Implementation of Brain Trauma Foundation guidelines in children with acute traumatic brain injury in tertiary-care hospital in Pakistan

Abstract

Previous reports have shown that the implementation of Brain Trauma Foundation guidelines for management of traumatic brain injury in adults has been associated with significant reduction in mortality and neurological disability. To compare two-cohorts on the clinical outcome in the management of children with TBI in the tertiary-care pediatric intensive care unit before and after the implementation of BTF guidelines, 34 children (age from 1 month to 14 years) with acute traumatic brain injury admitted in Pediatric Intensive Care Unit of AKUH from January 2000 to December 2007 were identified from electronic database. Twenty patients (Group I) were treated with traditional treatment before the implementation of BTF guidelines and 14 patients (Group II) treated with BTF guidelines as multidisciplinary team approach with special emphasis on initial prompt resuscitation to avoid hypoxia, hypotension, and maximize the cerebral oxygenation by reducing intracranial pressure, and optimize cerebral perfusion. We compared the mortality, Glasgow Outcome Scale (GOS) and length of stay (LOS) between two cohorts. Patients in two groups were similar with respect to age, gender, mode of injury, Glasgow Coma Scale and neurosurgical procedure before admission in PICU. Implementation of BTF guidelines was associated with a marked reduction in mortality from 40 % to 0% (relative risk 2.6; 95% confidence interval 1.3 -5.2; p<0.007) and decreased in the LOS (relative risk 2.2; 95% confidence interval 1.4-3.3; p<0.002). The absolute risk reduction of mortality is 0.4 Adherence to BTF guidelines in management of children with acute TBI was very effective. It can be successfully implemented in other regional hospitals.

Keywords

child - traumatic brain injury - outcome

• References

• 1 Ghajar J. Traumatic brain injury. Lancet 356 9233 2000; 923-929
• 2 Hesdorffer DC, Ghajar J. Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers. J Trauma 63 2007; 841-847 discussion 847-8
• 3 Keris V, Lavendelis E, Macane I. Association between implementation of clinical practice guidelines and outcome for traumatic brain injury. World J Surg 31 2007; 1352-1355
• 4 Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med 28 2002; 547-553
• 5 Fakhry SM, Trask AL, Waller MA, Watts DD. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma 56 2004; 492-499 discussion 499-500.
• 6 Adelson PD, Bratton SL, Carney NA. et al Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med 04 2003; S2-S75
• 7 Murthy TVSP. Propofol in Neurotrauma. Ind J Neurotrauma 05 2008; 41-44
• 8 Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 01 1975; 480-484
• 9 Hammond JJ. Protocols and guidelines in critical care: development and implementation. Curr Opin Crit Care 07 2001; 464-468
• 10 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practi a systematic review of rigorous evaluations. Lancet 342 8883 1993; 1317-1322
• 11 Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C. et al Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 07 2007; 29-39
• 12 Chesnut RM, Marshall LF, Klauber MR. et al The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34 1993; 216-222
• 13 Murthy TVSP, Bhatia P, Gogna RL. et al Secondary brain injuries: Prevention and Intensive care Management. Ind J Neurotrauma 02 2005; 7-12
• 14 Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg 28 1993; 310-314 discussion 315-6.
• 15 Figaji AA, Fieggen AG, Peter JC. Early decompressive craniotomy in children with severe traumatic brain injury. Childs Nerv Syst 19 2003; 666-673
• 16 Kunze E, Meixensberger J, Janka M, Sorensen N, Roosen K. Decompressive craniectomy in patients with uncontrollable intracranial hypertension. Acta Neurochir (Wien) 71 Suppl 1998; 16-18
• 17 Palmer S, Bader MK, Qureshi A, Palmer J, Shaver T, Borzatta M. et al The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. Americans Associations for Neurologic Surgeons. J Trauma 50 2001; 657-664