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Podcast Recap | Guidelines review: Management of severe traumatic brain injury

July 20, 2023

Acknowledging that severe brain injury has historically lacked clear evidence and has been difficult to treat, host Dr. Glenn Stevens and Dr. Gregory Hawryluk, a neurosurgeon at Cleveland Clinic Akron General and medical director and chair of the Scientific Advisory Board of the Brain Trauma Foundation (BTF) talk about the future of traumatic brain injury (TBI) management amid the BTF’s promising efforts to enhance patient outcomes. The episode also explores the origins, significance, and necessary steps the BTF has taken to advance TBI guidelines through innovative research and by establishing evidence-based guidelines.

1. Implementing the BTF's guidelines for TBIs can result in a 50% reduction in fatalities, but there’s still a significant need for reliable evidence.

The BTF first published guidelines for managing TBIs in 1996, which have since remained predominantly unchanged. They created the guidelines in response to an increase in evidence-based medicine and research on brain injuries conducted in the 1980s. Recognizing the need to standardize practice and support clinicians in treating TBI patients, the BTF published Guidelines for Managing Severe TBI.

Following the implementation of these guidelines, mortality rates for severe brain trauma have dropped by 50%. However, Dr. Hawryluk points out that clinicians who manage patients with brain injuries continue to face challenges due to the emergent nature of trauma. Traditional clinical research design is difficult to follow in these situations, which leads to a scarcity of good evidence and a lack of relevant guidelines for directing care.

To address this issue, the BTF gathered 42 world experts in head injury management to form a consensus-based algorithm. The primary objective of this collaborative effort was to translate evidence from the guidelines into practical steps for managing TBIs at the bedside.

2. Supportive care is essential for those with TBI, including adjusting threshold values of critical measurements and feeding protocols.

Managing TBI patients through supportive care is crucial. Controlling critical values such as blood pressure, brain pressure, and brain oxygenation can lead to better patient outcomes.

In the past, intracranial pressure guidelines allowed for a maximum of 25mmHg, but the current edition states that 22mmHg is the maximum safe pressure. Recent research suggests that lower values, such as 10mmHg, could be harmful. The upcoming fifth edition of the guidelines will redefine these values based on ongoing research.

As for feeding protocols, evidence indicates that feeding the patient within seven days post-TBI is the best approach. For other supportive care measures for TBI management, read over the guidelines.

3. Collaboration between the BTF and the Department of Defense (DOD) has provided more opportunities for research to generate evidence-based practices.

The BTF and DOD have created a partnership to identify the optimal time for individuals to return to combat following a TBI. Given that the military encounters a higher incidence of TBIs than the civilian population, they can conduct extensive testing of various methods and theories.

Notably, military practice has shown more favorable outcomes for penetrating brain injuries compared with civilian practice. One example is their approach of minimal debridement, which has resulted in fewer infections and has been successfully implemented in civilian medical practice.

4. The BTF is working toward establishing consistent guidelines for concussions based on various concussion subtypes.

Concussions can be an underestimated brain injury, often unreported and undiagnosed. The BTF recognizes the need for common language surrounding concussions to improve their management.

They have identified major subtypes of concussions based on the symptoms that are exhibited. The BTF wants to define and treat each subtype accordingly. They created a framework of guidelines with the intent of future research to evaluate each subtype, which will help clinicians better understand how to treat and manage concussions.

5. For the guidelines to advance, clinicians need to challenge the dogma and research new ideas for TBI management.

Dr. Hawryluk admits that the TBI management guidelines are struggling to advance. Due to the complexity of implementing traditional clinical research designs in emergent trauma situations, most evidence is derived from retrospective studies. To address this issue, the BTF is working toward developing and coordinating new studies to answer important questions related to brain trauma.

Moreover, Dr. Hawryluk urges medical students and professionals to challenge existing beliefs and develop new ideas for TBI management. It’s crucial to ask new questions and conduct further clinical research to establish evidence-based practices.

Any views, thoughts, and opinions expressed in this podcast recap are solely that of the host and guests and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.

Source:

Cleveland Clinic. (2023, May 15). Cleveland Clinic. Guidelines review: Management of severe traumatic brain injury. https://my.clevelandclinic.org/podcasts/neuro-pathways/guidelines-review-management-of-severe-traumatic-brain-injury