Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

Background Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. Objectives To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. Methods and Results After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. Conclusions The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.

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Head of bed elevation in pediatric patients with severe traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.4.peds20102 ◽

2020 ◽

Vol 26 (5) ◽

pp. 465-475

Author(s):

Shih-Shan Lang ◽

Amber Valeri ◽

Bingqing Zhang ◽

Phillip B. Storm ◽

Gregory G. Heuer ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Blood Flow ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Pediatric Patients ◽

Venous Outflow ◽

Optimal Position ◽

Significant Difference ◽

Severe Tbi ◽

Pediatric Tbi

OBJECTIVEHead of bed (HOB) elevation to 30° after severe traumatic brain injury (TBI) has become standard positioning across all age groups. This maneuver is thought to minimize the risk of elevated ICP in the hopes of decreasing cerebral blood and fluid volume and increasing cerebral venous outflow with improvement in jugular venous drainage. However, HOB elevation is based on adult population data due to a current paucity of pediatric TBI studies regarding HOB management. In this prospective study of pediatric patients with severe TBI, the authors investigated the role of different head positions on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral venous outflow through the internal jugular veins (IJVs) on postinjury days 2 and 3 because these time periods are considered the peak risk for intracranial hypertension.METHODSPatients younger than 18 years with a Glasgow Coma Scale score ≤ 8 after severe TBI were prospectively recruited at a single quaternary pediatric intensive care unit. All patients had an ICP monitor placed, and no other neurosurgical procedure was performed. On the 2nd and 3rd days postinjury, the degree of HOB elevation was varied between 0° (head-flat or horizontal), 10°, 20°, 30°, 40°, and 50° while ICP, CPP, and bilateral IJV blood flows were recorded.RESULTSEighteen pediatric patients with severe TBI were analyzed. On each postinjury day, 13 of the 18 patients had at least 1 optimal HOB position (the position that simultaneously demonstrated the lowest ICP and the highest CPP). Six patients on each postinjury day had 30° as the optimal HOB position, with only 2 being the same patient on both postinjury days. On postinjury day 2, 3 patients had more than 1 optimal HOB position, while 5 patients did not have an optimal position. On postinjury day 3, 2 patients had more than 1 optimal HOB position while 5 patients did not have an optimal position. Interestingly, 0° (head-flat or horizontal) was the optimal HOB position in 2 patients on postinjury day 2 and 3 patients on postinjury day 3. The optimal HOB position demonstrated lower right IJV blood flow than a nonoptimal position on both postinjury days 2 (p = 0.0023) and 3 (p = 0.0033). There was no significant difference between optimal and nonoptimal HOB positions in the left IJV blood flow.CONCLUSIONSIn pediatric patients with severe TBI, the authors demonstrated that the optimal HOB position (which decreases ICP and improves CPP) is not always at 30°. Instead, the optimal HOB should be individualized for each pediatric TBI patient on a daily basis.

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Community-Based Physical Activity Interventions for Individuals with Moderate to Severe Traumatic Brain Injury: Scoping Review Protocol (Preprint)

10.2196/preprints.24689 ◽

2020 ◽

Author(s):

Enrico Quilico ◽

Bonnie Swaine ◽

Christophe Alarie ◽

Angela Colantonio

Keyword(s):

Physical Activity ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Scoping Review ◽

Current Evidence ◽

Future Research ◽

Sex And Gender ◽

Community Based ◽

Severe Tbi

BACKGROUND Long-term physical, cognitive, and psychosocial problems resulting from moderate to severe traumatic brain injury (TBI) can prevent individuals from returning to preinjury lifestyles because of significant challenges with employment, leisure, and relationships. While physical activity (PA) is proposed as a cost-effective method to alleviate problems after moderate to severe TBI, there is no review to date that synthesizes the evidence for PA in the community-based context. Further, although sex- and gender-based considerations in research are considered requisite to good science, there is no review on PA and TBI that has included this explicit focus. OBJECTIVE The purpose of this review is to map and synthesize the current evidence identified through a systematic search of community-based PA interventions for individuals of all ages with moderate to severe TBI and provide an overview of that evidence by asking the following research questions: (1) what are the characteristics of community-based PA programs for individuals with moderate to severe TBI, (2) what are the reported health-related outcomes and measurement tools used to evaluate them, and (3) what considerations have been given to sex and/or gender? METHODS Searches will be conducted of six academic databases for peer-reviewed articles. Two reviewers will independently screen the articles for inclusion and extract data for the analysis. The extracted data will be coded according to the Consensus on Exercise Reporting Template checklist and the Template for Intervention Description and Replication checklist to provide sufficient detail for replication. RESULTS The abstract screening was completed by two reviewers and the extracted data were analyzed. A qualitative synthesis and description of community-based PA interventions for individuals with moderate to severe TBI will be provided. CONCLUSIONS This scoping review will generate new knowledge from published and publicly available literature. Dissemination of the results will include activities related to knowledge transfer for community-based PA after moderate to severe TBI for future research and practice. Evidence-based recommendations, future directions, potential limitations, use of online/digital components, and the possible need for a systematic review will be discussed as well. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/24689

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Community-Based Physical Activity Interventions for Individuals with Moderate to Severe Traumatic Brain Injury: Scoping Review Protocol

JMIR Research Protocols ◽

10.2196/24689 ◽

2021 ◽

Vol 10 (1) ◽

pp. e24689

Author(s):

Enrico Quilico ◽

Bonnie Swaine ◽

Christophe Alarie ◽

Angela Colantonio

Keyword(s):

Physical Activity ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Scoping Review ◽

Current Evidence ◽

Future Research ◽

Sex And Gender ◽

Community Based ◽

Severe Tbi

Background Long-term physical, cognitive, and psychosocial problems resulting from moderate to severe traumatic brain injury (TBI) can prevent individuals from returning to preinjury lifestyles because of significant challenges with employment, leisure, and relationships. While physical activity (PA) is proposed as a cost-effective method to alleviate problems after moderate to severe TBI, there is no review to date that synthesizes the evidence for PA in the community-based context. Further, although sex- and gender-based considerations in research are considered requisite to good science, there is no review on PA and TBI that has included this explicit focus. Objective The purpose of this review is to map and synthesize the current evidence identified through a systematic search of community-based PA interventions for individuals of all ages with moderate to severe TBI and provide an overview of that evidence by asking the following research questions: (1) what are the characteristics of community-based PA programs for individuals with moderate to severe TBI, (2) what are the reported health-related outcomes and measurement tools used to evaluate them, and (3) what considerations have been given to sex and/or gender? Methods Searches will be conducted of six academic databases for peer-reviewed articles. Two reviewers will independently screen the articles for inclusion and extract data for the analysis. The extracted data will be coded according to the Consensus on Exercise Reporting Template checklist and the Template for Intervention Description and Replication checklist to provide sufficient detail for replication. Results The abstract screening was completed by two reviewers and the extracted data were analyzed. A qualitative synthesis and description of community-based PA interventions for individuals with moderate to severe TBI will be provided. Conclusions This scoping review will generate new knowledge from published and publicly available literature. Dissemination of the results will include activities related to knowledge transfer for community-based PA after moderate to severe TBI for future research and practice. Evidence-based recommendations, future directions, potential limitations, use of online/digital components, and the possible need for a systematic review will be discussed as well. International Registered Report Identifier (IRRID) DERR1-10.2196/24689

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Early Coagulopathy in Pediatric Traumatic Brain Injury: A Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Retrospective Study

Neurosurgery ◽

10.1093/neuros/nyab157 ◽

2021 ◽

Author(s):

Shu-Ling Chong ◽

Gene Yong-Kwang Ong ◽

Charles Qishi Zheng ◽

Hongxing Dang ◽

Meixiu Ming ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Critical Care ◽

Brain Injury ◽

Multiple Trauma ◽

Functional Outcomes ◽

Critical Care Medicine ◽

Intracranial Bleed ◽

Severe Tbi ◽

Logistic Regressions ◽

Pediatric Tbi

Abstract BACKGROUND Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI. OBJECTIVE To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes. METHODS Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients <16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes. RESULTS Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS < 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P < .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006). CONCLUSION Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

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Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

Brain Sciences ◽

10.3390/brainsci11081044 ◽

2021 ◽

Vol 11 (8) ◽

pp. 1044

Author(s):

Cristina Daia ◽

Cristian Scheau ◽

Aura Spinu ◽

Ioana Andone ◽

Cristina Popescu ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Glasgow Coma Scale ◽

Severe Traumatic Brain Injury ◽

Functional Independence ◽

Unresponsive Wakefulness Syndrome ◽

Coma Scale ◽

Severe Tbi ◽

Neuroprotective Treatment ◽

Gcs Score

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

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Ketamine in acute phase of severe traumatic brain injury “an old drug for new uses?”

Critical Care ◽

10.1186/s13054-020-03452-x ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Daniel Agustin Godoy ◽

Rafael Badenes ◽

Paolo Pelosi ◽

Chiara Robba

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Acute Phase ◽

Severe Traumatic Brain Injury ◽

Safety Profile ◽

Point Of View ◽

Current Evidence ◽

Potential Benefits ◽

Sedation And Analgesia

AbstractMaintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.

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Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Clinical Rehabilitation ◽

10.1177/0269215517734294 ◽

2017 ◽

Vol 32 (5) ◽

pp. 692-704 ◽

Cited By ~ 6

Author(s):

Camille Chesnel ◽

Claire Jourdan ◽

Eleonore Bayen ◽

Idir Ghout ◽

Emmanuelle Darnoux ◽

...

Keyword(s):

Quality Of Life ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Significant Relationship ◽

Injury Severity ◽

Chronic Phase ◽

Functional Independence ◽

Severe Tbi

Objective: To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness. Design/Setting/Subjects: This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study). Intervention/Main measures: Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life. Results: A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)). Conclusion: Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

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Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study

BMJ Open ◽

10.1136/bmjopen-2020-047305 ◽

2021 ◽

Vol 11 (6) ◽

pp. e047305

Author(s):

Susan Alcock ◽

Divjeet Batoo ◽

Sudharsana Rao Ande ◽

Rob Grierson ◽

Marco Essig ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Cohort Study ◽

Brain Injury ◽

Early Diagnosis ◽

Hospital Mortality ◽

Brain Death ◽

Severe Traumatic Brain Injury ◽

Health Research ◽

Ct Perfusion ◽

Severe Tbi

IntroductionSevere traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI.Methods and analysisThe Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients.Ethics and disseminationThis study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study.Trial registration numberNCT04318665

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Blunt cerebrovascular injuries in severe traumatic brain injury: incidence, risk factors, and evolution

Journal of Neurosurgery ◽

10.3171/2016.4.jns152600 ◽

2017 ◽

Vol 127 (1) ◽

pp. 16-22 ◽

Cited By ~ 30

Author(s):

Pierre Esnault ◽

Mickaël Cardinale ◽

Henry Boret ◽

Erwan D'Aranda ◽

Ambroise Montcriol ◽

...

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Anticoagulation Therapy ◽

Spine Injury ◽

Hemorrhagic Complication ◽

Injury Incidence ◽

Severe Tbi ◽

Systemic Anticoagulation

OBJECTIVEBlunt cerebrovascular injuries (BCVIs) affect approximately 1% of patients with blunt trauma. An antithrombotic or anticoagulation therapy is recommended to prevent the occurrence or recurrence of neurovascular events. This treatment has to be carefully considered after severe traumatic brain injury (TBI), due to the risk of intracranial hemorrhage expansion. Thus, the physician in charge of the patient is confronted with a hemorrhagic and ischemic risk. The main objective of this study was to determine the incidence of BCVI after severe TBI.METHODSThe authors conducted a prospective, observational, single-center study including all patients with severe TBI admitted in the trauma center. Diagnosis of BCVI was performed using a 64-channel multidetector CT. Characteristics of the patients, CT scan results, and outcomes were collected. A multivariate logistic regression model was developed to determine the risk factors of BCVI. Patients in whom BCVI was diagnosed were treated with systemic anticoagulation.RESULTSIn total, 228 patients with severe TBI who were treated over a period of 7 years were included. The incidence of BCVI was 9.2%. The main risk factors were as follows: motorcycle crash (OR 8.2, 95% CI 1.9–34.8), fracture involving the carotid canal (OR 11.7, 95% CI 1.7–80.9), cervical spine injury (OR 13.5, 95% CI 3.1–59.4), thoracic trauma (OR 7.3, 95% CI 1.1–51.2), and hepatic lesion (OR 13.3, 95% CI 2.1–84.5). Among survivors, 82% of patients with BCVI received systemic anticoagulation therapy, beginning at a median of Day 1.5. The overall stroke rate was 19%. One patient had an intracranial hemorrhagic complication.CONCLUSIONSBlunt cerebrovascular injuries are frequent after severe TBI (incidence 9.2%). The main risk factors are high-velocity lesions and injuries near cervical arteries.

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Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort

Journal of Neurosurgery ◽

10.3171/2020.8.jns201243 ◽

2021 ◽

pp. 1-13

Author(s):

Halinder S. Mangat ◽

Xian Wu ◽

Linda M. Gerber ◽

Hamisi K. Shabani ◽

Albert Lazaro ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Emergency Department ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Ct Scanning ◽

Core Model ◽

Middle Income ◽

Tertiary Referral Center ◽

Severe Tbi ◽

Medical Therapies

OBJECTIVEGiven the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania.METHODSA neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model.RESULTSIn total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model.CONCLUSIONSThe 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

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