Traumatic Brain Injury Guidelines Research Articles

Chapter 8. Hyperosmolar therapy

Chapter 8. Hyperosmolar therapy

Chapter 4. Threshold for treatment of intracranial hypertension

Chapter 4. Threshold for treatment of intracranial hypertension

90 EMFProvider Adherence to Head CT Utilization Guidelines for Mild Traumatic Brain Injury

90 EMFProvider Adherence to Head CT Utilization Guidelines for Mild Traumatic Brain Injury

Use of a mild traumatic brain injury guideline to reduce inpatient hospital imaging and charges

Purpose In children, mild traumatic brain injuries (TBI) account for 70% to 90% of head injuries. Without clear guidelines, many of these children may be exposed to excess radiation owing to unnecessary imaging. The purpose of this study was to evaluate the impact of a mild TBI guideline in reducing hospital charges and repeated imaging of pediatric patients. Methods Charts of all children who had at least one head computed tomography and were admitted to our level 1 trauma center with a blunt TBI and Glasgow Coma Scale of 13 to 15 were retrospectively reviewed. Patients were divided into 2 groups relative to the implementation of a TBI management guideline. Results A total of 742 patients were included, 389 preguideline and 353 postguideline. Implementation of the guideline was associated with reductions in the average number of head computed tomographies performed (1.6 vs 1.3, P = .006), length of stay (2.3 vs 1.7 days, P < .0001), and overall hospital charges ($21,760 vs $13,980, P = .006). No children were readmitted for missed injuries. Conclusions Implementation of a simple guideline for the care of children with mild TBI can have significant impact on charges and length of stay while simultaneously reducing radiation exposure. Widespread implementation of such guidelines will improve efficiency without sacrificing quality of care in the management of mild TBI in the pediatric population.

Head injury in Germany: A population-based prospective study on epidemiology, causes, treatment and outcome of all degrees of head-injury severity in two distinct areas

Introduction: Little is known about the ratio of mild traumatic brain injury (TBI) to moderate and severe TBI, about the time that elapses until primary care is given, about the number of patients requiring immediate surgery and about the early outcome and the costs.Method: In a prospective study two regions taken as model examples were investigated: the City of Hanover with its surrounding catchment area and Münster with its regions.Results: From 1 March 2000 until 28 February 2001 all patients were recruited who were admitted to a hospital emergency department due to a TBI; 6783 patients (58.4% male, 41.6% female; 29.7% children < 16 years) were included; 5220 (73%) received in-hospital treatment; and 258 were given early rehabilitation. The incidence of TBI is 332 per 100 000 head of population. The GCS (Glasgow Coma Scale) or other forms of neurological examinations were performed in only 56% of all cases. According to the GCS status, 90.2% are classified as mild, 3.9% as moderate and 5.2% as severe. Intubation is given only to 76.1% of patients with severe TBI. Lethality was 1%. The predominant cause of TBI is falls, with 52.5% of all cases, while 26.3% were due to road accidents. The time elapsing between the accident event and initial examination at the hospital is less than 1 hour in 63% of all cases. X-rays were taken in 82% of all cases of TBI, with 19.3% of the patients receiving a CT scan; 58.7% of all TBI patients have additional injuries of the facial skull, 8.8% of the vertebral column, 7.2% of the thorax, 2.6% of the abdomen, 3.4% of the pelvis and 19.6% of one or more extremities. One year after the accident, 50% of all patients still required treatment even after mild TBI.Conclusion: It is necessary to follow the TBI guidelines, e.g. regarding intubation and neurological examination. The indication for cranial x-rays and CT should be reconsidered.

Novel Consensus of Management Guidelines for Severe Traumatic Brain Injury in Asia

Novel Consensus of Management Guidelines for Severe Traumatic Brain Injury in Asia

Hypothermia following pediatric traumatic brain injury.

Preclinical as well as clinical studies in traumatic brain injury (TBI) have established the likely association of secondary injury and outcome in adults in children following severe injury. Similarly, there is growing evidence in experimental laboratory studies that moderate hypothermia has a beneficial effect on outcome, though the exact mechanisms remain to be absolutely defined. The Pediatric TBI Guidelines provided the knowledge and background for standard management of children following severe TBI and highlighted that there are very few clinical studies to date. In particular with respect to temperature regulation and the use of hypothermia, initial findings of case series of small numbers were promising. Further preliminary randomized clinical trials, both single institution and multicenter, have provided the initial data on safety and efficacy, though larger, Phase III studies are necessary to ensure both the safety and efficacy of hypothermia in pediatric TBI prior to implementation as part of the standard of care. It is expected that hypothermia initiated early after severe TBI will have a protective effect on the pediatric brain and can be done safely, but this still remains to be definitively tested.

Fluid therapy and the use of albumin in the treatment of severe traumatic brain injury

Evidence-based guidelines for severe traumatic brain injury (TBI) do not include strategies for fluid administration. The protocol used in this study includes albumin administration to maintain normal colloid osmotic pressure and advocates a neutral to slightly negative fluid balance. The aim of this study was to analyze the occurrence of organ failure and the mortality in patients with severe TBI treated by a protocol that includes defined strategies for fluid therapy. Ninety-three patients with severe TBI and Glasgow Coma Score <or=8 were included during 1998-2001. Medical records of the first 10 days were retrieved. Organ dysfunction was evaluated with the Sequential Organ Failure Assessment (SOFA) score. Mortality was assessed after 10 and 28 days, 6 and 18 months. The total fluid balance was positive on days 1-3, and negative on days 4-10. The crystalloid balance was negative from day 2. The mean serum albumin was 38+/-6 g/l. Colloids constituted 40-60% of the total fluids given per day. Furosemide was administered to 94% of all patients. Severe organ failure defined as SOFA >or=3 was evident only for respiratory failure, which was observed in 29%. None developed renal failure. After 28 days, mortality was 11% and, after 18 months, it was 14%. A protocol including albumin administration in combination with a neutral to a slightly negative fluid balance was associated with low mortality in patients with severe TBI in spite of a relatively high frequency (29%) of respiratory failure, assessed with the SOFA score.

Traumatic brain injury in children: Recent advances in management

To define and discuss new developments in the field of pediatric traumatic brain injury (TBI). Review of several recent key studies on therapy since publication of the first U.S. traumatic brain injury guidelines in 2003. In addition, we discuss new developments in the use of biomarkers of brain injury in TBI diagnosis and also discuss recent advances in bedside neuromonitoring that may be helpful in the setting of pediatric brain injury. Important new information on optimal cerebral perfusion pressure management, cerebrospinal fluid drainage, decompressive craniectomy, hypothermia, biomarkers of brain injury along with advances in neuromonitoring are presented. The 2003 guidelines have stimulated important new research. This is reshaping bedside care.

Clinics in neurology and neurosurgery of sport: traumatic cerebral contusion

This case highlights the difficulties encountered in managing a sports player with traumatic brain injury. Fortunately, most head injuries in sport are minor and recover completely. Although the consensus definition1...

Epidemiology and 12-Month Outcomes From Traumatic Brain Injury in Australia and New Zealand

An epidemiologic profile of traumatic brain injury (TBI) in Australia and New Zealand was obtained following the publication of international evidence-based guidelines. Adult patients with TBI admitted to the intensive care units (ICU) of major trauma centers were studied in a 6-month prospective inception cohort study. Data including mechanisms of injury, prehospital interventions, secondary insults, operative and intensive care management, and outcome assessments 12-months postinjury were collected. There were 635 patients recruited from 16 centers. The mean (+/-SD) age was 41.6 years +/- 19.6 years; 74.2% were men; 61.4% were due to vehicular trauma, 24.9% were falls in elderly patients, and 57.2% had severe TBI (Glasgow Coma Scale score </=8). Secondary brain insults were recorded in 28.5% and 34.8% underwent neurosurgical procedures before ICU admission. There was concordance with TBI and ICU practice guidelines, although intracranial pressure monitoring was used in 44.5% patients with severe TBI. Twelve-month mortality was 26.9% in all patients and 35.1% in patients with severe TBI. Favorable outcomes at 12 months were recorded in 58.8% of all patients and in 48.5% of patients with severe TBI. In Australia and New Zealand, mortality and favorable neurologic outcomes after TBI were similar to published data before the advent of evidence-based guidelines. A high incidence of prehospital secondary brain insults and an ageing population may have contributed to these outcomes. Strategies to improve outcomes from TBI should be directed at preventive public health strategies and interventions to minimize secondary brain injuries in the prehospital period.

Using a Cost-Benefit Analysis to Estimate Outcomes of a Clinical Treatment Guideline: Testing the Brain Trauma Foundation Guidelines for the Treatment of Severe Traumatic Brain Injury

A decade after promulgation of treatment guidelines by the Brain Trauma Foundation (BTF), few studies exist that examine the application of these guidelines for severe traumatic brain injury (TBI) patients. These studies have reported both cost savings and reduced mortality. We projected the results of previous studies of BTF guideline adoption to estimate the impact of widespread adoption across the United States. We used surveillance systems and national surveys to estimate the number of severely injured TBI patients and compared the lifetime costs of BTF adoption to the current state of treatment. After examining the health outcomes and costs, we estimated that a substantial savings in annual medical costs ($262 million), annual rehabilitation costs ($43 million) and lifetime societal costs ($3.84 billion) would be achieved if treatment guidelines were used more routinely. Implementation costs were estimated to be $61 million. The net savings were primarily because of better health outcomes and a decreased burden on lifetime social support systems. We also estimate that mortality would be reduced by 3,607 lives if the guidelines were followed. Widespread adoption of the BTF guidelines for the treatment of severe TBI would result in substantial savings in costs and lives. The majority of cost savings are societal costs. Further validation work to identify the most effective aspects of the BTF guidelines is warranted.

Marked Improvement in Adherence to Traumatic Brain Injury Guidelines in United States Trauma Centers

Prior surveys of acute medical management of severe traumatic brain injury (TBI) indicate that care is fragmented and inconsistent, although Guidelines for the management of severe traumatic brain injury (guidelines) were distributed and endorsed by the American Association of Neurologic Surgeons. We conducted a survey of US trauma centers to evaluate guideline adherence, to examine predictors of adherence, and to compare our results with similar surveys conducted in 1991 and 2000. A Web-based survey was conducted in 413 designated trauma centers admitting patients with severe TBI. Good adherence was defined as adherence to the median number of guidelines (median = 6, interquartile range 5-7). In adjusted analysis, good adherence was predicted by Level I trauma center designation and presence of treatment protocols. Compared with trauma centers without these predictive factors, the likelihood of good guideline adherence increased 2.4-fold with each additional predictor (95% confidence interval = 1.8-3.3). Routine intracranial pressure monitor use increased from 32.4% in 1991 and 50.8% in 2000 to 77.4% in the current survey (p < 0.0001). Avoidance of steroids in TBI rose from 47.8% in 1991 and 52.4% in 2000 to 86.0% in 2006 (p < 0.0001). Lack of guideline adherence decreased significantly from 67% in 2006 to 34.5%. Adherence to evidence-based guidelines for severe TBI has improved dramatically since 1991. Trauma center level and treatment protocols were associated with good adherence, suggesting that directing patients with severe TBI to Level I and Level II trauma centers with treatment protocols will improve outcome for these patients.

Intensive care unit management of fever following traumatic brain injury

Fever, in the presence of traumatic brain injury (TBI), is associated with worsened neurologic outcomes. Studies prior to the publication of management guidelines revealed an undertreatment of fever in patients with neurologic insults. Presently the adult TBI guidelines state that maintenance of normothermia should be a standard of care therefore improvement in management of fever in these patients would be expected. The specific aims of the study were to: (1) determine the incidence of fever (T>or=38.5 degrees C) in a population of critically ill patients with TBI; (2) describe what interventions were recorded by intensive care unit (ICU) nurses in managing fever; (3) ascertain the rate of adherence with published normothermia guidelines. Medical record review of available hospital records was conducted on patients admitted to a level I trauma center following severe TBI (N=108) from the parent study. Temperature data was abstracted and contemporaneous nursing documentation was examined for evidence of intervention for fever and adherence with published standards. Data analyses were performed that included descriptive statistics. Seventy-nine percent of TBI patients (85/108) had at least one recorded fever event while in the ICU. However in only 31% of events did the patient receive any documented intervention by nursing staff for the elevated temperature. The most frequently documented intervention was pharmacologic (358/1166 elevations). Other nursing actions (e.g. use of fan) accounted for a minority (<1%) of nursing interventions documented. Patients were more likely to have a high temperature that exceeded 40 degrees C (13%) than a temperature that was normothermic (5%). There continues to be an under treatment of fever in patients with TBI by critical care nurses despite our knowledge of its negative effects on outcomes. There remains a gap in translation between patient outcomes research and bedside practice that needs to be overcome, thus research efforts need to now focus on understanding nurses' decision-making processes and the best methods of fever reduction in patients with TBI.

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Successful Outcome in Severe Traumatic Brain Injury

This case study describes the management of a 54-year-old male who presented to the Hospital of the University of Pennsylvania (HUP) with a traumatic brain injury (TBI) after being assaulted. He underwent an emergent bifrontal decompressive hemicraniectomy for multiple, severe frontal contusions. His postoperative course included monitoring of intracranial pressure, cerebral perfusion pressure, partial pressure of brain oxygen, brain temperature, and medical management based on HUP's established TBI algorithm. This case study explores the potential benefit of combining multimodality monitoring and TBI guidelines in the management of severe TBI.

Hyperosmolar Therapy in the Treatment of Severe Head Injury in Children

Traumatic brain injury is the result of a primary, acute injury and is complicated by the development of secondary injury due to hypotension and hypoxia. Cerebral edema due to brain injury compromises the delivery of essential nutrients and alters normal intracranial pressure. The Monroe-Kellie Doctrine defines the principles of intracranial pressure homeostasis. Treatment for intracranial hypertension is aimed at reducing the volume of 1 of the 3 intracranial compartments, brain tissue, blood, and cerebrospinal fluid. Hyperosmolar therapy is one treatment intervention in the care of patients with severe head injury resulting in cerebral edema and intracranial hypertension. The effect of hyperosmolar solutions on brain tissue was first studied nearly 90 years ago. Since that time, mannitol has become the most widely used hyperosmolar solution to treat elevated intracranial pressure. Increasingly, hypertonic saline solutions are being used as an adjunct to mannitol in basic science research and clinical studies. Hyperosmolar solutions are effective in reducing elevated intracranial pressure through 2 distinct mechanisms: plasma expansion with a resultant decrease in blood hematocrit, reduced blood viscosity, and decreased cerebral blood volume; and the creation of an osmotic gradient that draws cerebral edema fluid from brain tissue into the circulation. The pediatric section of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies adapted previously published guidelines for the treatment of adult brain injury into guidelines for the treatment of children with traumatic brain injury. These guidelines offer recommendations for the management of children with severe head injury, including the use of mannitol and hypertonic saline to treat intracranial hypertension. Acute and critical care pediatric advanced practice nurses caring for children with severe head injury should be familiar with management guidelines and the use of hyperosmolar solutions. The purpose of this article is to assist the advanced practice nurse in understanding the role of hyperosmolar therapy in the treatment of pediatric traumatic brain injury and review current guidelines for the use of mannitol and hypertonic saline.

An evaluation of the use of guidelines in prehospital management of brain injury

ObjectivesThe Brain Trauma Foundation (BTF) Guidelines for Prehospital Management of Traumatic Brain Injury (TBI) are intended to standardize treatment and improve outcomes in severe TBI patients. The key guideline components focus on airway management, blood pressure support, Glasgow Coma Score assessment, and transport. The purposes of this study were to determine if providers could learn and retain the guidelines (education), assess if providers would use the guidelines in practice (implementation), and evaluate the effect of guideline implementation on patients (outcomes). MethodsData were collected prospectively on all trauma patients for five months. Providers were then educated on the TBI guidelines over two months, and five additional months of data were collected. A knowledge test was given before and after the course and three months later to assess education. To assess implementation, data were analyzed to determine whether providers were using the key interventions more consistently after education. The clinical courses of TBI patients before and after guideline implementation were measured to assess outcomes. ResultsKnowledge of TBI care improved significantly after education and remained elevated at three months (62% vs. 82% vs. 79%, p < 0.001). For the 1,044 patients seen, providers demonstrated higher rates of appropriate care, resulting in lower rates of hypoxia (2.8% vs. 1.1%, p=0.010) and hypotension (4.8% vs. 2.0%, p=0.018). Mortality was significantly decreased (34.6% vs. 17.0%, p=0.039), and rates of patients with maximum functional scores at 14 days significantly increased (Glasgow Outcome Score 44.2% vs. 66.0%, p=0.025; Rancho Los Amigos Scale 55.9% vs. 77.3%, p=0.045). ConclusionProviders were able to learn and implement the BTF guidelines, and outcomes in TBI patients were significantly improved. All emergency medical services providers should be trained in these potentially lifesaving guidelines.

Critical evaluation of the existing guidelines on mild traumatic brain injury.

The purpose of guidelines is to reduce practice variability, but they need to be evidence-based. We examine current mild traumatic brain injury guidelines, critique their basis in evidence and examine their variability in recommendations. A systematic search of the literature found 38,806 abstracts, with 41 guidelines. There were 18 sports-related guidelines, 13 related to admission policies, 12 related to imaging and 5 related to neuropsychological assessment. Some guidelines addressed several areas. Only 5 guidelines reported a methodology for the assembly of evidence used to develop the guideline. After appraising the guidelines against a validated index, we found that 3 of the 41 guidelines could be categorized as evidence-based. Two of these focused on paediatric patients and 1 on adult patients. Limited methodological quality in the current guidelines results in conflicting recommendations amongst them.

AN EVALUATION OF THE USE OF GUIDELINES IN PREHOSPITAL MANAGEMENT OF BRAIN INJURY

Objectives. The Brain Trauma Foundation (BTF) Guidelines for Prehospital Management of Traumatic Brain Injury (TBI) are intended to standardize treatment and improve outcomes in severe TBI patients. The key guideline components focus on airway management, blood pressure support, Glasgow Coma Score assessment, and transport. The purposes of this study were to determine if providers could learn and retain the guidelines (education), assess if providers would use the guidelines in practice (implementation), and evaluate the effect of guideline implementation on patients (outcomes). Methods. Data were collected prospectively on all trauma patients for five months. Providers were then educated on the TBI guidelines over two months, and five additional months of data were collected. A knowledge test was given before and after the course and three months later to assess education. To assess implementation, data were analyzed to determine whether providers were using the key interventions more consistently after education. The clinical courses of TBI patients before and after guideline implementation were measured to assess outcomes. Results. Knowledge of TBI care improved significantly after education and remained elevated at three months (62% vs. 82% vs. 79%, p < 0.001). For the 1,044 patients seen, providers demonstrated higher rates of appropriate care, resulting in lower rates of hypoxia (2.8% vs. 1.1%, p = 0.010) and hypotension (4.8% vs. 2.0%, p = 0.018). Mortality was significantly decreased (34.6% vs. 17.0%, p = 0.039), and rates of patients with maximum functional scores at 14 days significantly increased (Glasgow Outcome Score 44.2% vs. 66.0%, p = 0.025; Rancho Los Amigos Scale 55.9% vs. 77.3%, p = 0.045). Conclusion. Providers were able to learn and implement the BTF guidelines, and outcomes in TBI patients were significantly improved. All emergency medical services providers should be trained in these potentially lifesaving guidelines.