive care, to the value of trauma systems. Not surprisingly, the management of elevated intracranial pressure (ICP) received a great deal of attention and the document provides algorithms that sequence and prioritize the available therapies. Several therapies deserve special mention because of current active research interest.Hypertonic (3%) saline has been shown in an open, prospective, randomized trial to reduce intensity of therapy for elevated ICP, to shorten ICU stay, to shorten duration of ventilatory support, and to reduce the frequency of complications in comparison to lactated Ringer’s solution.4 There was no effect on patient out-come, however. Other prospective observational studies have confirmed similar benefits from hypertonic saline for ICP control.Neurosurgical management of elevated ICP received a tentatively favorable review as well. A single-center, randomized, controlled trial of early bitemporal de-compressive craniectomy demonstrated impressive trends toward superior ICP control and superior out-comes at 6 months, but significance was not achieved after allowance for multiple statistical comparisons.5 Two other single-center, case-control studies also showed improved outcomes after decompressive craniectomy; one of these studies was expressly limited to abused infants.6 The pediatric experience complements a favorable adult literature, all of which, nevertheless, requires careful reading because of variations in timing and technique from one report to another.“The Pediatric Guidelines,” as they will soon come to be known in the culture of pediatric trauma care, are necessary and edifying reading for neurosurgeons, intensivists, pediatric surgeons, trauma surgeons, emergency physicians, and pediatricians involved in the initial stabilization or subsequent management of injured children. The paucity of clinical evidence on many important matters will leave readers dissatisfied, but hopefully this document will become a stimulus to rigorous clinical research and uniform, protocol-driven care like its adult predecessor.