Traumatic Brain Injury Guidelines Research Articles

Leveraging an EHR tool to improve provider adherence to the modified brain injury guidelines

IntroductionThe aim was to leverage electronic health record (EHR) smartphrases to improve compliance with the modified Brain Injury Guidelines (mBIG). MethodsSmartphrases were developed for the trauma team and radiology and implemented December 2022. Traumatic brain injury (TBI) patients meeting mBIG inclusion from 03/2021- 07/2023 were reviewed. Smartphrase usage and clinical compliance with mBIG (measured by percent reduction of repeat head imaging, ICU admissions, and neurosurgery consults) were compared pre- and post-intervention. Results268 cases were examined. Post-intervention, mBIG1 patients had significantly fewer neurosurgery consults (82.4 ​% vs. 50.0 ​%, OR ​= ​0.21, p ​= ​0.03), while mBIG2 patients had significantly fewer repeat head CTs (91.0 ​% vs. 66.7 ​%, OR ​= ​0.2, p ​= ​0.01), ICU admissions (66.7 ​% vs. 38.5 ​%, OR ​= ​0.31, p ​= ​0.02) and neurosurgery consults (93.9 ​% vs. 56.4 ​%, OR ​= ​0.08, p ​< ​0.01). ConclusionStandardized smartphrases can streamline workflow and significantly improve trauma team compliance with best practice guidelines for TBI and reduce unnecessary imaging, consults, and costly ICU admissions.

Using Physiological Biomarkers to Optimize Management of TBI in Austere Environments.

Multimodal monitoring is the use of data from multiple physiological sensors combined in a way to provide individualized patient management. It is becoming commonplace in the civilian care of traumatic brain-injured patients. We hypothesized we could bring the technology to the battlefield using a noninvasive sensor suite and an artificial intelligence-based patient management guidance system. Working with military medical personnel, we gathered requirements for a hand-held system that would adapt to the rapidly evolving field of neurocritical care. To select the optimal sensors, we developed a method to evaluate both the value of the sensor's measurement in managing brain injury and the burden to deploy that sensor in the battlefield. We called this the Value-Burden Analysis which resulted in a score weighted by the Role of Care. The Value was assessed using 7 criteria, 1 of which was the clinical value as assessed by a consensus of clinicians. The Burden was assessed using 16 factors such as size, weight, and ease of use. We evaluated and scored 17 sensors to test the assessment methodology. In addition, we developed a design for the guidance system, built a prototype, and tested the feasibility. The resulting architecture of the system was modular, requiring the development of an interoperable description of each component including sensors, guideline steps, medications, analytics, resources, and the context of care. A Knowledge Base was created to describe the interactions of the modules. A prototype test set-up demonstrated the feasibility of the system in that simulated physiological inputs would mimic the guidance provided by the current Clinical Practice Guidelines for Traumatic Brain Injury in Prolonged Care (CPG ID:63). The Value-Burden analysis yielded a ranking of sensors as well as sensor metadata useful in the Knowledge Base. We developed a design and tested the feasibility of a system that would allow the use of physiological biomarkers as a management tool in forward care. A key feature is the modular design that allows the system to adapt to changes in sensors, resources, and context as well as to updates in guidelines as they are developed. Continued work consists of further validation of the concept with simulated scenarios.

Equity considerations in clinical practice guidelines for traumatic brain injury and the criminal justice system: A systematic review.

Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect or are involved with the criminal justice system (CJS). In the absence of appropriate care, TBI-related impairments, intersecting social determinants of health, and the lack of TBI awareness in CJS settings can lead to lengthened sentences, serious disciplinary charges, and recidivism. However, evidence suggests that most clinical practice guidelines (CPGs) overlook equity and consequently, the needs of disadvantaged groups. As such, this review addressed the research question "To what extent are (1) intersections with the CJS considered in CPGs for TBI, (2) TBI considered in CPGs for CJS, and (3) equity considered in CPGs for CJS?". CPGs were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of identified CPGs on November 2021 and March 2023 (CPGs for TBI) and May 2022 and March 2023 (CPGs for CJS). Only CPGs for TBI or CPGs for CJS were included. We calculated the proportion of CPGs that included TBI- or CJS-specific content, conducted a qualitative content analysis to understand how evidence regarding TBI and the CJS was integrated in the CPGs, and utilised equity assessment tools to understand if and how equity was considered. Fifty-seven CPGs for TBI and 6 CPGs for CJS were included in this review. Fourteen CPGs for TBI included information relevant to the CJS, but only 1 made a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Two CPGs for CJS acknowledged the prevalence of TBI among individuals in prison and one specifically recommended considering TBI during health assessments. Both CPGs for TBI and CPGs for CJS provided evidence specific to a single facet of the CJS, predominantly in policing and corrections. The use of equity best practices and the involvement of disadvantaged groups in the development process were lacking among CPGs for CJS. We acknowledge limitations of the review, including that our searches were conducted in English language and thus, we may have missed other non-English language CPGs in this review. We further recognise that we are unable to comment on evidence that is not integrated in the CPGs, as we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs. Findings from this review provide the foundation to consider CJS involvement in CPGs for TBI and to advance equity in CPGs for CJS. Conducting research, including investigating the process of screening for TBI with individuals who intersect with all facets of the CJS, and utilizing equity assessment tools in guideline development are critical steps to enhance equity in healthcare for this disadvantaged group.

Neuromonitoring in neurocritical care for traumatic brain injury in the Thai context

The purposes of this review were to identify the incidence and types of traumatic brain injury (TBI) in Thailand, and recommend neuro-monitoring for limited resources in Thai patients. The monitoring methods focus on the targeted and personalized management in severe TBI such as intracranial pressure (ICP), pressure reactivity index (PRx), regional cerebral saturation (rSO2), cerebral autoregulation (CA), as well as noninvasive methods for example near-infrared spectroscopy (NIRS) and optic nerve sheath diameter (ONSD). These monitors are aimed to optimize brain oxygen delivery and prevent further neurologic deterioration in terms of increased ICP and decreased cerebral perfusion pressure (CPP). Some of these were implemented in neurological monitoring protocol and clinical practice guidelines for severe TBI. However, cost - effectiveness is concerned. Even though considering CA and the advance monitoring methods in continuous assessment are widely used, current therapeutic interventions which appear entirely to bedside approach for correct dysregulated CA are limited. In addition, understanding of basic molecular and cellular pathways involved in cerebral homeostasis ( brain oxygen delivery, cerebral blood flow, CA and cerebral vascular reactivity to oxygen and carbon dioxide) as well as secondary brain injury prevention are still necessary for improving TBI outcomes. In summary, further study in Thailand is required to determine optimal cerebral physiologic-based technology, monitoring parameters, and individualized thresholds to optimize CA and potentially improve neurologic outcomes across a spectrum of TBI patients, which focus in Thai rural areas where invasive monitoring is not routinely performed due to resources limitation. Encourage and training of non invasive methods might solve these issues.

Clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds.

Firearm injuries are now the leading cause of death in children and young adults younger than 25 years of age in the US. Current management of these injuries is extrapolated from adult blunt and penetrating traumatic brain injury guidelines. The objectives of this study were to investigate and analyze the clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds (GSWs). Medical records were screened for all patients younger than 21 years of age with an intracranial GSW who presented to the University Medical Center in New Orleans, Louisiana, from 2012 to 2022. Demographics and radiological, clinical, and laboratory data were extracted, and chi-square and Fisher's exact tests were used to evaluate individual association with mortality and functional outcome. Odds ratios were calculated from the cross tabulations for categorical variables and univariate binary logistic regression models for continuous variables. Multivariate binary logistic regression was used to adjust for effects of covariates and isolate the contributions of predictor variables for mortality and functional outcome. Ninety-six patients (82 male, 14 female) had a median age of 18 (interquartile range [IQR] 15-20) years. The 30-day inpatient, 60-day, and 6-month mortality rates among these patients were 53.1%, 0%, and 2.4%, respectively. Those who died were more likely to have an initial Glasgow Coma Scale score ≤ 8 (p < 0.001), bilateral fixed pupils (p < 0.001), transventricular trajectory (p < 0.001), deep nuclear/third ventricle involvement (p = 0.004), bihemispheric trajectory (p = 0.025), injury to ≥ 3 lobes (p = 0.015), parietal lobe involvement (p = 0.023), base deficit < -5 mEq/L (p = 0.013), international normalized ratio (INR) > 1.5 (p = 0.007), and a St. Louis Scale (SLS) score ≥ 5 (p < 0.001). The survivors with favorable functional outcome were more likely to have lower median SLS scores (p = 0.016) and injury to < 3 lobes (p < 0.001). In a multivariate analysis, bilaterally fixed nonreactive pupils were positively associated with mortality and negatively associated with favorable functional outcome, whereas the Injury Severity Score (ISS) and injury to ≥ 3 lobes were negatively associated with favorable functional outcome only. This is one of the largest series of pediatric intracranial GSWs to date. The authors identified certain clinical (bilateral fixed pupils, SLS score ≥ 5, ISS > 16), laboratory (INR > 1.5, base deficit < -5 mEq/L), and radiological (transventricular trajectory, deep nuclear/third ventricle involvement, parietal lobe involvement) factors that were associated with death and poor functional outcome in this pediatric cohort.

Nursing Interventions and Intracranial Pressure Change in Pediatric Patients With Severe Traumatic Brain Injury.

Nursing interventions in the care of pediatric patients with severe traumatic brain injury (TBI) can have a direct effect on intracranial pressure (ICP), yet they have been largely underexplored. Early evidence is therefore needed to describe these relationships and to determine intervention that promotes neuroprotection and recovery. The aim of this study was to examine nursing interventions within the first 72 hours of pediatric severe TBI and their effects on ICP. This is a retrospective review of pediatric patients admitted for severe TBI using a quasi-experimental approach to assess nursing interventions and their association with the patients' ICP values prior to and after each intervention. Of the 56 patients who met the inclusion criteria, 3392 intervention events (range, 31-138 events per patient) were reported. Paired t tests conducted for each intervention type found a statistically significant relationship with suctioning and percent change in ICP values (P = .045). All other interventions showed no significant differences. Standard nursing interventions, specifically suctioning, in pediatric severe TBI may affect ICP and therefore neuroprotection. Further work is needed to better understand the role and timing of nursing interventions and their influence on cerebral hemodynamics so that future TBI guidelines consider nursing care and their impact on brain injury recovery.

Screening Performance of S100 Calcium-Binding Protein B, Glial Fibrillary Acidic Protein, and Ubiquitin C-Terminal Hydrolase L1 for Intracranial Injury Within Six Hours of Injury and Beyond.

The Scandinavian NeuroTrauma Committee (SNC) guidelines recommend S100 calcium-binding protein B (S100B) as a screening tool for early detection of Traumatic brain injury (TBI) in patients presenting with an initial Glasgow Coma Scale (GCS) of 14-15. The objective of the current study was to compare S100B's diagnostic performance within the recommended 6-h window after injury, compared with glial fibrillary acidic protein (GFAP) and UCH-L1. The secondary outcome of interest was the ability of these biomarkers in detecting traumatic intracranial pathology beyond the 6-h mark. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core database (2014-2017) was queried for data pertaining to all TBI patients with an initial GCS of 14-15 who had a blood sample taken within 6 h of injury in which the levels of S100B, GFAP, and UCH-L1 were measured. As a subgroup analysis, data involving patients with blood samples taken within 6-9 h and 9-12 h were analyzed separately for diagnostic ability. The diagnostic ability of these biomarkers for detecting any intracranial injury was evaluated based on the area under the receiver operating characteristic curve (AUC). Each biomarker's sensitivity, specificity, and accuracy were also reported at the cutoff that maximized Youden's index. A total of 531 TBI patients with GCS 14-15 on admission had a blood sample taken within 6 h, of whom 24.9% (n = 132) had radiologically confirmed intracranial injury. The AUCs of GFAP (0.86, 95% confidence interval [CI]: 0.82-0.90) and UCH-L1 (0.81, 95% CI: 0.76-0.85) were statistically significantly higher than that of S100B (0.74, 95% CI: 0.69-0.79) during this time. There was no statistically significant difference in the predictive ability of S100B when sampled within 6 h, 6-9 h, and 9-12 h of injury, as the p values were >0.05 when comparing the AUCs. Overlapping AUC 95% CI suggests no benefit of a combined GFAP and UCH-L1 screening tool over GFAP during the time periods studied [0.87 (0.83-0.90) vs. 0.86 (0.82-0.90) when sampled within 6 h of injury, 0.83 (0.78-0.88) vs. 0.83 (0.78-0.89) within 6 to 9 h and 0.81 (0.73-0.88) vs. 0.79 (0.72-0.87) within 9-12 h]. Targeted analysis of the CENTER-TBI core database, with focus on the patient category for which biomarker testing is recommended by the SNC guidelines, revealed that GFAP and UCH-L1 perform superior to S100B in predicting CT-positive intracranial lesions within 6 h of injury. GFAP continued to exhibit superior predictive ability to S100B during the time periods studied. S100B displayed relatively unaltered screening performance beyond the diagnostic timeline provided by SNC guidelines. These findings suggest the need for a reevaluation of the current SNC TBI guidelines.

Abstract 252: End-Tidal CO2 and Glasgow Coma Scale in Non-Intubated Traumatic Brain Injury Patients: Evaluation of Prehospital Nasal Capnography and Level of Consciousness

Background: The EMS traumatic brain injury (TBI) guidelines recommend limiting intubation (ETI) to patients with profoundly-depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate with basic maneuvers. Thus, many major TBIs are managed without ETI in the field. Monitoring ETCO2 via nasal sensors (NC-CO2) in non-ETI patients may provide valuable information about ventilatory status and trends. However, EMS NC-CO2 remains unstudied. Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI. Methods: Cases from 7 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC TBI Study (NIH 1R01NS071049) were evaluated (4/13-4/18). Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: &lt;15, &lt;12, &lt;9, 3. Results: Included: 177 cases [median age: 52 (range: 9-94), 66% male]. Overall, while not statistically significant, NC-CO2 tended to be lower in patients with lower GCS (Table). In addition, minimum NC-CO2 was significantly lower (p=0.01) in patients with compromised LOC (Table). O2 management (Hi-flow/Lo-flow/No O2) was documented in 176 patients (99.4%). Among the 107 patients with all GCS = 15, 44 (41%) had Hi-flow administered compared to 47/69 (68%) with any GCS &lt;15 (p=0.0008). Conclusion: The utility of prehospital capnography in non-intubated patients is unknown. In this study, NC-CO2 tended to be lower in TBI patients with lower GCS. Whether this reflects physiological/respiratory differences with changes in LOC, or variations in methods of managing oxygenation is unclear. These intriguing new findings require future study to determine if NC-CO2 is directly reflective of LOC-related ventilatory patterns. Furthermore, studies are needed to evaluate whether NC-CO2 monitoring has clinical utility as a non-invasive adjunct to care in spontaneously-breathing, non-ETI patients.

Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review.

In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24h after head trauma), the incidence of intracranial pathology in early (24h) versus late (>24h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations. A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ2. Multivariate logistic regression analyses were used to identify TBI predictors. The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury. Patients coming to the emergency department after 24h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.

Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review

Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs. For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696). Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI. Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations. Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

Traumatic Brain Injury Intensive Evaluation and Treatment Program: Protocol for a Partnered Evaluation Initiative Mixed Methods Study.

The traumatic brain injury (TBI) Intensive Evaluation and Treatment Program (IETP) is an innovative modality for delivering evidence-based treatments in a residential, inpatient format to special operational forces service members and veterans with mild TBI. IETPs provide bundled evidence-based assessment, treatment, referral, and case management in concordance with the existing guidelines for mild TBI and commonly co-occurring comorbidities. To date, there has been no formal characterization or evaluation of the IETP to understand the determinants of implementation across the system of care. The goal of our partnered evaluation initiative (PEI) with an operational partner, the Physical Medicine and Rehabilitation National Program Office, is to facilitate the full implementation of the IETP across all 5 Veterans Health Administration TBI-Centers of Excellence (TBI-COE) and to inform minimum standards while supporting the unique characteristics of each site. This IETP partnered evaluation will describe each of the 5 TBI-COE IETP services and state of implementation to identify opportunities for adaptation and scale, characterize the relationship between patient characteristics and clinical services received, evaluate the outcomes for participants in the IETP, and inform ongoing implementation and knowledge translation efforts to support IETP expansion. In alignment with the goals of the protocol, ineffective treatment components will be targeted for deimplementation. A 3-year concurrent mixed methods evaluation using a participatory approach in collaboration with the operational partner and TBI-COE site leadership will be conducted. Qualitative observations, semistructured focus groups, and interviewing methods will be used to describe IETP, stakeholder experiences and needs, and suggestions for IETP implementation. Quantitative methods will include primary data collection from patients in the IETP at each site to characterize long-term outcomes and patient satisfaction with treatment and secondary data collection to quantitatively characterize patient-level and care system-level data. Finally, data sets will be triangulated to share data findings with partners to inform ongoing implementation efforts. Data collection began in December 2021 and is currently ongoing. The results and deliverables will inform IETP characterization, evaluation, implementation, and knowledge translation. The results of this evaluation seek to provide an understanding of the determinants affecting the implementation of IETPs. Service member, staff, and stakeholder insights will inform the state of implementation at each site, and quantitative measures will provide options for standardized outcome measures. This evaluation is expected to inform national Physical Medicine and Rehabilitation Office policies and processes and knowledge translation efforts to improve and expand the IETP. Future work may include cost evaluations and rigorous research, such as randomized controlled trials. DERR1-10.2196/44776.

Utility and Feasibility of Simulation-based Training in Teaching Concepts of Traumatic Brain Management to Neurology Trainees (P8-2.001)

<h3>Objective:</h3> To assess the feasibility and utility of simulation-based training in teaching concepts surrounding management of traumatic brain injury (TBI). <h3>Background:</h3> Neurology trainees respond to neurological emergencies but often do not have the opportunity to practice implementing their clinical knowledge and communication skills in managing such emergencies outside the clinical setting. <h3>Design/Methods:</h3> We developed a simulation-based training program for neurology residents to practice managing a patient presenting with acute TBI under the direct supervision of an expert in neurocritical care with opportunities for debriefing and feedback. The educational aims of the simulation were to familiarize learners with Brain Trauma Foundation guidelines on the management of TBI and to allow learners to practice closed loop communication in a multidisciplinary team. The simulation involved two learners, one confederate playing the role of emergency room nurse and ICU fellow, and a hired actor who played the role of the patient. Prior to the simulation, learners were given a 10-slide presentation to review relevant topics. A total of 40 minutes was allotted per session; 5 minutes to introduce the scenario, 20 minutes to complete the scenario, and 10 minutes for a debriefing. The effect of the simulation on learner aptitude in managing TBI was assessed via anonymous post-test. <h3>Results:</h3> A total of 8 learners participated in the simulation-based training. We were able to complete all simulation sessions in the allotted 40-minute time frame. On post-test reporting, 7/8 learners felt confident in managing TBI, 8/8 felt their confidence improved with the simulation, and 8/8 endorsed comfort in accessing resources regarding TBI guidelines. <h3>Conclusions:</h3> Teaching TBI management via simulation-based training is feasible and allows trainees to gain experience and comfort managing TBI. <b>Disclosure:</b> Dr. Franzova has nothing to disclose. Dr. Waldrop has nothing to disclose. Dr. Nwankwo has nothing to disclose. Dr. Ader has nothing to disclose. Dr. Bell has nothing to disclose. Dr. Velazquez has nothing to disclose. Dr. Agarwal has nothing to disclose. Dr. Roh has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Portola Pharmaceuticals. Dr. Park has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Neurocritical Care. The institution of Dr. Park has received research support from National Institutes of Health. Sander Connolly has received intellectual property interests from a discovery or technology relating to health care. Dr. Claassen has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Marinus. Dr. Claassen has stock in iCE Neurosystems. The institution of Dr. Claassen has received research support from NINDS. The institution of Dr. Claassen has received research support from McDonnel Foundation. Dr. Claassen has received publishing royalties from a publication relating to health care. Dr. Claassen has received publishing royalties from a publication relating to health care. Dr. Amiel has nothing to disclose. Dr. Ghoshal has nothing to disclose.

Associations between intracranial pressure thresholds and multimodal monitoring in acute traumatic neural injury: a scoping review

Current moderate/severe traumatic brain injury (TBI) guidelines suggest the use of an intracranial pressure (ICP) treatment threshold of 20 mmHg or 22 mmHg. Over the past decade, the use of various cerebral physiology monitoring devices has been incorporated into neurocritical care practice and termed "multimodal monitoring." Such modalities include those that monitor systemic hemodynamics, systemic and brain oxygenation, cerebral blood flow (CBF), cerebral autoregulation, electrophysiology, and cerebral metabolism. Given that the relationship between ICP and outcomes is not yet entirely understood, a comprehensive review of the literature on the associations between ICP thresholds and multimodal monitoring is still needed. We conducted a scoping review of the literature for studies that present an objective statistical association between ICP above/below threshold and any multimodal monitoring variable. MEDLINE, BIOSIS, Cochrane library, EMBASE, Global Health, and SCOPUS were searched from inception to July 2022 for relevant articles. Full-length, peer-reviewed, original works with a sample size of ≥50 moderate-severe TBI patients were included in this study. A total of 13 articles were deemed eligible for final inclusion. The included articles were significantly heterogenous in terms of their designs, demographics, and results, making it difficult to draw any definitive conclusions. No literature describing the association between guideline-based ICP thresholds and measures of brain electrophysiology, cerebral metabolism, or direct metrics of CBF was found. There is currently little literature that presents objective statistical associations between ICP thresholds and multimodal monitoring physiology. However, overall, the literature indicates that having ICP above guideline based thresholds is associated with increased blood pressure, increased cardiac decoupling, reduced parenchymal brain oxygen tension, and impaired cerebral autoregulation, with no association with CBF velocity within the therapeutic range of ICP. There was insufficient literature to comment on other multimodal monitoring measures.

Prehospital and emergency management of pediatric traumatic brain injury: a multicenter site survey.

There is a paucity of information on pediatric traumatic brain injury (TBI) care in Asia and Latin America. In this study, the authors aimed to describe the clinical practices of emergency departments (EDs) participating in the Saline in Asia and Latin-America Neurotrauma in the Young (SALTY) study, by comparing designated trauma centers (DTCs) and nontrauma centers (NTCs) in their networks. The authors performed a site survey study on pediatric TBI management in the EDs in 14 countries. Two European centers joined other participating sites in Asia and Latin America. Questions were formulated after a critical review of current TBI guidelines and published surveys. The authors performed a descriptive analysis and stratified centers based on DTC status. Of 24 responding centers (70.6%), 50.0% were DTCs, 70.8% had academic affiliations, and all centers were in urban settings. Patients were predominantly transferred to DTCs by centralized prehospital services compared to those sent to NTCs (83.3% vs 41.7%, p = 0.035). More NTCs received a majority of their patients directly from the trauma scene compared to DTCs (66.7% vs 25.0%, p = 0.041). Ten centers (41.7%) reported the use of a TBI management guideline, and 15 (62.5%) implemented CT protocols. Ten DTCs reported implementation of intervention strategies for suspected raised intracranial pressure (ICP) before conducting a CT scan, and 6 NTCs also followed this practice (83.3% vs 50.0%, p = 0.083). ED management for children with TBI was comparable between DTCs and NTCs in the following aspects: neuroimaging, airway management, ICP monitoring, fluid resuscitation, anticoagulant therapy, and serum glucose control. Hyperventilation therapy for raised ICP was used by 33.3% of sites. This study evaluated pediatric TBI management and infrastructure among 24 centers. Limited differences in prehospital care and ED management for pediatric patients with TBI were observed between DTCs and NTCs. Both DTCs and NTCs showed variation in the implementation of current TBI management guidelines. There is an urgent need to investigate specific barriers to guideline implementation in these regions.

The Utah Pediatric Trauma Network, a statewide pediatric trauma collaborative can safely help nonpediatric hospitals admit children with mild traumatic brain injury.

Created in 2019, the Utah Pediatric Trauma Network (UPTN) is a transparent noncompetitive collaboration of all hospitals in Utah with the purpose of improving pediatric trauma care. The UPTN implements evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. The first initiative was to help triage the care of traumatic brain injury (TBI) to prevent unnecessary transfers while ensuring appropriate care. The purpose of this study was to review the effectiveness of this network wide guideline. The UPTN REDCap database was retrospectively reviewed between January 2019 and December 2021. Comparisons were made between the pediatric trauma center (PED1) and nonpediatric hospitals (non-PED1) in admissions of children with very mild, mild, or complicated mild TBI. Of the total 3,315 cases reviewed, 294 were admitted to a non-PED1 hospital and 1,061 to the PED1 hospital with very mild/mild/complicated mild TBI. Overall, kids treated at non-PED1 were older (mean, 14.9 vs. 7.7 years; p = 0.00001) and more likely to be 14 years or older (37% vs. 24%, p < 0.00001) compared with those at PED1. Increased admissions occurred post-UPTN at non-PED1 hospitals compared with pre-UPTN (43% vs. 14%, p < 0.00001). Children admitted to non-PED1 hospitals post-UPTN were younger (9.1 vs. 15.7 years, p = 0.002) with more kids younger than 14 years (67% vs. 38%, p = 0.014) compared with pre-UPTN. Two kids required next-day transfer to a higher-level center (1 to PED1), and none required surgery or neurosurgical evaluation. The mean length of stay was 21.8 hours (interquartile range, 11.9-25.4). Concomitantly, less children with very mild TBI were admitted to PED1 post-UPTN (6% vs. 27%, p < 0.00001) and more with complicated mild TBI (63% vs. 50%, p = 0.00003) than 2019. Implementation of TBI guidelines across the UPTN successfully allowed nonpediatric hospitals to safely admit children with very mild, mild, or complicated mild TBI. In addition, admitted kids were more like those treated at the PED1 hospital. Prognostic/Epidemiological; Level IV.

Adherence to Traumatic Brain Injury Guidelines in Turkey: A National Survey Study.

To discuss adherence to guidelines for the management of traumatic brain injury (TBI) in Türkiye and physicians' attitudes toward standardized, evidence-based medical practice. Survey questions were uploaded on the website www.surveymonkey.com and sent to the participants via e-mail or social media applications. The first 10 questions were about the participants' profiles, and the rest were purposed on presenting the physicians' viewpoint on and barriers against CPG adherence. SPSS version 17.0 for Windows was used for statistical analysis. A total of 404 physicians (neurosurgeons, 59.5%; anesthesiologists, 16.7%; and emergency medicine practitioners, 23.9%) who were involved in TBI management were included in this study. Of them, 61.7% stated that they frequently adhere to the CPG recommendations for TBI. In their own experience, most of the respondents agreed that CPGs frequently improve outcomes. They stated that they would occasionally or never adopt recommendations with weak evidence. Physicians reached a consensus on individualizing the decision-making along with the CPG recommendations. Of the participants, 61% adopted the CPG recommendations. The main barriers to the implementation of the CPGs are the strength of evidence levels and the affordability of the recommendations.

Early Diagnostic Performance of S100B, GFAP and UCH-L1 Within the Timeframe Defined by the Scandinavian Traumatic Brain Injury Guidelines

Early Diagnostic Performance of S100B, GFAP and UCH-L1 Within the Timeframe Defined by the Scandinavian Traumatic Brain Injury Guidelines

A systematic review protocol for assessing equity in clinical practice guidelines for traumatic brain injury and homelessness.

BackgroundWhen used optimally, clinical practice guidelines (CPGs) can reduce inappropriate variations in practice, improve application of research to practice, and enhance the quality of healthcare. However, a common criticism, despite its potential, is the lack of consideration for equity and disadvantaged populations.ObjectivesThis protocol is for a systematic review of CPGs for traumatic brain injury (TBI) and homelessness that aims to assess (1) the extent to which evidence regarding TBI and homelessness is integrated in CPGs for homelessness and TBI, respectively, and (2) equity considerations in CPGs for TBI and homelessness.Methods and analysisThe methodology for this review is guided by the PRISMA-P, validated search filters for CPGs, and methodological guides to searching systematic reviews and gray literature. CPGs will be identified from (a) databases for peer-reviewed literature (MEDLINE, Embase, CINAHL, and PsycInfo), (b) targeted websites and Google Search for gray literature, and (c) reference lists of peer-reviewed and gray literature that meet the eligibility criteria. Searching for gray literature, including from guideline-specific resources, is a critical component of this review and is considered an efficient approach to identifying CPGs, given the low precision of searching peer-reviewed databases. Two independent reviewers will screen all articles based on pre-determined eligibility criteria. A narrative synthesis will be conducted to identify the proportion of CPGs that integrate evidence about TBI and homelessness and how TBI and homelessness is or is not integrated in CPGs. Quality appraisal will take the form of an equity assessment of CPGs and will be completed independently by two reviewers.ConclusionThis protocol outlines the methodology for a systematic review of CPGs for TBI and homelessness. The resulting systematic review from this protocol will form an evidence-based foundation to advance CPGs for individuals with lived experience of TBI and homelessness.Systematic review registrationidentifier: CRD42021287696.

Severe Pediatric Traumatic Brain Injury Treatment Approaches of Pediatric Intensivists in Turkey PICUs: National Survey Results

Objective:In patients with severe traumatic brain injury, it is possible to obtain a good long-term prognosis, prevent secondary injury, and decrease morbidity and mortality with the administration of appropriate treatments in the acute period. This study aims to evaluate the approaches of the pediatric intensive care specialists in Turkey towards the follow-up and treatment of severe traumatic brain injury by using a survey that had been prepared in light of the current pediatric severe traumatic brain injury guideline.Materials and Methods:The survey, which included 45 questions, was prepared on the SurveyMonkey® system sent by e-mail to the centers, which were members of the Turkish Society of Pediatric Emergency and Intensive Care Medicine.Results:A total of 45 centers participated in the survey. In all centers, computed tomography of the brain was found to be the first choice as an imaging method for traumatic brain injuries. In terms of hyperosmolar therapy, 30 (66.6%) centers stated that they used 3% hypertonic saline, and 16 (35.5%) centers stated using 3% hypertonic saline+mannitol. Forty (86.96%) centers stated that they did not use prophylactic hyperventilation in the first 48 hours. A total of 44 centers (97.78%) stated that they administered prophylactic antiepileptic drugs in the first 7 days while the most preferred antiepileptic drug was levetiracetam. Conclusion:The results of our survey supported that the pediatric intensive care specialists in Turkey planned a large percentage of the treatment for patients with severe traumatic brain injury in line with the published traumatic brain injury guidelines.

Relationship between guideline adherence and outcomes in severe traumatic brain injury.

Traumatic brain injury (TBI) is a leading cause of death and morbidity worldwide. Evidence-based guidelines for managing severe TBI have been available for over 25 years. However, adherence to guidelines remains variable despite evidence highlighting improvement in outcomes with individual recommendations. There is limited evidence to support a superior outcome with compliance to whole sets of recommendations. The aim of this review was to determine whether adherence to TBI guidelines as a package improves outcomes in adults and paediatric patients with severe TBI. A structured literature search was conducted using the MEDLINE®, Embase™, PubMed and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases. Studies were considered eligible for inclusion in this review if they were quantitative studies investigating the use of TBI guidelines in relation to one or more of the following outcomes: mortality, functional outcome and length of hospital stay. Nine cohort studies were identified that fulfilled the inclusion criteria and answered the clinical question. A review of these papers was conducted. Mortality after severe TBI improves with increasing adherence to evidence-based guidelines in both adults and children. The evidence also suggests that compliance with guideline recommendations results in improved functional outcomes and reduced length of hospital stay.