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  • Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition

    Final Number:

    Nancy Carney, PhD; Annette Totten, PhD; Cynthia Davis-O'Reilly, BSc; Jamie S. Ullman, MD, FACS; Gregory W. J. Hawryluk, MD, PhD, FRCSC; Michael J. Bell, MD; Susan Bratton, MD; Randall Matthew Chesnut, MD; Odette Harris, MD; Niranjan Kissoon, MD; Andres Mariano Rubiano, MD; Lori Shutter, MD; Robert Tasker, MD; Monica Vavilala, MD; Jack E. Wilberger, MD; David W. Wright, MD; Jamshid Ghajar, MD, PhD, FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: The Guidelines for the Management of Severe Traumatic Brain Injury was updated from its previous publication in 2007. Concurrently, we initiated a transition from the model of performing intermittent updates of the entire Guidelines, to a model of performing real-time literature searches and continual updates of specific topics as new evidence becomes available – the Living Guidelines model.

    Methods: Topics for investigation were categorized as Treatments, Monitoring, and Thresholds. Eleven treatment topics, three monitoring topics, and four thresholds topics were specified for investigation. MEDLINE was searched from 2006 through November 2013. Relevant studies referred to us that were published after November 2013 were also included. Two members of the methods team independently evaluated each study for potential for bias. Only studies rated Class 1 or 2 were used to derive treatment recommendations.

    Results: Fifty-two publications were used for evidence in this 4th Edition – six Class 1 and 46 Class 2 studies. During the seven years between the 3rd and 4th Editions of this work, 28 new studies were added to the library of evidence. One Level I, eight Level IIA, and ten Level IIB recommendations were made. For six topics, there was insufficient evidence from which to derive a recommendation. Further information will be provided at the time of this presentation, following publication.

    Conclusions: While there have been some major developments in severe TBI management, for many topics in this edition it was not possible to make evidence-based recommendations. Our goal is to create a recursive structure for the guidelines to contribute to the development and execution of a research agenda that will in turn provide the evidence base for better guidelines; and to promote the development and use of rigorous research methods in individual studies as well as reviews.

    Patient Care: Over a 10-year period, application of the 3rd Edition of these guidelines decreased 2-week mortality by 50% in the New York State hospital system. The use of these updated guidelines are expected to continue to improve patient outcomes.

    Learning Objectives: By the conclusion of this session, participants should be able to (1) understand the criteria for strong evidence for the effectiveness of treatments for TBI, (2) interpret the recommendations, and (3)be more effective in reading the literature about treatments for TBI.


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