Family physicians who encounter children in the emergency department with a severe traumatic brain injury (TBI) or who manage neurologically injured children in the ICU should take note of an updated set of guidelines from the Brain Trauma Foundation.
Earlier this month, the foundation released the third edition(journals.lww.com) of its "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury." The guidelines were published as a supplement to the March issue of Pediatric Critical Care Medicine and include several new recommendations designed to improve patient care and increase survival and recovery in children who experience a severe TBI.
"These guidelines are vital to the proper care and treatment of children with serious brain injury," said Nathan Selden, M.D., Ph.D., Mario and Edith Campagna professor and chair of the Department of Neurological Surgery at Oregon Health and Science University (OHSU) School of Medicine in Portland and a co-author of the guidelines, in an OHSU Research News blog post.(blogs.ohsu.edu)
For readers who don't wish to pore through the entire hefty guidelines tome, an executive summary(journals.lww.com) offers a more manageable version of the publication's highlights.
- The Brain Trauma Foundation has published an updated edition of guidelines for the management of severe traumatic brain injury (TBI) in children.
- The update guidelines contain more than 20 recommendations that cover monitoring, treatment thresholds and treatments for severe pediatric TBI.
- An accompanying article presents an algorithm that outlines the use of first- and second-tier therapies and addresses general and specific approaches to the management of children with severe TBI.
The third edition updates the foundation's 2012 guidelines and includes information from 48 new studies. Of the 22 recommendations contained in the new edition, nine are new or revised. All recommendations are grouped into three categories -- monitoring, thresholds and treatments -- and are graded according to the quality of evidence on which they are based:
- Level I recommendations were based on a high-quality body of evidence.
- Level II recommendations were based on moderate-quality evidence.
- Level III recommendations were based on low-quality evidence.
Although monitoring does not directly affect patient outcomes, information obtained from monitoring can help direct treatment decisions, which may, in turn, lead to better outcomes than those based on clinical assessments alone.
The guidelines offer four recommendations that cover three types of monitoring: intracranial pressure (ICP) monitoring, advanced cerebral monitoring and neuroimaging. Only one of these recommendations, which deals with neuroimaging, is new to this edition. All four recommendations are graded level III.
For your convenience, the specific recommendations for this and the other two guidelines sections have been aggregated and can be accessed as a separate PDF file.(207 KB PDF)
Recommendations in this section pertain to threshold values that are monitored during inpatient management of children with severe TBI. Thresholds for ICP and CPP are included among these values. None of the three recommendations in this section is new, and all are graded level III.
Pediatric Severe TBI: By the Numbers
According to the CDC,(www.cdc.gov) traumatic brain injury (TBI) leads to about 640,000 emergency department visits, 18,000 hospitalizations and 1,500 deaths in children ages 14 and younger each year. TBI-related emergency department visits, hospitalizations and deaths occur more frequently(www.cdc.gov) in children ages 4 and younger (1,591.5 per 100,000 population) than in any other age group except those 75 and older (2,232.2 per 100,000).
The Glasgow Coma Scale (GCS) is the tool used most often to classify TBI as mild, moderate or severe, with severe TBI defined(www.cdc.gov) as an injury that results in a GCS score of 3 to 8.
Research published in the Journal of Pediatric Health Care(www.ncbi.nlm.nih.gov) in 2015 indicated that more than 37,000 children sustain a severe TBI each year. According to the CDC report, these children are more likely than those with mild TBI to be hospitalized, and up to 61 percent of children with moderate-to-severe TBI experience a lifelong disability.
The 15 recommendations in this category address 10 different treatment options and are specific to inpatient management of TBI or are related to risks experienced by pediatric TBI patients.
Those options are hyperosmolar therapy; analgesics, sedatives and neuromuscular blockade; cerebrospinal fluid drainage; seizure prophylaxis; ventilation therapies; temperature control/hypothermia; barbiturates; decompressive craniectomy; nutrition; and corticosteroids.
More than half of the treatment recommendations are new or revised. Level II recommendations cover hyperosmolar therapy for intracranial pressure control, as well as temperature control and nutrition to improve overall outcomes. All other recommendations are graded level III.
In addition to the guidelines, the foundation published an algorithm(journals.lww.com) on the use of first- and second-tier therapies for pediatric severe TBI. It is designed to serve as a supplement to the recommendations and outlines both general and specific approaches to managing children with TBI.
The algorithm is derived from evidence in the studies used to create the updated guidelines, as well as expert consensus when evidence is not available. The authors stated that this combination "provides additional and much-needed guidance for clinicians at the bedside" by addressing a number of important issues not covered in previous guidelines.
The authors welcomed the increase in both the number of studies of pediatric TBI and the number of level II recommendations. Although the larger evidence base boosts the value of the current recommendations, much work remains to create fully evidence-based treatments that improve outcomes in children with severe TBI, they said.
"Since studies are difficult to perform in this population, it remains likely that guidelines like this will be largely based on expert opinion or extrapolated data," said family physician Jason Matuszak, M.D., director of the Sports Concussion Center at Excelsior Orthopaedics in Buffalo, N.Y., and a former member of the AAFP's Commission on Health of the Public and Science. "As such, these guidelines will give practicing family physicians who treat these types of challenging patients trusted information from experts and a useful clinical algorithm."
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