Brain Trauma Foundation guidelines for TBI management achieve 50 per cent reduction in mortality

Imagine a pill was invented that reduced mortality from traumatic brain injury by 50 per cent. Despite tremendous advancement in many areas of medicine, progress in brain injury care has lagged. Scientists have spent billions of research dollars trying to develop a treatment for traumatic brain injury but nothing has translated to an effective remedy as of yet.

Given this, a treatment leading to a 5 per cent or 10 per cent improvement in outcome from brain injury would be hailed as a major advancement. 50 per cent improvement seems beyond reach and perhaps too much to hope for. If ever achieved, it would potentially be worthy of a Nobel Prize.

Yet, we have already achieved precisely that result. The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury have repeatedly achieved a 50 per cent reduction in mortality – whether introduced in eastern Europe or New York State. In fact, the Foundation’s Prehospital Guidelines were recently shown to triple the odds of survival in the sickest patients. These achievements serve as a reminder of the progress that has been made.

Evidence-based medicine was beginning to take root in the 1990s. In 1993, Drs. Jamshid Ghajar, Randall Chesnut and Donald Marion met in Vancouver, Canada amid the annual Congress of Neurological Surgeons meeting.

Methodology for the development of evidence-based guidelines had only recently been described, and this trio had the foresight to recognise the important contribution that guidelines could have to the field of head injury. The BTF has since published 15 full length guideline documents, each taking about 5 years to complete.

Remarkably, the first BTF guidelines took only two years to create and publish. At the time, they were the first ever evidence-based guidelines to have been published by a surgical specialty. Through three subsequent editions, these “adult coma guidelines” have remained relatively unchanged, which highlights the brilliance and tenacity of the original panellists.

Dr. Ross Bullock, a prominent member of the early guideline panels and past Medical Director of the Brain Trauma Foundation, remarked that the expert panellists recognised that their work on the guidelines was perhaps the most important contribution to the field they would make in their careers.
The BTF guidelines have evolved and expanded over the years, covering new topics like injuries sustained in combat, paediatric care and concussion treatment.

Despite the widespread respect this work has earned BTF, the methodology employed during development of the Guidelines for the Treatment of Severe TBI, 4th Edition received pushback.

In an effort to produce the highest standard of guidance, BTF planned to exclude low quality, ‘Class 3’ evidence from the published product. Based on feedback Class 3 evidence was ultimately included, but expert opinion was not. Indeed, evidence often proves expert opinion wrong! The final recommendations were thus viewed as being statements of evidence that did not provide sufficient guidance as to how patients should realistically be managed.

This prompted a period of introspection for the organisation. With new leadership at the helm and valuable input from leading experts around the globe, BTF set a new course. The first order of business was to bridge the gap between published evidence and the realities of patient care. Expert opinion was reintroduced to guideline development through the Delphi Process and is labelled as such.

Experts complete blind voting to reduce the risk of bias and must reach a pre-determined consensus threshold to be included. All guideline projects also now require treatment algorithms that combine a visual tool with the rigorous expert opinion to provide another means of guiding the end-user in making therapeutic decisions.

Realising the need for increased adoption and implementation of the guidelines, the BTF has also initiated educational initiatives. The Foundation recently launched an online course in collaboration with the American College of Surgeons to help ensure that insights about best practices from the guidelines reach more practitioners and their patients.

We also recognise the need to reach a greater proportion of the world’s population, as the highest burden of brain injury is in less developed nations. In collaboration with the Military Traumatic Brain Injury Initiative, the BTF is nearing completion of guidelines tailored to the treatment of TBI in austere or combat environments – areas which may lack a neurosurgeon, advanced imaging or intensive care treatment facilities.

Our guidelines have always been tailored to optimally resourced environments. Initially, there was a fear that producing guidelines for less resourced environments would reduce or remove the aspiration to fully resource patient care and thus, ultimately be a disservice.

However, we acknowledge the overall benefit this will have on the global community and are pressing forward. The BTF is also in the planning stages of Guidelines for the Treatment of Severe TBI, 5th Edition, our flagship adult coma resource with the intention of developing recommendations stratified for different levels of care resources.

The impact the Brain Trauma Foundation and its guidelines have made in the world of medicine is undeniable.

The 4th edition Guidelines for the Treatment of Severe TBI have been cited more than 3,800 times since publication in 2017 and was the most accessed article of 2023 in the journal NEUROSURGERY – over 18,000 times, and three times as often as the second-place article which was another BTF article. Our Guidelines for the Management of Pediatric Severe TBI, 3rd Edition took the third-place spot with more than 3,600 accesses in the same year.

In another new initiative, the BTF has also – for the first time – launched a multicentre clinical trial aimed at developing a new treatment for traumatic brain injury. Our External Lumbar drainage to Abort Severe Traumatic IntraCranial hypertension (ELASTIC) trial is studying lumbar cerebrospinal fluid drainage as a strategy to prevent and treat intracranial pressure elevation, which is a common and life-threatening complication of brain injury.

The study is now open to enrolment at several sites across America and holds promise for improving patient outcomes and enabling treatment when a neurosurgeon is not immediately available.

We recognise the importance of our work within medicine and are committed to further improving outcomes from brain injury worldwide. We will achieve this through approaches that are both old and new to the BTF and we will endeavour to continue producing highly respected and innovative work products that are widely adopted around the world.