Updates to the Brain Trauma Foundation Guidelines for the Management of Severe Pediatric TBI Part I: Monitoring and Thresholds

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. The researchers scanned the existing literature for evidence of improved outcomes, and they used this evidence to make changes to 15 guideline topics related to monitoring, diagnostic threshold values, and treatments for severe pediatric TBI. The first of this two-part series will summarize the current recommendations for monitoring and threshold values. 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.

Monitoring

1. Intracranial pressure (ICP): ICP is used to help doctors determine whether brain swelling is occurring as a result of TBI. Brain swelling can lead to further complications that are associated with increased risk of severe disability or death. Although the body of evidence is limited, the guidelines support the use of ICP monitoring to reduce the likelihood of poor outcomes, which are known to include seizure, stroke, neurological damage, and death.

Evidence Quality: Level III

2. Advanced Neuromonitoring: Advanced neuromonitoring is a medical technique that measures the brain’s electrical activity and the levels of fluid present in the brain. There was not sufficient evidence that such monitoring improved patient outcomes, and the guidelines suggest that advanced neuromonitoring should only be used when clinicians are certain that the tests will have no adverse effects on the patient.

Evidence Quality: Level III

3. Neuroimaging: Neuroimaging involves tests such as computerized tomography (CT) scans to determine whether patients have elevated ICP and whether surgery is needed. The evidence suggests that, while CT scans are useful if conducted within six hours of the initial injury, repeated scans or scans later after the injury do not improve outcomes. However, if evidence suggests that the patient’s condition is worsening or ICP is increasing, repeated scans may be appropriate.

Evidence Quality: Level III

Thresholds

4. ICP: Similar to the way a simple barometer uses mercury (Hg) to measure atmospheric pressure, ICP is measured in millimeters of mercury (mmHg). A healthy adult is expected to have an ICP measurement between 7 to 15 mmHg, and previous guidelines indicated that doctors should try to maintain an ICP less than 20 mmHg for patients with TBI. Current guidelines support this value, but the researchers suggest that lower ICP values may be more appropriate for younger children and infants.

Quality of Evidence: Level III

5. Cerebral Perfusion Pressure (CPP): CPP is a measurement that helps doctors understand how much blood is flowing to the brain. A higher value indicates greater blood flow. The recommendation from these guidelines is to maintain a CPP between 40 and 50 mmHg.

Quality of Evidence: Level III

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