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CME

Moderate to Severe Traumatic Brain Injury

General Information

Description

  • traumatic brain injury is structural injury and/or physiologic disruption of brain function resulting from blunt trauma, acceleration or deceleration forces (even without external trauma to the head), penetration of foreign body, or exposure to blast or other forces1
  • includes new onset or worsening of1
    • any period of confusion, disorientation, altered consciousness, or amnesia that may or may not be transient
    • neurologic deficit, such as, weakness, loss of balance, change in vision, praxis, paresis, sensory loss, or aphasia
    • intracranial lesion
  • moderate-to-severe traumatic brain injury characterized by any of1
    • abnormal findings on structural brain imaging
    • loss of consciousness > 30 minutes
    • altered mental status > 24 hours
    • posttraumatic amnesia > 1 day
    • best Glasgow Coma Scale score < 13 in first 24 hours

Also called

  • closed head injury
  • TBI

Types

  • for severity classification (defined by acute injury findings) select more severe category if symptoms fall into ≥ 1 category1
    Table 2. Classification of Traumatic Brain Injury Severity
    Severity of Traumatic Brain InjuryStructural Brain Imaging Loss of Consciousness Alteration of Consciousness/Mental State (Immediately Related to Head Trauma)Posttraumatic Amnesia Glasgow Coma Scale (Best Available Score in First 24 Hours)
    MildNormal0-30 minutes≤ 24 hours≤ 24 hours13-15
    ModerateNormal or abnormal30 minutes to 24 hours> 24 hours24 hours to 7 days9-12
    SevereNormal or abnormal> 24 hours> 24 hours> 7 days< 9

References

General references used

  1. Management of Concussion/mild Traumatic Brain Injury Working Group. United States Department of Veterans Affairs/Department of Defense (VA/DoD) clinical practice guideline for management of concussion/mild traumatic brain injury. VA/DoD 2016PDF
  2. National Institute for Health and Care Excellence (NICE). Head injury: assessment and early management. NICE 2017 Jun:CG176PDF
  3. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15PDF

Recommendation grading systems used

  • European Society of Intensive Care Medicine (ESICM) recommendation grading system
    • strength of recommendation
      • Level 1 - strong recommendation
        • most individuals should receive recommended course of action
        • adherence to recommendation according to guideline could be used as quality criterion or performance indicator
        • formal decision aids not likely to be needed
      • Level 2 - conditional recommendation
        • different choices will be appropriate for different patients
        • clinician should expect to spend more time with patient working toward management decision consistent with patient's values and preferences
        • decision aids may be useful
    • certainty of evidence rating
      • A - high confidence that true effect lies close to estimated effect
      • B - moderate confidence in estimated effect; true effect likely to be close to effect estimate, but possibility of substantial difference
      • C - low confidence in estimated effect; true effect may be substantially different from estimated effect
      • D - very low confidence in estimated effect; true effect is likely to be substantially different from estimated effect
    • Reference - ESICM clinical practice guideline on early enteral nutrition in critically ill patients (mnh28168570pcxh121412438pmdc28168570pIntensive Care Med 2017 Mar;43(3):380full-text)
  • Eastern Association for the Surgery of Trauma (EAST) grading system for recommendations
    • classifications of recommendation
      • Level 1 - convincingly justifiable based on available scientific information alone
      • Level 2 - reasonably justifiable by available scientific evidence and strongly supported by expert opinion
      • Level 3 - supported by available data but adequate scientific evidence is lacking
    • levels of evidence
      • Class I - prospective, randomized controlled trials
      • Class II - clinical studies in which data was collected prospectively or retrospective analyses based on clearly reliable data; includes observational studies, cohort studies, prevalence studies, and case control studies
      • Class III - studies based on retrospectively collected data; includes clinical series, database or registry review, large series of case reviews, and expert opinion
    • Reference - EAST practice management guideline on blunt cerebrovascular injury (J Trauma 2010 Feb;68(2):471)
  • Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (SCCM/ASPEN) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
    • levels of evidence
      • High-quality evidence - randomized controlled trials (RCTs) without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      • Moderate-quality evidence - RCT with important inconsistency (heterogeneity across studies, as I2 > 0.5 or some say yes but others say no)
      • Low-quality evidence
        • RCT with some or major uncertainty about directness (outcome variable not direct measure of process)
        • observational study with significant relative risk of > 2 (< 0.5) based on consistent evidence from ≥ 2 observational studies with no plausible confounders
      • Very low-quality evidence
        • RCT with imprecise or sparse data (combined effect size not significant, small number of patients)
        • RCT with high probability of reporting bias
        • observational study with significant relative risk of > 5 (< 0.2) based on direct evidence with no major threats to validity
        • observational study with evidence of dose-response gradient
      • Good Practice Statement - ungraded
    • Reference - SCCM/ASPEN guideline on provision and assessment of nutrition support therapy in the adult critically ill patient (26773077JPEN J Parenter Enteral Nutr 2016 Feb;40(2):159), correction can be found in JPEN J Parenter Enteral Nutr 2016 Nov;40(8):1200, commentary can be found in JPEN J Parenter Enteral Nutr 2016 Nov;40(8):1197
  • American College of Emergency Physicians (ACEP) grading system
    • levels of recommendation
      • Level A - generally accepted principles for patient management with high degree of clinical certainty (Class I evidence or overwhelming Class II evidence that directly addresses all the issues)
      • Level B - moderate clinical certainty (Class II evidence that directly addresses the issue, decision analysis that directly addresses the issue, or strong consensus of Class III studies)
      • Level C - based on preliminary, inconclusive, or conflicting evidence, or based on panel consensus without any published literature
    • classification of evidence
      • Class I studies
        • for therapy - randomized trial or meta-analysis of randomized trials
        • for diagnosis - prospective cohort using criteria standard
        • for prognosis - population prospective cohort study
      • Class II studies
        • for therapy - nonrandomized trial
        • for diagnosis - retrospective observational study
        • for prognosis - retrospective cohort or case-control study
      • Class III studies - case series, case report, or other (for example, consensus, review) for any type of study
    • Reference - ACEP/Centers for Disease Control and Prevention (CDC) clinical policy on neuroimaging and decision-making in adult mild traumatic brain injury in acute setting (19027497Ann Emerg Med 2008 Dec;52(6):714)
  • Brain Trauma Foundation (BTF) grading system for recommendations
    • levels of recommendation
      • Level I - based on high-quality body of evidence
      • Level IIA - based on moderate-quality body of evidence
      • Level IIB - based on body of evidence with Class 2 studies that provided direct evidence but were of overall low quality
      • Level III - based on Class 3 studies or on Class 2 studies providing only indirect evidence
    • Reference - BTF guideline on management of severe traumatic brain injury (27654000Neurosurgery 2017 Jan 1;80(1):6)
  • American College of Chest Physicians (ACCP) recommendation grading system
    • strength of recommendations
      • Grade 1 (Strong) - benefits clearly outweigh risk and burdens or vice versa
      • Grade 2 (Weak) - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burden
    • quality of evidence
      • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
      • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, and indirect or imprecise results) or very strong evidence from observational studies
      • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53Sfull-text), commentary can be found in 23546508Chest 2013 Apr;143(4):1190
  • Centers for Disease Control and Prevention (CDC) uses American Academy of Neurology (AAN) levels of recommendation
    • strength of recommendation
      • Level A - recommendation almost always should be followed
      • Level B - recommendation usually should be followed
      • Level C - recommendation may sometimes be followed
      • Level U - insufficient evidence to make a recommendation
      • Level R - intervention generally should not be done outside research setting (applicable only to recommendations related to interventions)
    • level of confidence
      • High
      • Moderate
      • Low
      • Very low
    • Reference - CDC guideline on diagnosis and management of mild traumatic brain injury among children (JAMA Pediatr 2018 Nov 1;172(11):e182853)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
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    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
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  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T900588, Moderate to Severe Traumatic Brain Injury; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T900588. Registration and login required.

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