Updates to the Brain Trauma Foundation Guidelines for the Management of Severe Pediatric TBI - Part II: Treatments

The Brain Trauma Foundation has recently updated its guidelines for the management of severe pediatric traumatic brain injury (TBI). These recommendations were informed by a comprehensive search of publications related to severe pediatric TBI that were published between 2010 and 2017. Part II of this series summarizes the current recommendations for treatment of pediatric severe TBI. The recommendations are described as Level I (based on high-quality evidence), Level II (based on moderate-quality evidence), or Level III (based on low-quality evidence). Note: When interpreting these recommendations, it is important to remember that low-quality of evidence does not mean that the recommendation is incorrect. Rather, a Level III evaluation often indicates that there are simply not enough studies to more strongly support the recommendation.

Treatments

1. Hyperosmolar therapy: This technique aims to reduce intracranial pressure (ICP). Clinicians do so by infusing cerebrospinal fluid, which surrounds the brain, with solutions that change the fluid’s concentration of salt. The updated guidelines make both Level II and Level III recommendations. Level II data support the use of boluses, or short bursts of hypertonic saline (HTS) at a concentration of 3% for 10 to 20 minutes to reduce ICP. On the other hand, Level III recommendations suggest a continuous infusion of 3% HTS rather than boluses. Level III data also recommend using HTS boluses with a much higher concentration of saline (23.4%) but in doses of smaller volume.

Quality of Evidence: Level II and III

2. Analgesics, sedatives, and neuromuscular blockade (NMB): Analgesics, sedatives, and NMB agents are used to control pain and lower ICP. These include medications such as propofol, ketamine, fentanyl, and midazolam. There was very little data to support the use one medication over another; however, it is noted that the FDA does not support the long-term use of propofol for sedation or management of ICP.

Quality of Evidence: Level III

3. Cerebrospinal fluid (CSF) drainage: This technique involves draining some cerebrospinal fluid to reduce ICP. Previous guidelines supported CSF drainage through a port in the lumbar spine, which is located in the lower back, but current guidelines recommend drainage through a small catheter placed in the brain.

Quality of Evidence: Level III

4. Seizure prophylaxis: Seizures can occur after TBI, and researchers have debated the benefit of treating seizures before they happen. Current guidelines suggest that seizure prophylaxis, or preventative treatment, is recommended up to 7 days after injury to prevent the negative outcomes associated with injury-related seizure.

Quality of Evidence: Level III

5. Ventilation therapies: In some cases, TBI may be severe enough that a patient can no longer breathe without ventilation therapy, which mechanically assists or replaces normal breathing. Hyperventilation, which causes the patient to expel more air than they intake, has been used in the past as a way to reduce ICP. Current guidelines do not support the use of hyperventilation to prevent increased ICP before it occurs; however, it may be used as a treatment strategy when ICP does increase. In this case, it is suggested that patients are closely monitored during hyperventilation.

Quality of Evidence: Level III

6. Temperature control: Hyperthermia (higher-than-normal body temperature) can occur after trauma, and some studies have explored whether lowering the body temperature (hypothermia) preventatively can have positive outcomes. Currently, the guidelines do not support preventative hypothermia. If the body is cooled in the course of treatment, the guidelines suggest warming the patient back up to a normal temperature at a rate of 0.5 to 1 degree Celsius (or about 33 to 34 degrees Fahrenheit) every 12 to 24 hours.

Quality of Evidence, Level II and Level III

7. Barbiturates: Barbiturates are sedatives that work by making the central nervous system less active. They reduce the rate of normal functions like breathing and heart rate, which makes them dangerous to use without clinical supervision. However, barbiturates can help to treat TBI patients because they reduce metabolic activity, allowing the brain to have extra oxygen and promoting faster recovery. The guidelines support the carefully monitored use of barbiturates in patients whose blood flow is stable.

Quality of Evidence: Level III

8. Decompressive Craniotomy (DC): DC is a surgical procedure during which a neurosurgeon removes part of the skull to reduce pressure on the brain. Like any surgical intervention, this procedure certainly carries risks. However, in many patients the benefits of DC are worthwhile, so current guidelines do support the use of DC in appropriate cases.

Quality of Evidence: Level III

9. Nutrition: Recovery from TBI requires energy, which we typically get from food. Patients with severe TBI may require a feeding tube (known as enteral nutrition, or EN), and guidelines suggest starting EN within 72 hours from injury. Some studies have explored whether a diet that supports immune health is beneficial, but current guidelines do not suggest any benefit to these specialized diets and do not recommend using them.

Quality of evidence, Level II and Level III

10. Corticosteroids: Corticosteroids are a class of hormones that are naturally produced by the body but may also be administered therapeutically. For TBI patients, some studies have explored whether corticosteroids might improve outcomes by reducing ICP. However, evidence shows that this does not improve outcomes, so the guidelines do not recommend using corticosteroids to treat elevated ICP.

Quality of Evidence: Level III

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