[Guidelines and standards: assessment and risk management of severe neurological complications following mild traumatic brain injury]

Lorthios-Guilledroit A, Ferrari N, Dugas M
Record ID 32018001163
Original Title: Évaluation et gestion du risque de complications neurologiques graves à la suite d’un traumatisme craniocérébral léger : guide réalisé en soutien à la révision de l’algorithme sur l’évaluation et la gestion du risque de complications neurologiques graves à la suite d’un traumatisme craniocérébral léger
Authors' objectives: Traumatic brain injury (TBI) is generally defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. The mildest form of TBI, mild traumatic brain injury (mTBI), is the most common and results in a significant number of medical visits, both in health clinics and in the emergency department. In patients with mTBI, the probability of severe neurological injury that requires neurosurgical intervention is very low (less than 1%). Although this probability is low, the consequences of such an injury can be fatal if not identified in time. The acute management phase, which involves the assessment and management of the risk of severe neurological complications, is an essential step in mitigating the health consequences of mTBI. Current recommended practices in Québec for the acute management of mTBI are outlined in two decision-making algorithms, one for adults and one for children. As part of the revision of the Ministerial orientations guiding the offer of services to victims of mTBI, the Trauma and Critical Care Evaluation Unit of the Institut national d’excellence en santé et en services sociaux (INESSS) published a knowledge update on mTBI in 2018. This report highlighted the need to revisit the decision rules for identifying patients at risk for severe neurological complications, to review the relevance of including anticoagulation use or presence of coagulopathy as a risk factor, and to re-evaluate the criteria for transferring mTBI patients to neurotrauma centres. Revising transfer criteria has also been a concern of professionals in the field, who contend that many transfers could be avoided in patients with mTBI. It was in this context that the Ministère de la Santé et des Services sociaux (MSSS) asked INESSS to revise the decision-making algorithms for managing the risk of severe neurological complications following mTBI. This request is part of an effort to improve the quality of care and services and to optimize resource utilization for trauma patients.
Authors' results and conclusions: Literature Review Results The Canadian CT Head Rule (CCHR) remains the most sensitive and specific decision rule for identifying patients at risk of neurosurgical injury in adult patients. The evidence also supports the recommendation that anticoagulant use or the presence of coagulopathy in adult patients who have sustained mTBI should be considered as risk factors requiring CT scanning. Few studies or practice guidelines have published clear recommendations regarding the establishment of transfer criteria based on the characteristics of injuries demonstrated on CT. Currently available data on injury characteristics do not allow for major changes to the present transfer criteria, except in the case of subarachnoid hemorrhage, which is no longer considered clinically important with regard to size but rather its complexity (diffuse versus focal). For pediatric patients, the majority of practice guidelines identified recommend applying the Pediatric Emergency Care Applied Research Network (PECARN) decision rule to identify patients at low risk of clinically important intracranial injury. This recommendation is reinforced by the results of systematic reviews that show PECARN to be more sensitive and specific than other rules, including the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule previously recommended by the algorithm. Very few studies have addressed the need for neurosurgical intervention according to injury characteristics in children. Specific transfer criteria are thus difficult to develop in these cases, beyond the presence of intracranial injury. Issues Highlighted in Expert Committee Discussions The experts emphasized the high volume of unnecessary CT scans in both adult and pediatric patients and the importance of discussing why a CT scan should or should not be performed with the patient or parent to avoid overuse. The experts also believe that tele-expertise could go a long way in reducing the volume of unnecessary transfers. They suggest that healthcare centres be given the option of a remote consultation before deciding about transferring to a neurotrauma centre, without making a recommendation until the relevant organizational guidelines are clearly defined. Patient and Informal Caregiver Perspectives The consultation with patients and informal caregivers underlined the importance of certain elements that should be addressed by the tools used to manage patients who have sustained mTBI. Notably, the consultation reinforced the clinical experts’ observations on the need to integrate discussions with the patient in a more systematic manner and at all stages of the care episode. While the interviews focused on the acute phase of the episode of care, it was the post-acute phase of the care continuum that raised the most concerns among patients and caregivers: e.g., lack of information at discharge, access to post-acute services and management of persistent symptoms. Conclusion Within the framework of the revision of Ministerial guidelines on mTBI, the update of the algorithms aims at more efficient management of mTBI patients and better integration of patients in the decision-making process that concerns them, while ensuring quality of care. The recommendations from the present report will be included in decision-making algorithms that will be available on the INESSS website. An implementation and evaluation strategy that can be used by MSSS and healthcare facilities is proposed to pave the way for the changes introduced by these recommendations (e.g., training clinicians at first receiving centres who may not normally keep certain patients with such injuries at their facility) and to ensure that the algorithms will lead to the most appropriate care and services for patients. While the lack of evidence on transfer criteria restricts the extent of changes to be made at this time and their impact on reducing the number of transfers, the dissemination and implementation of the revised algorithms will provide an opportunity to all physicians who might assess mTBI patients to refresh and update their knowledge and ensure that they have the proper evaluation tools. Work currently underway in Québec could also modify or nuance the algorithms’ recommendations. The algorithms will therefore need to be updated in light of the results of this effort over the next few years
Authors' methods: This guide is intended to support the assessment and management of the risk of severe neurological complications following mTBI for adults and children who visit a hospital emergency department. Specifically, the work aims to: 1. review the clinical criteria associated with a higher risk of severe neurologic complications following mTBI; 2. identify the type of injuries observed on CT that are clinically important and require management by specialized neurotrauma centres. 3. establish clinical criteria that justify the transfer of patients who have suffered mTBI to a specialized neurotrauma centre. The methodology used includes a literature review as well as consultations with an expert committee and interviews with patients and informal caregivers. The scientific evidence extracted from the identified studies was summarized in the form of a narrative synthesis, from which proposals for modifications to the algorithms were drafted and submitted to the expert committee. Besides commenting on these proposals, the experts had the opportunity to provide contextual information on the organization of care for victims of mTBI in Québec. In parallel, six patients and caregivers participated in one-on-one interviews to provide their perspective on acute care for mTBI and referral to specialized resources. Following the consultation process, the proposals for modifications to the algorithms were formulated as recommendations, taking into account data from the literature, expert opinion, and the views of patients and informal caregivers
Project Status: Completed
Year Published: 2021
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: Canada
Province: Quebec
MeSH Terms
  • Brain Injuries, Traumatic
  • Critical Care
  • Practice Guidelines as Topic
  • Adult
  • Child
  • Adolescent
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)
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