Level IIB recommendations were based on a body of evidence with Class 2 studies that provided direct evidence but were of overall low quality. They both also detected an increased rate of some levels of poor outcomes with DC. , Laviolle B, Dahyot-Fizelier Cet al. , Tsai JT, Lin CMet al. Subperiosteal vs Subdural Drains After Burr-Hole Drainage of Chronic Subdural Hematoma … Contributors Col Randall McCafferty, USAF, MC CDR … The central nervous system is unquestionably the most important organ of our body, and injury to the brain or spinal cord has devastating consequences. We also provide 3 new level-IIA recommendations. Guidelines are not intended to supplant physician judgment with respect to particular patients or special clinical situations and are not a substitute for physician-patient consultation. Central to the debate around the performance of DC is the issue of what constitutes acceptable (or “good”) neurological recovery. In these tables, the recommendations in bold are new or have been revised; those in regular text have not changed. Ideally, a treatment should be effective across various clinical environments. Neurosurgery. ... the remaining two-thirds are evenly split between trauma ICUs and general ICUs. Dhandapani Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019 Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society. However, there is an increased risk for expansion of intracranial hemorrhage. JW 14–16 Many of the included trials are small, unblinded, more than 15 years old, with omitted use of routine mechanical thromboprophylaxis and with a general focus on … A brief assessment called the SPinal Emergency Evaluation of Deficits (SPEED) uses foot motor and sensory function to indicate injury severity and C3 dermatome sensation, handgrip strength and location of spinal pain to indicate the level of injury. The authors debated the extent to which the bifrontal surgical procedures performed in the DECRA and RESCUEicp studies should be extrapolated to the lateral decompressions more popular in North America. M Mohseni JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINE (JTS CPG) Neurosurgery and Severe Head Injury (CPG ID: 30) Provides guidelines and recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources and follow-on care may be limited. W DECRA and RESCUEicp were consistent in demonstrating that DC reduces ICP and duration of intensive care. (2) They used the median score for each group on the 8-item GOS-E scale to calculate the odds of worse outcomes. Cervical Vertebrae zSmall vertebral bodies zless weight to carry zExtensive joint surfaces zgreater ROM. Using the median score for each group of the GOS-E measured at 6 mo postinjury (3: DC, 4: No DC), the unadjusted odds ratio (OR) for worse outcomes in the DC group was 1.84 (95% CI 1.05-3.24), P = .03, but after adjustment, the OR was no longer significant. DECRA was conducted in 3 countries over an 8-yr period and included 15 medical centers. 1. The rationale for subjecting an effective single-center trial to the variability encountered in a large multi-center trial is valid. Hawryluk GWJ, Aguilera S, Buki A et al. , Temkin N, Carney Net al. (1) They compared group differences in control of ICP, mortality, and distribution of the GOS-E ratings. Ficker R, Gachter A. Lateral flexion/extension radiographs: still recommended following cervical spine injury. Our intention is that … The characteristics and results of class 1 and 2 studies of DC are summarized in Table 2. Developing protocols that integrate TBI-specific, evidence-based recommendations with general best practices for trauma patients, and that provide guidance, suggestions, or options in areas of TBI management where the evidence is insufficient, is outside the scope of these guidelines. Sorrentino . ME Specialized branches have developed to cater to special and difficult conditions. In the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury published in 2017,12 the lead chapter provided 2 level-IIA recommendations on the topic of DC. These recommendations served to update the first published clinical practice guidelines for DC provided in conjunction with the Brain Trauma Foundation's Guidelines for the Surgical Management of Traumatic Brain Injury published in 2006.13 Here, we present an update of the 2017 recommendations following the adjudication and consideration of the evidence provided by RESCUEicp11 as well as DECRA’s recently published 12-mo outcome data.10 One of the previous recommendations was retained and 3 new level-IIA recommendations are now provided on this topic. • Prolonged prophylactic hyperventilation with PaCO. ... trauma, pediatrics neurosurgery, vascular surgery, minimal invasive neurosurgery. We anticipate that this agenda also will promote the development and use of increasingly rigorous research methods in individual studies as well as reviews. The operational guidelines of the scheme are being released as a reference tool for the policy makers at the State & the Trauma Care . This new iteration of the guidelines reflects the most current methodologic standards and establishes more rigorous procedures for future work. Applicability is the extent to which research findings are useful for informing recommendations for a broader population (usually the population that is the target of the recommendations). As such, they do not constitute a complete protocol for clinical use. . Conversely, limited resources in low-and-middle-income countries often do not allow for technology-based monitoring, and medical decisions may be driven by clinical assessment alone. Seguin , Stefanovic I, Novak V, Veselinovic D, Ivanov G, Veselinovic A. Liew , Michel ME, Ansell Bet al. LM Collaborators MCT, Perel P, Arango M et al. The Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, and other collaborating organizations are not engaged in rendering professional medical services and assume no responsibility for patient outcomes resulting from application of these general recommendations in specific patient circumstances. New recommendation #1 relates to the positive findings of the RESCUEicp study,11 while new recommendation #2 relates to the negative findings of the DECRA study.9,10 Recommendation #4 reflects findings consistent in both studies.9-11, The scope of this update was limited to the addition of the RESCUEicp study and the 12-mo DECRA outcome data to the existing body of evidence. There is also a growing sense that the traditional trial endpoint–the GOSE score at 6 mo–assesses outcomes prematurely and that longer term follow-up would be preferred in severe TBI treatment studies. Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary Neurosurgery June, 2019 (Issue 6) Written and audio translations of the Introduction and Methodology abstract for the above guidelines in ten languages. Acosta-Escribano Consultant, Immediate Past Honorary Secretary. The process should include (1) identification and refinement of topics for studies that could serve to fill critical gaps in the guidelines, (2) improvement of study designs, and (3) incorporation of state-of-the-art methods for synthesizing literature, assessing bodies of evidence, and generating guidelines. As new studies are generated and added to the evidence base, we expect to see changes in the assessment of the quality of the body of evidence. P This synopsis provides an overview of the process, includes the updated recommendations, and describes the new evidence added. This material is based upon work supported by (1) the US Army Contracting Command, Aberdeen ProvingGround, Natick ContractingDivision, through a contract awarded to Stanford University (W911 QY-14-C-0086). Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. (2) They dichotomized the 8-item GOS-E scale to compare favorable vs unfavorable outcomes between groups. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. (1) They compared group differences in control of ICP, days of mechanical ventilation, days in intensive care unit (ICU), and mortality. S • Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS. An analysis of Eastern Association for the Surgery of Trauma practice guidelines for cervical spine evaluation in a series of patients with multiple imaging techniques. , Chen YS, Hong WCet al. The 41 studies listed in Table 4 contributed to additions or changes to the recommendations. , Nilsson P, Ronne-Engstrom E, Howells T, Enblad P. Huang Clifton , McEwen J, Kurth T, Chittock DR. Chourdakis In DECRA, bifrontal decompressions were performed exclusively, and they were performed more commonly than lateral decompressions in RESCUEicp. Am Surg. Even if a recommendation was not made, the evidence was included to acknowledge its place in the body of evidence and make it accessible for future consideration. All patients arriving at VUMC as a Level 1 trauma, including isolated gunshot wounds to the head will be evaluated by the Trauma Surgery Service. Treatment informed by data from monitoring may result in better outcomes than treatment informed solely by data from clinical assessment. Elf For example, preoperative magnetic resonance imaging scans could reveal devastating structural brain lesions (such as in the brainstem) not seen on computed tomography, which would predict a lack of benefit from surgical decompression. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. These recommendations are intended to provide the foundation on which protocols can be developed that are appropriate to different treatment environments. We would like to thank the following people at the Pacific Northwest Evidence-Based Practice Center at Oregon Health & Science University for their invaluable assistance in producing this document: Molly Stillwell, MA; Ngoc Wasson, MPH; Sandra Assasnik, MA; Elaine Graham, MLS; Leah Williams, BS; and Roger Chou, MD. RM • High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. The Neurosurgery Division of Trauma/Critical Care provides care to the critically injured patient who suffers brain or spinal trauma. These recommendations are related to threshold values for parameters that are monitored during the in-hospital management of patients with severe TBI. It demonstrated an increase in the rate of poor outcomes when comparing the distribution of GOS-E ratings, but no difference in outcomes using the dichotomized GOS-E. Of note, for the secondary outcome at 12 mo postinjury, significantly more patients in the DC group than the No DC group had favorable outcomes, using the dichotomized score of GOS-E (P = .01). The new DECRA publication10 was similarly evaluated, and we determined that the new information provided about the study should not change the rating.9. Brenner Finally, we would like to recognize the American Association of Neurological Surgeons and the Congress of Neurological Surgeons Joint Guidelines Committee for providing feedback on the Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, and the American Association of Neurological Surgeons and Congress of Neurological Surgeons leadership for their endorsement. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries 3. D , Talving P, Lam L, Chan LS, Ives C, Demetriades D. Scudday Hutchinson PJ, Kolias AG, Tajsic T et al. Hartl aBtpO2, brain tissue O2 partial pressure; CBF, cerebral blood flow; CSF, cerebrospinal fluid drainage; DC, decompressive craniectomy; EEG, electroencephalogram; EVD, external ventricular drainage; GCS, Glasgow Coma Scale; GOS-E, Glasgow Outcome Scale—Extended; ICP, intracranial pressure; ICU, intensive care unit; LMWH, low molecular weight heparin; PaCO2, partial pressure of arterial carbon dioxide; PI, povidone-iodine; PTS, posttraumatic seizures; RESCUEicp trial, Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP trial; SjO2, jugular venous oxygen saturation; TBI, traumatic brain injury. This document provides recommendations only when there is evidence to support them. Guidelines for Evaluation and Management of Neurosurgical/Spine Trauma Patients Reviewed: 10/31/2017 . In patients with severe TBI, high-dose methylprednisolone was associated with increased mortality and is contraindicated. , Stein DM, Hu PF, Aarabi B, Sheth K, Scalea TM. Patients with intracranial mass lesions were excluded from enrollment. The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. S The importance of incising the falx when a bifrontal DC is performed was questioned in conjunction with the interpretation of the DECRA trial, but this too remains insufficiently understood. The methodology and analytical framework employed were consistent with those used for the previously published fourth edition.12. Subarachnoid hemorrhage (SAH) results frequently from traumatic brain injury (TBI). Several meta-analyses and the 2012 American College of Chest Physicians clinical practice guidelines have assessed randomised trials of various methods of thromboprophylaxis in patients undergoing neurosurgical procedures. Clinical and Inflammatory Features of Exacerbation-Prone Asthma: A Cross-Sectional Study Using Multidimensional Assessment. • There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis. Alali GL , Chiu YL, Gerber LM, Ghajar J, Greenfield JP. However, there is no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia. DECRA compared outcomes for patients with diffuse brain injury treated with early bifrontal DC to those treated with medical management. Detailed inclusion criteria and a list of studies excluded after full-text review are in the comprehensive guideline document in Appendices E and F. All included studies were assessed for potential bias, which is a systematic approach to assessing the internal validity or quality of studies. , Costa J, Sampaio C, Pappamikail L. Wang RESCUEicp underwent an independent assessment for quality by 2 reviewers using the same instrument as used to assess the DECRA trial and all other studies included in the fourth edition. Log In. Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial causes. This study is a randomized, controlled trial that evaluates decompressive craniectomy as a secondary procedure, after ICP-targeted medical therapies have failed.2 The results of this trial will be evaluated and may impact recommendations related to decompressive craniectomy as well as ICP thresholds. Seattle International severe traumatic Brain Injury Consensus Conference. As a result, the guidelines include changes in the evaluation of previous work, an increase in the quality of the included studies, and essential improvements in the precision of the recommendations. Fehlings MG, Nater A. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. , Steltzer H, Bauer P, Dolanski-Aghamanoukjan L, Metnitz P. Shafi The standard management for these patients includes brief admission by the acute care surgery (trauma) service with neurological checks, neurosurgical consultation and repeat head CT within 24 hours to identify any progression or resolution. It will be desirable in the future, however, to determine if there are differences in the risk:benefit ratios of these surgeries and whether one or the other should be applied preferentially in specific circumstances. More recently, the DECRA investigators published the 12-mo outcome data from their study. A paucity of literature currently informs primary DC, or the practice of leaving the bone flap off following an initial surgery to evacuate an intracranial mass lesion. Details on the changes within each topic from the Third1 to this Fourth Edition are listed in Appendix A in the complete Fourth Edition Guidelines and are described in the sections on each topic in the comprehensive guideline document. , Yeh TC, Sung KC, Wang CC, Chen CW, Chio CC. MJ However, the AANS and CNS also assert that these guidelines must be of the highest possible quality in order to limit the potential for unjustified restriction of provider autonomy and flexibility in the pursuit of optimal clinical care. The addition of these studies to the available research evidence is the basis for the following updated recommendations: Level IIA–to improve mortality and overall outcomes. Using the dichotomized score (1-4 vs 5-8), both unadjusted and adjusted odds of unfavorable outcomes were significantly greater in the DC group. , Fernandez-Vivas M, Grau Carmona Tet al. This chapter emphasizes some aspects of the Brazilian Guidelines for the Assessment of Head Injury Patients, written based on the experience of the Emergency Service, Neurosurgical Division of the University of São Paulo Medical School Hospital, and sponsored by the Brazilian Society of Neurosurgery. (3) They dichotomized the 8-item GOS-E scale to calculate the odds of unfavorable outcomes. The updated recommendations were then extensively discussed and revised. A static document that is updated after several years no longer responds to the demands of the community we serve. Cooper The final phase of the evidence review is the synthesis of individual studies into information that the Clinical Investigators and the Methods Team use to develop recommendations. Hutchinson PJ, Kolias AG, Timofeev IS et al. ... 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