Treatment Algorithms From the Brain Trauma Foundation Guidelines for the Management of Penetrating Traumatic Brain Injury, Second Edition

BACKGROUND: – Penetrating traumatic brain injury (pTBI) is an important wounding mechanism which is seen increasingly as a result of violent crime and armed conflicts. pTBI is very challenging to manage as it is often highly complex yet requires expeditious treatment. Treatment algorithms thus can assist even experienced clinicians to avoid pitfalls while caring for these patients.METHODS: – To supplement the evidence-based recommendations produced in conjunction with the Brain Trauma Foundation Guidelines for the Management of Penetrating Brain Injury, Second Edition, we developed protocols for care to help bridge limitations of published evidence with care decisions required at the bedside. Our working group of over 30 diverse expert panelists identified care, care pathways and key decisions relevant to pTBI care through discussion. A rigorous, blinded Delphi consensus process was then applied. Items achieving at least an 80% consensus vote were incorporated into the treatment algorithms. Consensus voting also approved the final versions of the care pathways.RESULTS: – To meet the needs of diverse pTBI patients we created a Master Care Pathway relevant to all patients. We also created ‘Toolkits’ designed to address care issues that only some patients will have. Toolkits for surgical management, protruding foreign bodies, severe injury, skull base injury and vascular injury were developed. In addition, a futility assessment is provided to assist with delineating the small proportion of patients for whom initial non-aggressive care might be considered with the recognition that avoidance of nihilism is critical to achieving best outcomes in pTBI victims.CONCLUSIONS: – Care pathways are presented which reflect suggestions for care that aim to inspire thoughtful management. The algorithms also aim to avoids potential pitfalls in management to help achieve best possible outcomes for pTBI patients.