• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: brain-targeted therapy. New York (NY): Brain Trauma Foundation; 2005. 13 p. [58 references]

This is the current release of the guideline.

"Degrees of Certainty" (Standards, Guideline, Options) and "Classification of Evidence" (Class I to III) and the correlation between the two are defined at the end of the "Major Recommendations" field.

Recommendations

1. Standards

   Insufficient data to support a treatment standard for any brain-targeted therapy for patients with severe head injury.

2. Guidelines

   Data supports the use of mannitol in response to herniation at doses of 1.4–2.1 g/kg if supported by the capacity to provide high fluid volume compensation for any ensuing urine loss.

3. Options

   Hypertonic Saline

   Hypertonic saline appears to reduce intracranial pressure (ICP) when given as a bolus and may be given for this purpose although an improvement in neurological outcome with resuscitation with hypertonic saline over standard fluid resuscitation has not been demonstrated.

   Hyperventilation

   Hyperventilation is to be avoided both as an intended therapy and inadvertently as part of other airway management, except in the context of visible signs of cerebral herniation, when its use may delay herniation.

   Antibiotic Prophylaxis for Penetrating Brain Injury

   Use of prophylactic broad-spectrum antibiotics is recommended for patients with penetrating brain injury.

   Treatments to Optimize Patient Transport

   While sedation and analgesia will be given for many reasons to the brain-injured patient, no literature supports a specific brain-targeted or protective effect from these medications.

   Treating Other Causes of Altered Mental Status

   Hypoglycemia can result in altered mental status and coma. Exact correlation between symptoms and serum glucose levels does not exist. Finger-stick serum glucose should be obtained as soon as possible in the patients care and any hypoglycemia corrected.

Summary

The brain-targeted therapies possible away from a treatment facility in a prehospital or remote environment are hyperventilation, hyperosmolar therapy, sedation, and control of glucose. Hyperventilation will delay herniation but can also impact outcomes by creating ischemia, limiting its use to patients who show clinical evidence of herniation. Hyperosmolar therapy has been shown to improve outcome. Unfortunately, the hyperosmolar agent demonstrated to provide benefit, mannitol, is a high volume agent. The lower volume agent, hypertonic saline, has shown neither benefit nor detriment over isotonic solutions. While analgesics, sedatives and lidocaine will continue to be part of the early care of brain-injured patients, no evidence exists for a specific beneficial brain effect. Prevention of hypoglycemia should continue to be a priority. The impact on neurological outcome of limiting hyperglycemia is still to be determined. Although obtaining tight control of serum glucose in the prehospital environment may not be practical in all cases, checking and managing serum glucose as soon as practical in the patient's course is advisable.

Definitions:

Classes of Evidence

Class I: Evidence from good quality randomized controlled trials (RCT)

Class II: Evidence from moderate or poor quality RCT, good quality cohort, or good quality case-control studies

Class III: Evidence from moderate or poor quality cohort; or moderate or poor quality case-control; or case series, databases, or registries

Degrees of Certainty

Standards: Reflect a high degree of clinical certainty as indicated by the scientific evidence available (supported by Class I evidence).

Guidelines: Reflect a moderate degree of clinical certainty as indicated by the scientific evidence available (supported by Class II evidence).

Options: Reflect unclear clinical certainty as indicated by the scientific evidence available (supported by Class III evidence).

A clinical algorithm for "Field Management of Combat-Related Head Trauma" is provided in the original guideline document.

An evidentiary table appears at the end of each major section of the guideline document, which classifies each citation based on the quality of the evidence (Class I-III; see "Major Recommendations" for definitions).  The recommendations in this summary are supported by nine Class III studies and five Class II studies.

• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: brain-targeted therapy. New York (NY): Brain Trauma Foundation; 2005. 13 p. [58 references]

Not applicable: The guideline was not adapted from another source.

2005

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation

Uniformed Services University of the Health Sciences

Not stated

Authors: Tom Knuth, MD, MPH, FACS, COL, Medical Corps, US Army, Chief, Combat Casualty Care Integrated Concepts Team, Directorate of Combat Doctrine and Development, Army Medical Department Center and School, Fort Sam Houston, Texas; Peter B. Letarte, MD, FACS, Neurosurgeon, Hines VA Medical Center, Loyola University Medical Center; Geoffrey Ling, MD, PhD, LTC, Medical Corps, US Army, Professor and Vice-Chair of Neurology, Director of Critical Care Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Leon E. Moores, MD, FACS, LTC, Medical Corps, US Army, Assistant Professor of Surgery and Pediatrics, Uniformed Services University of the Health Sciences, Chief of Neurosurgery, Director of Pediatric Neurological Surgery, Walter Reed Army Medical Center; Peter Rhee, MD, MPH, FACS, FCCM, CAPT, Medical Corps, US Navy, Professor of Surgery/Molecular Cellular Biology, Director, Navy Trauma Training Center, Los Angeles County Medical Center, University of Southern California; David Tauber, CCEMT-P, NREMT-P, I\C, Executive Director, Advanced Life Support Institute (New Hampshire) Medical Specialist/Hazardous Materials Technician, FEMA USAR Team MA1; Art Trask, MD, FACS, INOVA Regional Trauma Center, INOVA Fairfax Hospital

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on August 24, 2007. The information was verified by the guideline developer on January 28, 2008.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.