Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

Karin Reuter-Rice, PhD, CPNP-AC; Elise Christoferson, BA


Am J Crit Care. 2020;29(1):e13-e18. 

In This Article


The revision of the third edition of the guidelines for the management of pediatric severe TBI was approached in 2 phases (Figures 1 and 2): (1) the systematic review, which included the identification, assessment, and synthesis of literature, and (2) the use of that foundation to develop evidence-based recommendations. The key criteria for inclusion in the guidelines were (1) the study population included pediatric patients (≤ 18 years) with severe TBI (score of 3–8 on the Glasgow Coma Scale [GCS]) and (2) the study assessed for and included outcome data such as neurologic function, mortality, or appropriate intermediate targeted topic outcomes. All included studies were then assessed for potential bias and internal validity. Key data elements were then selected and placed into tables summarized by topic, each assigned a class (1–3) depending on the quality of the evidence (see Figure 1 for a description of the classes). The final phase of the evidence review was the synthesis, which is described for each topic in the third edition of the guidelines in the section titled, "Evaluation of the Evidence."

Figure 1.

Methods used for systematic evidence review and synthesis in the development of the third edition of the guidelines for the management of pediatric severe traumatic brain injury.

Next, the quality of the body of evidence was assessed using the 4 domains described in Figure 1. The number of studies and number of study participants included were also considered when assessing the quality of the body of evidence. An overall assessment was then made as to whether the quality of the body of evidence was high, moderate, low, or insufficient. Finally, the applicability of studies is discussed for each topic in the guidelines found in the "Quality of the Body of Evidence" and "Applicability" sections.

Decisions to use identified evidence when formulating recommendations were based on both the quality and the applicability of the body of evidence. If no evidence was identified, no recommendations were formulated. If the identified evidence was extremely limited, it could be considered insufficient to formulate a recommendation. Even if a recommendation was not made, the studies contributing evidence remained in the full guidelines to acknowledge their place in the body of evidence and to make the evidence accessible for possible future consideration. Recommendations were then designated as level I, II, or III (defined further in Figure 2).

Figure 2.

Approach used to create and develop recommendations for the third edition of the guidelines for the management of pediatric severe traumatic brain injury. Recommendations were based on the evidence obtained and synthesized from the systematic evidence review described in Figure 1.

The guideline authors chose to include all topics found in the second edition of the guidelines and did not add any new topics. Major changes for the third edition are described within the guidelines' Appendix C. Supportive data that were included in the third edition are representative of the most current literature at the time of the guidelines' revision, and the rationale for replacing old data is explained within the guidelines' Appendix E. Likewise, recommendations were changed or removed from the second edition in instances where the current literature provided more accurate or newer information for the third edition.