Author: Daniel B. Michael, MD, PhD
The latest addition to the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury 4th edition was e-published in September of 2016 and the print synopsis was published in Neurosurgery in January 2017.1 New levels of recommendation are labeled from highest quality to lowest: level I, IIA, IIB, and III. Some of the authors of the updated guidelines are members of our section and are to be congratulated for their hard work on this project. The guidelines were vetted by our Section Executive Committee and endorsed by our parent organizations. The new guidelines are different in many ways from the old guidelines. The following is a brief summary of the updated treatment recommendations, but I encourage you to review the complete documents closely.
Updated Treatment Recommendations
- Bifrontal decompressive craniectomy is not recommended to improve outcomes. However, a large frontotemporal decompressive craniectomy is recommended over a small such craniectomy to reduce mortality and improve neurologic outcomes in patients with severe TBI (IIA).
- Hypothermia: Early short-term hypothermia is not recommended to improve outcomes (IIB).
- Spinal fluid drainage: An EVD zeroed at midbrain with continuous drainage may be considered to lower ICP more effectively than intermittent use, and the use of such drainage in patients with initial GCS less than six in the first 12 hours after injury may be considered (III).
- Nutritional replacement by the fifth day, and by the seventh day at most, is recommended to decrease mortality level (IIA).
- Trans-gastric jejunal feeding is recommended to reduce the incidents of ventilator associated pneumonia (IIB).
- Infection prophylaxis: use of povidone iodine oral care is not recommended to reduce ventilator associated pneumonia level (IIA).
- Antimicrobial-impregnated catheters may be considered to prevent catheter related infections for EVDs (III).
- Seizure prophylaxis: There is insufficient evidence to recommend levetiracetam over phenytoin for preventing early post-traumatic seizures (IIA).
- ICP monitoring: Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital, two-week post-injury mortality (IIB).
- CPP monitoring: Management of TBI patients based on CPP is recommended (IIB).
- Thresholds for blood pressure maintenance are as follows: BP greater than or equal to 100 mm of mercury for patients 50- to 69-years-old, and greater than or equal to 110 mm of mercury or above for patients 15- to 49-years-old, or greater than 70-yearsold, may be considered to decrease mortality and improve outcomes (III).
- ICP threshold: Treating ICP greater than 22 mm of mercury is recommended, because levels above this level are associated with increased mortality (IIB). The recommended target for CPP values for favorable outcome is between 60 and 70 mm of mercury (IIB). The only level I recommendation in the updated version of the guidelines remains the nonuse of steroids for TBI patients. Because of the lack of quality evidence, many of these recommendations are weak, either IIB or III.
Criteria for Improving Overall Care
Using high-quality evidence undoubtedly will improve patient care. In an effort to improve the overall care of trauma patients, the American College of Surgeons (ACS) established the criteria for Level I, II, and III trauma centers, and outlined these criteria in the book Resources for Optimal Care of the Injured Patient.2 Chapter eight is devoted entirely to criteria for trauma centers regarding neurosurgery. I recommend all neurosurgeons be familiar with these criteria, particularly those participating in call at Level I and II trauma centers.
Here is a synopsis of these criteria: Surgeons taking trauma calls should be aware of, and compliant with, clinical care parameters established in various neurotrauma guidelines. Neurosurgeons should provide advice and input to the trauma program. A neurosurgeon should respond within 30 minutes, in accordance with institutional specific criteria. A backup plan should be in place for all levels of trauma systems for neurotrauma care if that institution is overwhelmed. In the case of Level III or rural trauma facilities, a trauma surgeon should be periodically credentialed so they may be qualified to evaluate and stabilize neurotrauma patients until transfer. Emergency neurosurgery coverage of Level I and II centers should be "immediately" available. All neurosurgeons providing neurotrauma coverage must be board-certified or have completed an alternative pathway of certification. Those neurosurgeons providing neurotrauma care must have general neurosurgery privileges.
Commitment to trauma excellence may be demonstrated in various ways. Neurosurgeons must participate in trauma care review. CME for the neurotrauma director requires 16 hours per year of external trauma- related credits. All others participating in neurotrauma call must have 16 hours of trauma credits per year averaged over three years, obtained either internally or externally. The neurosurgeons should also participate in performance improvement and patients' safety (PIPS) activities at their institution.
These criteria set forth by the ACS were used to develop various institutional criteria to determine neurosurgical participation and quality of care. Such criteria, in my opinion, should be based on the highest quality of evidence, such as the Brain Trauma Foundation Guidelines level I and IIA recommendations. Otherwise, we risk judging the neurotrauma providers by sub-optimal criteria. The criteria in the ACS resources is reasonable, but attempting to judge neurotrauma quality and commitment by applying criteria based on low-quality evidence is not.
For example, as the Brain Trauma Foundation Guidelines struggle to define the appropriate role of ICP monitoring in severe traumatic brain injured patients, it is not appropriate to use the number of ICP monitors placed as a quality indicator. Rather, clear outcomes of the TBI patient such as mortality, stratified by severity, would seem to be a better quality indicator. There is little dispute preventing neurotrauma is the best treatment, so trauma center sponsorship of a ThinkFirst chapter would also be another good, quality measure of neurotrauma care at an institution, in my opinion.
Neurotrauma Section Collaborations
The AANS/CNS Section on Neurotrauma and Critical Care is committed to collaborating with the ACS and other professional organizations to further the goal of optimal care for our patients. Several members of our Section serve on the ACS Committee on Trauma and attended its 2017 annual meeting. We learned about "Zero Preventable Deaths," the new, congressionally-enabled program to establish a national trauma system in collaboration with our military. To learn more about this effort we support, see the report at CNS.org/traumacare. Our section also supports the ACS initiative "Stop the Bleed," which would teach traumatic hemorrhage control in a way similar to public service efforts to teach CPR.
We thank you for your ongoing support and ask you to consider joining our Section to continue our mission of improving neurotrauma and critical care through education, research, and advocacy.
- Carney N, Totten AM, O’Reilly C, Ullman JS, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery 2017; 80: 6-13.
- Resources for Optimal Care of the Injured Patient 2014. American College of Surgeons. https://www.facs.org/quality-programs/trauma/vrc/resources. Published 2014.