BTF guidelines

Brain Trauma Foundation Guidelines

1. BTF Guidelines Dr Dikpal

2. History : BTF 1986 Dr Jam Ghajar HQ : Campbell, California Guidelines and Research fellowships in TBI Current is 4 th Edition : 2016 Living Guideline Model

3. Methods Systemic review Class 1: Good quality RCT Class 2: Mod RCT , Good Cohort / CCS Class 3: low RCT, mod – low Cohort / CCS Synthesis of evidence Derivation of recommendation

4. Level of Evidence LEVEL I (Standard) Prospective, Randomized, Controlled Trials LEVEL II (Guideline) A : obtained from well-designed controlled trials without randomization B : obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group LEVEL III (Optional) Case Series Case Reports Expert Opinion

5. Overview Indications for Surgery Treatment recommendation Monitoring recommendation Threshold recommendation

6. Epidural Hematoma Indications Volume greater than 30cc should be evacuated regardless of GCS Volume less than 30cc/less than 15mm thickness/less than 5mm midline shift/GCS greater than 8 may be managed non-operatively Timing Any patient with acute EDH/GCS<9/ anisocoria should undergo operation “as soon as possible”

7. Current perspective in EDH CAN EDH > 30 cc be conserved ?

8. Subdural Hematoma Indications SDH with thickness > 10mm/midline shift > 5mm should be evacuated regardless of GCS  Patients with acute SDH and GCS < 9 should have ICP monitoring SDH with thickness < 10mm or < 5mm midline shift should be evacuated if GCS drops 2 or more points from injury to admission, pupillary function is abnormal, or ICP> 20 mm Hg Methods Craniotomy with or without bone flap removal/ duroplasty

9. Traumatic Parenchymal Lesions Indications Parenchymal mass lesion with referable neurologic deterioration, medically refractory intracranial hypertension or signs of mass effect on CT should be evacuated   Patients with GCS 6-8, with frontal or temporal lesion volume > 20cc with midline shift >5mm or cisternal compression, or any lesion volume > 50cc should be evacuated   Parenchymal mass lesions without clinical neurologic compromise, with no signs of mass effect and with controlled ICP can be treated non-operatively

10. Posterior Fossa Mass Lesions Indications Patients with mass effect on CT or neurologic dysfunction or deterioration referable to a lesion should undergo evacuation; “mass effect” is defined as distortion of the 4 th ventricle, effacement of basilar cisterns or obstructive hydrocephalus Patients without mass effect of neurologic dysfunction may be treated non-operatively Methods Suboccipital craniectomy is the predominant method reported and is therefore recommended

11. Depressed Cranial Fractures Indications Open fractures with depression greater than the thickness of the skull should be treated surgically to prevent infection Open depressed skull fractures may be treated non-operatively provided there is no evidence of dural penetration, intraparenchymal hematoma, depression > 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus , or gross wound contamination Closed depressed skull fractures may be treated non-operatively

12. Methods Elevation and debridement is recommended Primary bone fragment replacement is an option in the absence of wound infection at the time of surgery  All management options for open depressed fractures should include antibiotics

13. Treatment guidelines 1. Decompressive Craniectomy 2. Prophylactic Hypothermia 3. Hyperosmolar Therapy 4. Cerebrospinal Fluid Drainage 5. Ventilation Therapies 6. Anesthetics, Analgesics, and Sedatives 7. Steroids 8. Nutrition 9. Infection Prophylaxis 10. Deep Vein Thrombosis Prophylaxis 11. Seizure Prophylaxis

14. DECOMPRESSIVE CRANIECTOMY There was insufficient evidence to support a Level I recommendation for this topic. Level IIA - Bifrontal DC is not recommended to improve outcomes -A large frontotemporoparietal DC (12 x 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC   RESCUEicp trial 

15. PROPHYLACTIC HYPOTHERMIA No Level I / II A LEVEL II B: Early (within 2.5 hours), short-term (48 hours post-injury) prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury.

16. HYPEROSMOLAR THERAPY LEVEL I, II, AND III: Although hyperosmolar therapy may lower intracranial pressure, there was insufficient evidence about effects on clinical outcomes to support a specific recommendation, or to support use of any specific hyperosmolar agent, for patients with severe traumatic brain injury.

17. CEREBROSPINAL FLUID DRAINAGE There was insufficient evidence to support a Level I or II recommendation for this topic. LEVEL III An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use. Use of CSF drainage to lower ICP in patients with an initial Glasgow Coma Scale (GCS) <6 during the first 12 hours after injury may be considered

18. VENTILATION THERAPIES There was insufficient evidence to support a Level I or II A recommendation for this topic LEVEL II B Prolonged prophylactic hyperventilation with partial pressure of carbon dioxide in arterial blood (PaCO 2 ) of 25 mm Hg or less is not recommended.

19. ANESTHETICS, ANALGESICS, AND SEDATIVES LEVEL II B Administration of barbiturates to induce burst suppression measured by EEG as prophylaxis against the development of intracranial hypertension is not recommended. High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy. Although propofol is recommended for the control of ICP, it is not recommended for improvement in mortality or 6-month outcomes

20. STEROIDS LEVEL I : The use of steroids is not recommended for improving outcome or reducing ICP. In patients with severe TBI, high-dose methylprednisolone was associated with increased mortality and is contraindicated.

21. NUTRITION LEVEL II A: Feeding patients to attain basal caloric replacement at least by the 5 th  day and at most by the 7 th  day post-injury is recommended to decrease mortality. LEVEL II B: T ransgastric jejunal feeding is recommended to reduce the incidence of ventilator-associated pneumonia.

22. INFECTION PROPHYLAXIS LEVEL II A : Early tracheostomy is recommended to reduce mechanical ventilation days when the overall benefit is felt to outweigh the complications associated with such a procedure. However, there is no evidence that early tracheostomy reduces mortality or   the rate of nosocomial pneumonia. The use of povidone -iodine (PI) oral care is not recommended LEVEL III : Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections during external ventricular drainage.

23. DEEP VEIN THROMBOSIS PROPHYLAXIS LEVEL III: Low molecular weight heparin (LMWH) or low-dose unfractioned heparin may be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage. In addition to compression stockings, pharmacologic prophylaxis may be considered if the brain injury is stable and the benefit is considered to outweigh the risk of increased intracranial hemorrhage. There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis.

24. SEIZURE PROPHYLAXIS LEVEL II A: Prophylactic use of phenytoin or valproate is not recommended for preventing late post traumatic seizures (PTS). Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury), when the overall benefit is felt to outweigh the complications associated with such treatment. However, early PTS have not been associated with worse outcomes. At the present time there is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity.

25. The risk factors for early PTS include: Glasgow Coma Scale (GCS) score of ≤10; immediate seizures; post-traumatic amnesia lasting longer than 30 minutes; linear or depressed skull fracture; penetrating head injury; subdural, epidural, or intracerebral hematoma; cortical contusion; age ≤65 years; or chronic alcoholism.

26. Monitoring recommendation Intracranial Pressure Monitoring Cerebral Perfusion Pressure Monitoring Advanced Cerebral Monitoring

27. INTRACRANIAL PRESSURE MONITORING LEVEL II B: Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality.

28. CEREBRAL PERFUSION PRESSURE MONITORING LEVEL II B: Management of severe TBI patients using guidelines-based recommendations for CPP monitoring is recommended to decrease 2-week mortality.

29. ADVANCED CEREBRAL MONITORING LEVEL III: Jugular bulb monitoring of arteriovenous oxygen content difference (AVDO 2 ), as a source of information for management decisions, may be considered to reduce mortality and improve outcomes at 3 and 6 months post-injury.

30. Threshold guidelines Blood Pressure Thresholds Intracranial Pressure Thresholds Cerebral Perfusion Pressure Thresholds Advanced Cerebral Monitoring Threshold

31. Blood Pressure Thresholds LEVEL III: Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes.

32. INTRACRANIAL PRESSURE THRESHOLDS LEVEL II B: Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality. LEVEL III: A combination of ICP values and clinical and brain CT findings may be used to make management decisions.

33. CEREBRAL PERFUSION PRESSURE THRESHOLDS LEVEL II B: The recommended target cerebral perfusion pressure (CPP) value for survival and favorable outcomes is between 60 and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum optimal CPP threshold is unclear and may depend upon the patient’s autoregulatory status. LEVEL III: Avoiding aggressive attempts to maintain CPP above 70 mm Hg with fluids and pressors may be considered because of the risk of adult respiratory failure.

34. ADVANCED CEREBRAL MONITORING THRESHOLDS LEVEL III: Jugular venous saturation of <50% may be a threshold to avoid in order to reduce mortality and improve outcomes.