PI’s: Randy S. Bell; Gregory Hawryluk
The 1st edition Guidelines for the Management of Penetrating Traumatic Brain Injury (pTBI) were published in the Journal of Trauma in 2001.1 More than 70% of the current body of literature related to pTBI was published after 2001. In response to the recent and ongoing military conflicts around the world, the United States Army Medical Research and Development Command, in conjunction with the Brain Trauma Foundation, assembled a group of international and multi-disciplinary subject matter experts to create new and updated guidelines. Over the past three years, a complete systematic review governed by pre-published methodology was completed.2 The product of this effort is currently being reviewed by the AANS/CNS Joint Guidelines Review Committee, with anticipated online and print publication within the next six to nine months.
In creating these updated guidelines, and despite the increase in recent publication, we discovered that there remains little high-quality, hypothesis-driven evidence upon which to base recommendations. Most of what is available is case series or individual studies without control populations documenting a single institutional experience with purely descriptive analysis. While some aspects of study in pTBI are not amenable to hypothesis driven research, there are aspects that are. The subject matter experts concluded that, going forward, we as editors and reviewers must raise the bar concerning what is considered acceptable for publication in this area.
There are several key differences between the first and second editions:
- The 2nd edition methodology creates distinct and clearly defined levels of evidence, and though included, does not admix the lowest level of evidence with expert consensus.
- There is no distinction in the 2nd edition between military, civilian or other pTBI populations unless the evidence specifically indicates a reason for the distinction.
- Treatment algorithms based on evidence and expert consensus will be provided to aid in translation of the evidence to the bedside.
- Nearly half of the 1st edition guidelines focused on variables related to prognosis. The presentation of these prognostic variables focused on poor outcome or death rather than good outcome. Given recent evidence suggesting that we as practitioners are not highly effective at determining prognosis, the 2nd edition intentionally de-emphasizes consideration of prognosis in early decision making. Instead, and in an effort to reduce nihilism, the updated guidelines and algorithm recommend early surgical decision-making based on medical futility.
- The 2nd edition pTBI guidelines will be available online and open source.
Two major geopolitical conflicts, political violence and mass shootings, have unfortunately created an intensive need for and interest in our work. While we hope that our guidelines succeed in improving the outcomes of pTBI victims, we hope even more for an end to the violence that currently plagues humanity.
- Part 1: Guidelines for the management of penetrating brain injury. Introduction and methodology. J Trauma 2001;51(2 Suppl):S3-6
- Hawryluk GWJ, Selph S, Lumba-Brown A, et al. Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma Rep 2022;3(1):240-247, doi:10.1089/neur.2022.0008