Managing Severe Traumatic Brain Injury (Podcast)

There has been a 50% reduction in mortality from head injuries since the Brain Trauma Foundation published its first guidelines on managing severe traumatic brain injury (TBI) in 1996. But there’s still more work to be done to connect and advance evidence-based guidance and clinical practice to improve care for patients with TBI.

“A head injury can profoundly change a person — their ability to work, to do the things they normally do,” says Gregory Hawryluk, MD, PhD, a neurosurgeon at Cleveland Clinic Akron General and medical director and chair of the Brain Trauma Foundation’s scientific advisory board. “Head injury care has been slower to advance than other areas of medicine.”

Dr. Hawryluk is at the forefront of writing neurotrauma treatment guidelines that are followed by trauma centers around the world. In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, he discusses the latest evidence and guidelines, as well as ongoing work to better support healthcare professionals in the field. He covers:

• The evolution of TBI treatment during the past 50 years
• The Brain Trauma Foundation’s guidelines for management of severe TBI, as well as guidelines for pediatric TBI and combat, concussion and other head injury subtopics
• Efforts to define concussion and work to examine its subtypes and to advise on readiness to return to work, sports or other activities
• Collaboration with the U.S. Department of Defense on a penetrating head injury guideline
• Efforts on the horizon to learn more about the physiology of brain injury and to better serve physicians at the bedside

Click the podcast player above to listen to the 32-minute episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

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Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: What have the guidelines shown us that we should be doing?

Dr. Hawryluk: I think the biggest thing that is helping in head injury is supportive care. We’ve learned that there are critical values of brain pressure, blood pressure and brain oxygenation, and that certain threshold values are associated with better outcomes. For the past 20 years we have been refining what those numbers are.

For instance, the critical value for brain pressure used to be 25 mm Hg. Further research led us to recommend 20 mm Hg in the second edition of the guidelines. Today the value we use is 22 mm Hg. We should be starting work on the fifth edition of the adult severe head injury guidelines in about three years. What’s really interesting is that we’ve had a couple of recent papers that suggest that values as low as 10 mm Hg might actually be associated with some harm. So we might be revisiting what those critical numbers are.

There are other areas where the guidelines are bringing forward new treatments. One of them has been antibiotic-impregnated external ventricular drains. For those who aren’t neurosurgeons, one of the common things we do in a head injury is to put a tube through the skull down into the fluid-filled chambers of the brain. That allows us to measure the pressure in the brain, to make sure we’re below that 22 mm Hg value. It also allows us to drain brain fluid to help achieve that. If a patient is in crisis, even one cubic centimeter can be critical. When I was a resident physician, one of the major complications of these tubes was that they could get infected. Then, if someone got ventriculitis, they sometimes would spend months in the ICU going through cycles where the care team would try to clear the infection and then perhaps try to put in a shunt. Antibiotic-impregnated drains have since been introduced, and they have been a game changer. The infection rate is very low now, even if the tubes are left in as long as three weeks. So we now have evidence to use these drains.

Another thing we now have evidence for is the importance of feeding patients. If you reinitiate feeding within the first week, those patients do better. The point is that there are a lot of interventions in the guidelines that are helping us provide better care to patients.