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DRAFT VERSION OF DIAGNOSTIC, THERAPEUTIC, AND ORGANIZATIONAL RECOMMENDATIONS FOR brain injury MANAGEMENT

Motto:
"Now is no time to think of what you do not have. Think of what you can do with what there is."

Ernest Hemingway1

    The standardization of diagnostical and therapeutical procedures is medically and economically very important2-16. Its aim is to arrange known facts into logical groups and then to determine whether they are based on scientific and clinical evidence, or myths3,16-19. A proven method of standards development is the consensus conference6,13. Consensus conferences have not been organized in the Czech Republic to date. How does one prepare a methodically correct consensus conference? Our answer can be found in the text "National Conferences of Acute Medicine Project (NCAM)".

    The value given to a particular standard depends on the quality of relevant clinical studies classified according to a generally accepted American classification of published data3,4.

    The standards are based on available clinical outcome data20. Our interest concerned primary endpoint3. It is clear that this evidence-based aproach cannot be used for all standards20. Many studies did not have sufficient outcome data to assess the effectiveness of the treatment3. In addition, following and assessing the outcome of severe head injury is awkward, expensive and ethically impossible3. Assessment of a particular intervention based on physiological parameters such as ICP, CBF, and SjvO2 can be a substitute3,20,21 since changes in these variables are correlated with poorer outcome22-24. Where no data are available expert opinion is of value13,21. However, even experts can come to or support inaccurate conclusions17. Developing the following standards, we have combined American "evidence-based approach"3,20 and European "expert opinion approach"21,25 as the intersection of euroamerican thinking.

    Each standard has a number and one to three asterisks corresponding to its value. Our system of evaluation is as follows:

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Options

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Guidelines

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Standards

    Neurotraumatological centres undertaking basic and clinical research on brain injuries employ similar diagnostic and therapeutic procedures, referral policy, and admission care20,21. Although they differ in some details, most of them follows this protocol20,21,25-28:
* fast transport,
* early intubation,
* agressive resuscitation,
* urgent head CT,
* prompt surgical evacuation of intracranial haematomas,
* ICP monitoring,
* maintaining the adequate CPP,
* intensive care to prevent secondary damage to the injured brain.

    Although these principles are widely agreed on, single neurotraumatological centres differ hugely, particularly in the care of comatose patients3. Several recent recommendations on the management of TBI casualties20,21,25, 26,29,30 have proven necessary to the unification of diagnostic, therapeutic, and organizational procedures.

    In the past, The Ministry of Health of the former Czech Socialist Republic used to issue Methodical Guidelines. The first set of guidelines was issued in 197731. Drabkova et al.29 published a review on the pre-hospital and in-hospital emergency care of brain injured patients. The third and the last attempt to unify management protocols was the Methodical Recommendation by Tichacek and Drabkova30 which focused on pre-hospital emergency care of isolated brain injuries. NCAM Project was designed to promote discussion among concerned medical doctors and scientists on various issues in acute medicine.

References:
1. Hemingway E: The old man and the sea. Arrow Books Ltd.;1993:95.
2. American Medical Association, Office of Quality Assurance and Healthcare Organizations: Attributes to Guide the Development of Practice Parameters. Chicago 1990: American Medical Association.
3. Narayan RK: Development of guidelines for the management of severe head injury. J Neurotrauma 1995;12:907-912.
4. Sackett DL: Rules of evidence and clinical recommendations. Can J Cardiol 1993;9:487-489.
5. National Committee to Advise on Tropical Medicine and Travel (CATMAT): Evidence-based medicine. (From CCDR) Can Med Assoc J 1995;152(2):201-204.
6. Guidelines for the planning and management of NIH Consensus Development Conferences Online. Bethesda (MD): National Institutes of Health, Office of the Director, Office of Medical Applications of Research;1993 May. 13p. Updated March 1995. http://www.consensus.nih.com
7. Mareček V: Projekt akutní medicíny v dnešním zdravotnictví (NKAM). Lékařské listy (Příloha Zdravotnických novin) 12.4.1996, s.15. or too Projekt NKAM Online. http://www.medgate.cz/nkam.
8. Mareček V: Projekt národní konference akutní medicíny (NKAM). Medica Rev 1996;3:52-53.
9. Mareček V: Standardy ano, ale jak? Čas Čes lék Komory 1997;6(10):12.
10. Gladkij I: Klinická doporučení a klinické algoritmy a jejich význam pro kvalitu zdravotní péče a kontrolu její
spotřeby. Zdravot Zdrav Poj 1997;1:23-25.
11. Linhart J: Standardy vyšetřovacích a léčebných postupů. Marketing pro zdraví 1997;7(3):8.
12. Čerbák M: Standardy diagnostických a léčebných postupů. I. část. Věstník MZ ČR 1997, částka 8, s.13-46.
13. Woolf SH: Practice guidelines, a new reality in medicine. II. Methods of developing guidelines. Arch Intern Med 1992; 152:946-952.
14. Rosenberg J, Greenberg MK: Practice parameters: Strategies for survival into the nineties. Neurology 1992;42:1110-1115.
15. Tannenbaum SJ: What physicians know. N Engl J Med 1993; 329:1268-1270.
16. Ginsburg WH: When does a guideline become a standard? The new American Society of Anesthesiologists Guidelines give us a clue. Ann Emerg Med 1993;22:1891-1896.
17. Evidence-Based Medicine Working Group: Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA 1992;268:2420-2425. (český překlad: JAMA-CS 1993;1:182-186)
18. Hayward RSA, Wilson MC, Tunis SR, et al: Users' guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? JAMA 1995; 274:570-574.
19. Hroboň P: Účinnost léčby je třeba systematicky hodnotit. Zdravotnické noviny 1.8.1997, s.4.
20. Bullock R, Chesnut RM, Clifton C, et al: Guidelines for the management of severe head injury. J Neurotrauma 1996; 13:643-734.
21. Maas AIR, Dearden M, Teasdale GM, et al: EBIC-Guidelines of severe head injury in adults. Acta Neurochir (Wien) 1997;139:286-294.
22. Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-222.
23. Miller JD, Sweet RC, Narayan R, et al: Early insults to the injured brain. JAMA 1978;240:439-442.
24. Bouma GJ, Muizelaar JP: Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury. J Neurotrauma 1992;9(Suppl 1):S333-S348.
25. Gentleman D, Dearden M, Midgley S, Maclean D: Guidelines for resuscitation and transfer of patients with serious head injury. BMJ 1993;307:547-552.
26. Guidelines for initial management after head injury in adults. Suggestions from a group of neurosurgeons. BMJ 1984;288:983-985.
27. Gentleman D, Jennett B: Audit of transfer of unconscious head-injured patients to a neurosurgical unit. Lancet 1990;335:330-334.
28. Ghajar JB, Hariri R, Narayan RK, et al: Survey of critical care management of comatose, head-injured patients in the United States. Crit Care Med 1995;25:560-567.
29. Drábková J, Pokorný J, Getlík P, Ročeň M: Okamžitá a neodkladná péče při mozkolebečních poraněních. In Současné trendy kortikoterapie v akutních a v kritických stavech. Sborník ze symposia firmy UPJOHN, Praha 1993:67-76.
30. Ticháček M, Drábková J: Ošetření izolovaných mozkolebečních poranění v přednemocniční péči. Metodický list č.1. Společnost přednemocniční neodkladné péče a medicíny katastrof ČLS JEP. Anest Neodkl Péče 1997;5(Suppl):II-III.
31. Péče o nemocné s kraniocerebrálním poraněním. Věstník MZ ČSR 1977, č.21, s.105-106.

Vit Marecek
Czech Neurotrauma Consensus Coordinator

Last updated: 1999-09-06