Review

. 2019 Nov 29:14:53.

doi: 10.1186/s13017-019-0270-1. eCollection 2019.

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

Edoardo Picetti¹, Sandra Rossi¹, Fikri M Abu-Zidan², Luca Ansaloni³, Rocco Armonda⁴, Gian Luca Baiocchi⁵, Miklosh Bala⁶, Zsolt J Balogh⁷, Maurizio Berardino⁸, Walter L Biffl⁹, Pierre Bouzat¹⁰, Andras Buki^{11

12}, Marco Ceresoli^{13

14}, Randall M Chesnut¹⁵, Osvaldo Chiara¹⁶, Giuseppe Citerio^{14

17}, Federico Coccolini³, Raul Coimbra¹⁸, Salomone Di Saverio¹⁹, Gustavo P Fraga²⁰, Deepak Gupta²¹, Raimund Helbok²², Peter J Hutchinson^{23

24}, Andrew W Kirkpatrick²⁵, Takahiro Kinoshita²⁶, Yoram Kluger²⁷, Ari Leppaniemi²⁸, Andrew I R Maas²⁹, Ronald V Maier³⁰, Francesco Minardi¹, Ernest E Moore³¹, John A Myburgh³², David O Okonkwo³³, Yasuhiro Otomo³⁴, Sandro Rizoli³⁵, Andres M Rubiano^{36

37}, Juan Sahuquillo³⁸, Massimo Sartelli³⁹, Thomas M Scalea⁴⁰, Franco Servadei⁴¹, Philip F Stahel⁴², Nino Stocchetti^{43

44}, Fabio S Taccone⁴⁵, Tommaso Tonetti¹, George Velmahos⁴⁶, Dieter Weber⁴⁷, Fausto Catena⁴⁸

Affiliations

¹ 1Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100 Parma, Italy.
² 2Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
³ 3Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy.
⁴ 4Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC USA.
⁵ 5Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
⁶ 6Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
⁷ Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW Australia.
⁸ 8Department of Anesthesiology, CTO Hospital, Turin, Italy.
⁹ 9Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA USA.
¹⁰ Department of Anaesthesiology and Critical Care, Grenoble Alps Trauma Center, University Hospital of Grenoble-Alpes, Grenoble Cedex, France.
¹¹ 11Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.
¹² 12János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.
¹³ 13Department of General and Emergency Surgery, ASST, San Gerardo Hospital, Monza, Italy.
¹⁴ 14School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
¹⁵ 15Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA.
¹⁶ 16General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy.
¹⁷ 17Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy.
¹⁸ 18Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, CA USA.
¹⁹ 19Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
²⁰ 20Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil.
²¹ 21Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India.
²² 22Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria.
²³ 23Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
²⁴ 24NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
²⁵ 25Departments of General Acute Care, Abdominal Wall Reconstruction and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada.
²⁶ Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan.
²⁷ 27Department of General Surgery, Rambam Health Campus, Haifa, Israel.
²⁸ 28Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland.
²⁹ Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
³⁰ 30Department of Surgery, Harborview Medical Centre, University of Washington School of Medicine, Seattle, WA USA.
³¹ 31Department of Trauma Surgery, Denver Health, Denver, CO USA.
³² 32Department of Intensive Care Medicine, St. George Clinical School, University of New South Wales and The George Institute for Global Health, Sydney, Australia.
³³ 33Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA.
³⁴ 34Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.
³⁵ 35Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar.
³⁶ 36INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.
³⁷ MEDITECH Foundation, Clinical Research, Cali, Colombia.
³⁸ Neurosurgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain.
³⁹ General Surgery, Macerata Hospital, Macerata, Italy.
⁴⁰ 40R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA.
⁴¹ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
⁴² 42College of Osteopathic Medicine, Rocky Vista University, Parker, CO USA.
⁴³ 43Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴⁴ 44Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴⁵ Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
⁴⁶ 46Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA.
⁴⁷ 47Trauma and General Surgery, Royal Perth Hospital, Perth, Australia.
⁴⁸ 48Department of Emergency Surgery, Parma University Hospital, Parma, Italy.

PMID: 31798673
PMCID: PMC6884766
DOI: 10.1186/s13017-019-0270-1

Review

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

Edoardo Picetti et al. World J Emerg Surg. 2019.

. 2019 Nov 29:14:53.

doi: 10.1186/s13017-019-0270-1. eCollection 2019.

Authors

Affiliations

¹ 1Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100 Parma, Italy.
² 2Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
³ 3Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy.
⁴ 4Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC USA.
⁵ 5Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
⁶ 6Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
⁷ Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW Australia.
⁸ 8Department of Anesthesiology, CTO Hospital, Turin, Italy.
⁹ 9Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA USA.
¹⁰ Department of Anaesthesiology and Critical Care, Grenoble Alps Trauma Center, University Hospital of Grenoble-Alpes, Grenoble Cedex, France.
¹¹ 11Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.
¹² 12János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.
¹³ 13Department of General and Emergency Surgery, ASST, San Gerardo Hospital, Monza, Italy.
¹⁴ 14School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
¹⁵ 15Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA.
¹⁶ 16General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy.
¹⁷ 17Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy.
¹⁸ 18Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, CA USA.
¹⁹ 19Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
²⁰ 20Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil.
²¹ 21Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India.
²² 22Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria.
²³ 23Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
²⁴ 24NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
²⁵ 25Departments of General Acute Care, Abdominal Wall Reconstruction and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada.
²⁶ Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan.
²⁷ 27Department of General Surgery, Rambam Health Campus, Haifa, Israel.
²⁸ 28Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland.
²⁹ Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
³⁰ 30Department of Surgery, Harborview Medical Centre, University of Washington School of Medicine, Seattle, WA USA.
³¹ 31Department of Trauma Surgery, Denver Health, Denver, CO USA.
³² 32Department of Intensive Care Medicine, St. George Clinical School, University of New South Wales and The George Institute for Global Health, Sydney, Australia.
³³ 33Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA.
³⁴ 34Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.
³⁵ 35Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar.
³⁶ 36INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.
³⁷ MEDITECH Foundation, Clinical Research, Cali, Colombia.
³⁸ Neurosurgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain.
³⁹ General Surgery, Macerata Hospital, Macerata, Italy.
⁴⁰ 40R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA.
⁴¹ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
⁴² 42College of Osteopathic Medicine, Rocky Vista University, Parker, CO USA.
⁴³ 43Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴⁴ 44Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴⁵ Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
⁴⁶ 46Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA.
⁴⁷ 47Trauma and General Surgery, Royal Perth Hospital, Perth, Australia.
⁴⁸ 48Department of Emergency Surgery, Parma University Hospital, Parma, Italy.

PMID: 31798673
PMCID: PMC6884766
DOI: 10.1186/s13017-019-0270-1

Abstract

The acute phase management of patients with severe traumatic brain injury (TBI) and polytrauma represents a major challenge. Guidelines for the care of these complex patients are lacking, and worldwide variability in clinical practice has been documented in recent studies. Consequently, the World Society of Emergency Surgery (WSES) decided to organize an international consensus conference regarding the monitoring and management of severe adult TBI polytrauma patients during the first 24 hours after injury. A modified Delphi approach was adopted, with an agreement cut-off of 70%. Forty experts in this field (emergency surgeons, neurosurgeons, and intensivists) participated in the online consensus process. Sixteen recommendations were generated, with the aim of promoting rational care in this difficult setting.

Keywords: Bleeding; Hemorrhage; Management; Monitoring; Polytrauma; Traumatic brain injury.

PubMed Disclaimer

Conflict of interest statement

Competing interestsAWK has consulted for the Innovative Trauma Care and Acelity Corporations. PFS is the co-inventor of the US patent no. 11.441.828 entitled: “Inhibition of the alternative complement pathway for treatment of traumatic brain injury, spinal cord injury, and related conditions.” All other authors declare that they have no competing interests.

Figures

**Fig. 1**
Consensus algorithm. (1) Lower values could be tolerated, for the shortest possible time, in case of difficult intraoperative bleeding control. (2) Higher threshold could be used in patients “at risk” (i.e., elderly and/or with limited cardiovascular reserve because of pre-existing heart disease). (3) Lower values, temporarily, only in case of impending cerebral herniation. (4) Afterwards, this ratio can be modified according to laboratory values. (5) Not only in case of impending cerebral herniation but also for cerebral edema control. (6) This value should be adjusted (individualized) considering neuromonitoring data and cerebral autoregulation status. (7) This approach is recommended in the absence of possibilities to target the underlying pathophysiologic mechanism of IH. *Abbreviations:* SMS = systemic multisystem surgery (including radiologic interventional procedures), CT = computed tomography, GCS = Glasgow Coma Scale (mot = motor part of GCS), MAP = mean arterial pressure, SBP = systolic blood pressure, Hb = hemoglobin, PaO2 = arterial partial pressure of oxygen, PaCO2 = arterial partial pressure of carbon dioxide, RBC = red blood cell, P = plasma, PLT = platelet, PT = prothrombin time, aPTT = activated partial thromboplastin time, TEG = thromboelastography, ROTEM = rotational thromboelastometry, ICP = intracranial pressure, CPP = cerebral perfusion pressure, IH = intracranial hypertension, EES extracranial emergency surgery

See this image and copyright information in PMC

References

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WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

Affiliations

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

Authors

Affiliations

Abstract

Conflict of interest statement

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References

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Grants and funding

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Full Text Sources

Medical