Guidelines-based care linked to better outcomes for child TBI

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Guidelines-based care linked to better outcomes for child TBI

Study validates 2003 instruction; caregivers should abide, lead author says
Michael McCarthy

[12 p.m. 8.20: Update noting that the guidelines were updated and republished in 2012]

Children with severe traumatic brain injury (TBI) do better when medics and hospital teams adhere to evidence-based treatment guidelines, a new multi-center study suggests.

The guidelines, published by the Brain Trauma Foundation in 2003 and updated in 2012, were established for caregivers who treat infants and children with brain injury. Until now, though, no study had examined whether adherence to the guidelines correlated with better patient outcomes. 

Dr. Monica Vavilala directs the Injury Prevention and Research Center at Harborview Medical Center.
picture of Dr. Monica Vavilala

“Despite existence of the guidelines since 2003, some clinicians have not adopted their use because there was a lack of evidence that they work,” said lead author Dr. Monica S. Vavilala, University of Washington professor of anesthesiology and pediatrics. “Our findings that show that adherence to these guidelines is associated with lower mortality and less neurological impairment. We hope this finding will lead to more widespread adoption of the guidance.”

Vavilala and colleagues examined the medical records of 236 children ages 17 and younger who had been treated in five Level I pediatric trauma centers from 2007 through 2011. The researchers scrutinized 16 guideline-relevant aspects of care before hospital admission, in the emergency department, in the operating room, and in the intensive care unit during the first 72 hours of hospitalization.

Outcomes were survival to discharge and the child's degree of the neurological impairment upon discharge from the hospital.

The average age of the 236 children was 8 years. Thirty-one children (13%) died from their injuries. Among survivors, nearly half (48%) left the hospital with major neurological impairment. The centers' overall adherence rate, across 16 guidelines, was 73%.

Greater adherence to the guidelines was significantly associated with better outcomes, the researchers found: Every 1% increase in adherence was associated with a 6% lower risk of death and a 1% lower risk of having a major neurologic impairment or being in a vegetative state at time of discharge.

Among factors associated with survival were maintaining a good blood-oxygen level in the child by first-responders, early initiation of nutrition in the intensive care unit, and not over- or under- ventilating patients. 

Flickr | jcgladiators4
Youth football and other high-contact sports put players at risk of traumatic brain injury.
Youth football and other high-contact sports put players at risk of traumatic brain injury.

Indicators associated with better neurological outcomes were maintaining good blood flow to the brain in the operating room and intensive care unit, and not needing surgery.

“Avoiding hypoxia should be a priority for caregivers at the scene, during transport and at hospitals that will transfer the patient to a pediatric trauma center," Vavilala said. "Maintaining cerebral perfusion pressure above 40 mm Hg should be a high priority in managing these patients while they are in the operating room and ICU."
Participating centers included the Harborview Medical Center, Seattle, WA; Children’s Hospital of Pittsburgh in Pennsylvania; Ann and Robert H. Lurie Children’s Hospital of Chicago, Ill.; Harbor-University of California, Los Angeles Medical Center, Torrance, Calif.; and Nationwide Children’s Hospital, Columbus, Ohio.
This study was supported by funding from the National Institutes of Health. NINDS # R01 NS072308-04
Editors: Please contact Susan Gregg (206.616.6730; to interview Dr. Monica Vavilala.
Flickr photos used under Creative Commons license: Football photo link  Accident aftermath link