Traumatic Brain Injury Guidelines Research Articles

Assessment and rehabilitation of acquired communication disorders in Aboriginal and Torres Strait Islander adults with stroke or traumatic brain injury: a retrospective chart review

Purpose Speech-language pathologists’ (SLP) management practices for Aboriginal and Torres Strait Islander adults with acquired communication disorder (ACD), following stroke or traumatic brain injury (TBI), are not well understood. This study explores SLPs’ management approaches for ACDs for Aboriginal and Torres Strait Islander adults post-stroke or TBI. Materials and methods SLPs’ documented notes were analysed from a two-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years), admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI. Results SLPs frequently used informal approaches to assess ACDs. English-language formal assessment tools were also used in conjunction with the informal approaches. ACD diagnosis was more common in stroke than TBI patients. One-third of patients with ACD received inpatient rehabilitation at the study site. SLPs infrequently documented cultural or linguistic adaptions to assessment or interventions. Conclusions Informal approaches to assess ACDs were commonly employed which may be because they are perceived to be more culturally appropriate. Clinical guidelines for stroke and TBI should accommodate the diversity of cultures and languages. Better consideration of Aboriginal and Torres Strait Islander communication styles and incorporation of these into SLP ACD management approaches may facilitate accurate diagnosis and culturally safe rehabilitation services. Implications for Rehabilitation Informal approaches for assessment and intervention of ACDs, that incorporate yarning and salient tasks, are likely to be more culturally appropriate and safe for Aboriginal and Torres Strait Islander peoples. More flexibility and guidance in the use of culturally and linguistically appropriate alternative assessment approaches are required in the National stroke guidelines for Aboriginal and Torres Strait Islander peoples. The adoption of enhanced models of culturally secure ACD service provision, that incorporate frequent SLP engagement with an Aboriginal or Torres Strait Islander support person during assessment and rehabilitation, are needed. There is an imperative for health professionals to actively account for culture and language difference in rehabilitation practices to ensure Indigenous peoples worldwide receive equitable and culturally-responsive services.

Opportunities and Challenges in High-Quality Contemporary Data Collection in Traumatic Brain Injury: The CENTER-TBI Experience

Strong evidence in support of guidelines for traumatic brain injury (TBI) is lacking. Large-scale observational studies may offer a complementary source of evidence to clinical trials to improve the care and outcome for patients with TBI. They are, however, challenging to execute. In this review, we aim to characterize opportunities and challenges of large-scale collaborative research in neurotrauma. We use the setup and conduct of Collaborative European Neurotrauma Effectiveness Research in TBI (CENTER-TBI) as an illustrative example. We highlight the importance of building a team and of developing a network for younger researchers, thus investing toward the future. We involved investigators early in the design phase and recognized their efforts in a group contributor list on all publications. We found, however, that translation to academic credits often failed, and we suggest that the current system of academic credits be critically appraised. We found substantial variability in consent procedures for participant enrollment within and between countries. Overall, obtaining approvals typically required 4-6months, with outliers up to 18months. Research costs varied considerably across Europe and should be defined by center. We substantially underestimated costs of data curation, and we suggest that 15-20% of the budget be reserved for this purpose. Streamlining analyses and accommodating external research proposals demanded a structured approach. We implemented a systematic inventory of study plans and found this effective in maintaining oversight and in promoting collaboration between research groups. Ensuring good use of the data was a prominent feature in the review of external proposals. Multiple interactions occurred with industrial partners, mainly related to biomarkers and neuroimaging, and resulted in various formal collaborations, substantially extending the scope of CENTER-TBI. Overall, CENTER-TBI has been productive, with over 250 international peer-reviewed publications. We have ensured mechanisms to maintain the infrastructure and continued analyses. We see potential for individual patient data meta-analyses in connection to other large-scale projects. Our collaboration with Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) has taught us that although standardized data collection and coding according to common data elements can facilitate such meta-analyses, further data harmonization is required for meaningful results. Both CENTER-TBI and TRACK-TBI have demonstrated the complexity of the conduct of large-scale collaborative studies that produce high-quality science and new insights.

Evolution and Impact of the Brain Trauma Foundation Guidelines.

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care. Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

Levetiracetam vs phenytoin prophylaxis in severe traumatic brain injury: Systematic review and meta-analysis

BackgroundProphylaxis against seizures has been recommended in the guidelines for severe traumatic brain injury. Levetiracetam has been suggested as an alternative pharmacotherapy to phenytoin due to more favorable side effects profile. The aim of this study is to compare the evidence for levetiracetam versus phenytoin for the prophylaxis of early seizures after severe brain trauma. MethodsWe searched the EMBASE, MEDLINE and COCHRANE databases for relevant articles from inception to February 16, 2021 using key words related to traumatic brain injury, levetiracetam and phenytoin. Studies retrieved were screened to include observational studies or randomized controlled trials of adult patients with severe brain trauma with comparison of levetiracetam and phenytoin for the prophylaxis of seizures within the first week after trauma. Study characteristics and outcomes were extracted from each included study. The meta-analysis was conducted in compliance with PRISMA guidelines using a random-effects model programmed in R. Data were independently extracted by 2. The primary outcome was seizure incidence within the first 7 days after admission. Secondary outcomes include mortality rate and hypotension incidence. Results485 articles were screened via abstract and title, after which 67 were screened by full text. 5 articles were included in the meta-analysis. There was no significant difference found between levetiracetam and phenytoin for the outcomes of early seizure, mortality, or hypotension. GRADE analysis showed very low-quality evidence for all three outcomes, with limitations primarily due to risk of bias, and inconsistency. Furthermore, seizures and hypotension can be considered indirect measures for long-term functional outcomes. ConclusionsHigh quality, well powered randomized clinical trials comparing levetiracetam and phenytoin, preferably with long-term functional outcomes, need to be performed to improve the quality of the evidence for early seizure prophylaxis in severe traumatic brain injury. Level of evidenceSystematic Review, level IV, therapeutic.

Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal.

Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care. A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%. Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence. Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.

Choice of Whole Blood versus Lactated Ringer's Resuscitation Modifies the Relationship between Blood Pressure Target and Functional Outcome after Traumatic Brain Injury plus Hemorrhagic Shock in Mice.

Civilian traumatic brain injury (TBI) guidelines recommend resuscitation of patients with hypotensive TBI with crystalloids. Increasing evidence, however, suggests that whole blood (WB) resuscitation may improve physiological and survival outcomes at lower resuscitation volumes, and potentially at a lower mean arterial blood pressure (MAP), than crystalloid after TBI and hemorrhagic shock (HS). The objective of this study was to assess whether WB resuscitation with two different MAP targets improved behavioral and histological outcomes compared with lactated Ringer's (LR) in a mouse model of TBI+HS. Anesthetized mice (n = 40) underwent controlled cortical impact (CCI) followed by HS (MAP = 25-27 mm Hg; 25 min) and were randomized to five groups for a 90 min resuscitation: LR with MAP target of 70 mm Hg (LR70), LR60, WB70, WB60, and monitored sham. Mice received a 20 mL/kg bolus of LR or autologous WB followed by LR boluses (10 mL/kg) every 5 min for MAP below target. Shed blood was reinfused after 90 min. Morris Water Maze testing was performed on days 14-20 post-injury. Mice were euthanized (21 d) to assess contusion and total brain volumes. Latency to find the hidden platform was greater versus sham for LR60 (p < 0.002) and WB70 (p < 0.007) but not LR70 or WB60. The WB resuscitation did not reduce contusion volume or brain tissue loss. The WB targeting a MAP of 60 mm Hg did not compromise function versus a 70 mm Hg target after CCI+HS, but further reduced fluid requirements (p < 0.03). Using LR, higher achieved MAP was associated with better behavioral performance (rho = -0.67, p = 0.028). Use of WB may allow lower MAP targets without compromising functional outcome, which could facilitate pre-hospital TBI resuscitation.

Effect of an Educational Intervention on the Knowledge about Traumatic Brain Injury Guidelines among Clinical Nurses

Abstract Objective Traumatic brain injury (TBI) is a major cause of death and disability throughout the world including developing countries like India. Adherence to guideline based TBI management has proven to decrease death rate and improve neurological outcomes. This study aimed to assess the knowledge of TBI guidelines among clinical nurses caring for TBI patients, and to determine the effect of an educational intervention on their knowledge. Methods Preexperimental, one group pretest and posttest design was used. A purposive sample of 60 nurses was included in the study. A structured questionnaire was prepared to assess the knowledge of nurses. Educational intervention was given in the form of a planned teaching program that was prepared based on the national TBI guidelines. Results There was a significant gain in the knowledge scores of the nurses after the educational intervention when compared with the knowledge scores before the intervention (p = 0.001) Nurses who were experienced more than 10 years were found to have significantly higher knowledge score than others with lesser years of experience. Discussion This study demonstrates important knowledge gap about TBI guidelines among clinical nurses. Educational interventions can be effectively used to improve the knowledge about TBI guidelines among nurses.

Barriers and facilitators to the management of mental health complications after mild traumatic brain injury.

Background:Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI.Methods & results:Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains.Conclusion:Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

Acute traumatic brain injury and the use of head computed tomography scans in the emergency department

Introduction The use of CT head scanning for traumatic brain injury (TBI) is a vital diagnostic tool, guided by risk stratification tools. This study aims to review the use of CT head scans and adherence to guidelines for TBI in two New Zealand emergency departments (EDs). Methods Retrospective observational study of patients referred for head CT from EDs to exclude a significant intracranial injury between 1st September 2018 and 31st August 2019. Clinical data were collected regarding presenting patterns, identification of injuries on CT scan and adherence to National Institute of Clinical Excellence (NICE) CT head guidelines. Results Out of 425 included cases, 41 (10%) patients had an intracranial injury seen on their CT head scan. Patients who reported loss (32% vs 20%, p &lt; 0.05) or possible loss of consciousness (34% vs 22%, p &lt; 0.05) and had a Glasgow Coma Score (GCS) &lt;13 (17% vs 8%, p &lt; 0.05) or focal neurology (10% vs 3%, p &lt; 0.05) were more likely to have an intracranial injury on CT. Interestingly, 17 (41%) patients with CT diagnosed injuries had a GCS 15 and no focal neurology. NICE guidelines were adhered to in 364 (86%) of CT requests. In the 14% of cases that did not meet guideline criteria, all CT head scans were negative. Conclusion CT head scans are a valuable tool in TBI, and guidelines successfully identify those with significant intracranial injuries. However, the rate of significant injury for the total population requiring head CT remains low, with over 90% of head CTs in the population normal, despite high guideline compliance, perhaps identifying a role for novel objective tests in ED guidelines internationally.

The utility of decompressive craniectomy in severe traumatic brain injury in Saudi Arabia trauma centers

ABSTRACT Background: Decompressive craniectomy (DC) represents an effective method for intracranial pressure (ICP) reduction in cases of severe traumatic brain injury (TBI). However, little is known regarding the attitude of practicing neurosurgeons toward decompressive craniectomy (DC) in Saudi Arabia. Objective: We aimed to explore the perspective on DC among neurosurgeons in Saudi Arabia. Methods: An electronic survey was distributed via e-mail to members of the Saudi Association of Neurological Surgery (SANS). Results: A total of 52 neurosurgeons participated in this survey. The majority of these neurosurgeons practice in a governmental (95.2%), tertiary hospital (75.5%) with academic affiliations (77.6%). Most surgeons (71.4%) agreed that the DC approach for managing refractory ICP is supported by evidence-based medicine. The majority of the participants choose to perform DC on a unilateral basis (80%). Interestingly, DC followed by duraplasty was performed by only 71% of these surgeons, with 29% of the respondents not performing expansive duraplasty. Conclusion: In Saudi Arabia, the utility of DC in cases of TBI with refractory intracranial hypertension has not been clearly defined among practicing neurosurgeons. The development of appropriate, widely adopted TBI guidelines should thus be a priority in Saudi Arabia to reduce variability among TBI care practices. In addition, a national TBI registry should be established for documenting different practices and longitudinal outcomes.

Lost in Translation Between Evidence and Recommendations: Expert Opinion is Needed to Define “Level I”

Abstract The aims of clinical practice guidelines (CPGs) are to provide clinicians with both a comprehensive review of the available evidence as well as to offer practical recommendations to reflect best patient care. Clinicians trust level I recommendations, issued on preponderantly solid randomized clinical trials (RCTs), to guide best practice decision-making. However, sometimes physicians following one CPG find themselves in the situation in which they do not follow another, issued on the same strong evidence base. Our aim is to reflect on the consistency of recommendations in different guidelines (between-guideline consistency).We also consider within-guideline consistency (or durability), defined as the amount of recommendations carried over from one edition to another in consecutive editions of the same CPG. For illustration purposes, we use two examples: hypertension guidelines and traumatic brain injury (TBI) guidelines. We conclude that just like research, CPGs also need to have between-guideline and within-guideline consistency (akin to reproducibility of studies). Clinicians and researchers should take into account the lower consistency of guidelines that are not based on at least one strong RCT.

How much oxygen for the injured brain - can invasive parenchymal catheters help?

Each year in the United States there are over 2.5 million visits to emergency departments for traumatic brain injury (TBI), 300,000 hospitalizations, and 50,000 deaths. TBI initiates a complex cascade of events which can lead to significant secondary brain damage. Great interest exists in directly measuring cerebral oxygen delivery and demand after TBI to prevent this secondary injury. Several invasive, catheter-based devices are now available which directly monitor the partial pressure of oxygen in brain tissue (PbtO2), yet significant equipoise exists regarding their clinical use in severe TBI. There are currently three ongoing multicenter randomized controlled trials studying the use of PbtO2 monitoring in severe TBI: BOOST-3, OXY-TC, and BONANZA. All three have similar inclusion/exclusion criteria, treatment protocols, and outcome measures. Despite mixed existing evidence, use of PbtO2 is already making its way into new TBI guidelines such as the recent Seattle International Brain Injury Consensus Conference. Analysis of high-fidelity data from multimodal monitoring, however, suggests that PbtO2 may only be one piece of the puzzle in severe TBI. While current evidence regarding the use of PbtO2 remains mixed, three ongoing clinical trials are expected to definitively answer the question of what role PbtO2 monitoring plays in severe TBI.

The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges.

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.

Evaluation of Software for Automated Measurement of Adherence to ICP-Monitoring Threshold Guideline.

Challenges inherent in clinical guideline development include a long time lag between the key results and incorporation into best practice and the qualitative nature of adherence measurement, meaning it will have no directly measurable impact. To address these issues, a framework has been developed to automatically measure adherence by clinicians in neurological intensive care units to the Brain Trauma Foundation's intracranial pressure (ICP)-monitoring guidelines for severe traumatic brain injury (TBI).The framework processes physiological and treatment data taken from the bedside, standardises the data as a set of process models, then compares these models against similar process models constructed from published guidelines. A similarity metric (i.e. adherence measure) between the two models is calculated, composed of duration and scale of non-adherence.In a pilot clinical validation test, the framework was applied to physiological/treatment data from three TBI patients exhibiting ICP secondary insults at a local neuro-centre where clinical experts coded key clinical interventions/decisions about patient management.The framework identified non-adherence with respect to drug administration in one patient, with a spike in non-adherence due to an inappropriately high dosage; a second patient showed a high severity of guideline non-adherence; and a third patient showed non-adherence due to a low number of associated events and treatment annotations.

1127: Local Implementation and Standardization of the Pediatric Severe Traumatic Brain Injury Guidelines

Brown, Michelle1; Brunner, Sarah1; Gilbert, Ariel2; Benton, Tara1; Tieves, Kelly3; Wallisch, Jessica1 Author Information

Abstract 362: Differential Effect of the Prehospital Traumatic Brain Injury Guidelines on Survival in Isolated and Multisystem Traumatic Brain Injury

Introduction: The Prehospital TBI Guidelines (PTGs) are intended for both isolated and multisystem TBI (ITBI/MTBI). However, uncontrolled hemorrhage and potential detrimental effects of fluid resuscitation in MTBI may lead to differential effectiveness compared to ITBI. Methods: Preplanned subgroup analysis of PTG effectiveness in ITBI and MTBI from EPIC (before/after system study; 133 agencies, &gt;11,000 trained; NIH R01NS071049). Interventions: Prevention/treatment of hypoxia, hypotension, hyperventilation. Inclusion: Barell Matrix 1; 1/07-6/15. Severity subgroups [Head Region Severity Score (HRSS; AIS equivalent)]: Moderate = 1-2; Severe = 3-4; Critical = 5-6. Definitions: ITBI: TBI with no other RSS ≥3 injury. MTBI: TBI plus non-head region RSS ≥3 injuries. Pre (P1) and post-implementation (P3) cohorts were compared using logistic regression. Results: Cases: 21,852; median age 45 (IQR 24, 66); 67% male. ITBI: 16,663 (76.3%); P1 = 11,602, P3 = 5061. MTBI: 5189 (23.7%); P1 = 3626, P3 = 1563]. Hypotension occurred much more frequently in MTBI (15.8%) than ITBI (4.5%; OR = 3.9 (3.5, 4.4); p&lt;0.0001) and, after PTG implementation, MTBI patients were much more likely to receive a fluid bolus (10.7%; 167/1563) than ITBI (5.3%; 267/5061; p&lt;0.0001). There was highly significant improvement in aOR for survival in severe (HRSS 3-4) ITBI and MTBI (Fig 1). Furthermore, the severe ITBI and MTBI patients who were intubated or who received any positive pressure ventilation (PPV; basic or advanced) also improved dramatically (Fig 2). Conclusions: PTG implementation was independently associated with improved odds of survival in severe ITBI and MTBI. Despite a rate of hypotension 4 times higher in MTBI, survival improvement was at least as strong as for ITBI. Since the MTBI cohort was much more likely to receive fluid resuscitation, these findings support the PTG recommendation for aggressive treatment of hypotension in TBI even in patients with potential ongoing hemorrhage.

Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids)

We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio= 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio= 9.13; 95% confidence interval 0.79 to 100+). Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Rural Primary Care Providers' Experience and Usage of Clinical Recommendations in the CDC Pediatric Mild Traumatic Brain Injury Guideline: A Qualitative Study.

In 2018, the Centers for Disease Control and Prevention (CDC) released an evidence-based guideline on pediatric mild traumatic brain injury (mTBI) to educate health care providers on best practices of mTBI diagnosis, prognosis, and management/treatment. As residents living in rural areas have higher rates of mTBI, and may have limited access to care, it is particularly important to disseminate the CDC guideline to rural health care providers. The purpose of this paper is to describe rural health care providers' experience with pediatric mTBI patients and their perceptions on incorporating the guideline recommendations into their practice. Interviews with 9 pediatric rural health care providers from all US regions were conducted. Interview transcripts were coded and analyzed for themes for each of the main topic areas covered in the interview guide. Common causes of mTBI reported by health care providers included sports and all-terrain vehicles. While health care providers found the guideline recommendations to be helpful and feasible, they reported barriers to implementation, such as lack of access to specialists. To help with uptake of the CDC guideline, they suggested the development of concise implementation tools that can be referenced quickly, integrated into electronic health record-based systems, and that are customized by visit type and health care setting (eg, initial vs follow-up visits and emergency department vs primary care visits). Length, accessibility, and usability are important considerations when designing clinical tools for busy rural health care providers caring for pediatric patients with mTBI. Customized information, in both print and digital formats, may help with uptake of best practices.

Traumatic Brain Injury Practice Guidelines: Variability in U.K. PICUs.

Traumatic brain injury in children is a leading cause of morbidity and mortality. Lack of high-quality evidence may lead to variation in management within and between PICUs. We examined U.K. pediatric traumatic brain injury management guidelines for extent of variability. Analysis of U.K. PICU traumatic brain injury guidelines for areas of consistency and variation among each other and against the second edition of Brain Trauma Foundation pediatric traumatic brain injury guidelines. Not applicable. Not applicable. Textual analysis of U.K. PICU guidelines. Twelve key clinical topics in three traumatic brain injury management domains were identified. We performed textual analysis of recommendations from anonymized local guidelines and compared them against each other and the Brain Trauma Foundation pediatric traumatic brain injury guidelines. Fifteen guidelines used by 16 of the 20 U.K. PICUs that manage traumatic brain injury were analyzed. Relatively better consistency was observed for intracranial pressure treatment thresholds (10/15), avoiding prophylactic hyperventilation (15/15), cerebrospinal fluid drainage (13/15), barbiturate (14/15), and decompressive craniectomy (12/15) for intracranial hypertension. There was less consistency in indications for intracranial pressure monitoring (3/15), cerebral perfusion pressure targets (2/15), target osmolarities (7/15), and hyperventilation for intracranial hypertension (2/15). Variability in choice and hierarchy of the interventions for intracranial hypertension were observed, albeit with some points of consistency. Significant variability in pediatric traumatic brain injury management guidelines exists. Despite the heterogeneity, we have highlighted a few points of consistency within the key topic areas of pediatric traumatic brain injury management. We anticipate that this provides impetus for further work around standardization.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n= 4) or ICP monitor placement (n= 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.