bcc4: anthony delaney on traumatic brain injury in the real world
TRANSCRIPT
TRAUMATIC BRAIN INJURY IN THE REAL WORLD
Anthony Delaney MBBS MSc FACEM FCICM
Staff Specialist Malcolm Fisher Department of Intensive Care Medicine
The real world?
A couple of new issues in the field
Field intubation
ICP monitoring
“severe” traumatic brain injury
Brain trauma foundation guidelines
Chapter 1
Avoid SBP <90 mm Hg
Avoid SpO2 < 90%
g
Pre-hospital intubation
Setting: Melbourne, Geelong, Ballarat and Bendigo
EMS 1700 paramedics
360 trained to intubate
Road ambulances (trauma <30 minutes from a trauma centre)
16 hours of training 4 hours in a class
8 hours with an anaesthetist
4Hour simulation based exam
Pre-hospital intubation
Population:
Head trauma
Age ≥15
GCS ≤9
Intact airway reflexes
Excluded
<10 minutes from hospital
Allergy to RSI drugs
Helicopter transport
Pre-hospital intubation
Intervention: BVM 3 minutes
Fentanyl 100 micrograms, midazolam 0.1mg/kg, suxamethonium 1.5mg/kg
500ml Hartmanns
Half dose drugs if SBP <100 or age >60
Cricoid pressure
Pancuronium, morphine and midazolam
Max 2 attempts
Pre-hospital intubation
Comparison:
Oxygen at 12L/min
BVM
Guedells or NP airway if needed
Morphine if combative
Intabated at the hospital
Pre-hospital intubation
Outcome 6 month Extended Glasgow Outcome Scale
Pre-hospital intubation
Sample size
To detect a 1 point median change in GOSe
+ 20% for loss to follow-up
80% power
Primary outcome
Mann-Whitney U test
Pre-hospital intubation
Internal validity:
Randomisation: Computer generated sequence
Allocation concealment: Sealed opaque envelopes
Blocks of 10
Blinded outcome assessment
Complete follow-up :
3 (1.9%) lost from RSI group, 10 (6.6%) lost from usual care group (p=0.048)
Pre-hospital intubation
Internal validity:
Intention to treat
Yes
Baseline balance
Yes
Concomittant therapy
Note RSI patients were colder than usual care patients !
35.0 v 35.6 (p<0.0005)
Longer at scene and more ivi fluids
Pre-hospital intubation
Results
160 participants allocated to RSI
Intubation attempted in 157
Successful in 152 (97%)
10 cardiac arrests in the RSI group v 2 in the usual care group
Pre-hospital intubation
Results No statistically significant difference in primary
outcome Median 5 v 3 (p=0.28)
Secondary outcome GOSe good in 51% v 39% (p=0.046) (1 patient either way would render this result > 0.05)
Conclusions: In adults with severe TBI, prehospital rapid
sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.
So… Pre-hospital intubation
Might be able to be done safely by paramedics (NB increase cardiac arrests)
Hypothermia may have confounded the results
No difference in primary outcome
Severe head injury is still bad for you
Intracranial pressure monitoring
Measurement of ventricular pressure in trauma began with Guillaume and Janny in 1951 and Lundberg in the 1960’s
BEST: TRIPBenchmark Evidence from South American Trials:
Treatment of Intracranial Pressure
Setting: Bolivia and Ecuador ICP monitoring not routinely used ICUs with intensivists, 24 hour CT, neurosurgery and high
volumes of patients 2008-2011
Population: >13 years GCS 3-8 (Motor 1-5 if intubated), within 48 hours of injury Exclusion Bilateral fixed dilated pupils Unsurvivable injury
BEST: TRIP
Intervention both groups
CT at baseline, 48 hours and 5-7 days
Mechanical ventilation, sedation and analgesia,
Aggressively managed non-neurological problems?
BEST: TRIP
Intervention group Intraparenchymal monitor ICP <20 mm Hg Guidelines based on the guidelines for management of
severe traumatic brain injury EVD for CSF drainaage
Control group Clinical examination and CT to look for Intracranial
hypertension Hyperosmolar therapy PaCO2 30-35 EVD for CSF drainage Treatments for “neuroworsening”
Neuroworsening?
Dude
Neuroworsening?
Stat!
BEST: TRIP
Outcome
Composite outcome
21 measures
Survival time, duration and level of impaired consciousness, sum of errors on orientation questions on the GOAT test, GOSE at 3 months, functional and neuropsychological components
3 and 6 months
Blinded assessments
Average of the 21 measures
BEST: TRIP
Internal validity: Randomisation
Stratified by site
Block size 2 or 4
Allocation concealment Not in the main paper
Centralised computer system or
Telephone coin toss
Intention to treat Yes
Baseline balance Yes
BEST: TRIP
Sample size80% power to detect a 10% increase in good clinical outcomes (OR 1.5)
Very complicated analysis
BEST: TRIP
Internal validity:
Follow-up
BEST: TRIP
Results
Favourable outcome in ICP group???
Favourable outcome
To rule out a favourable outcome in ICP group???
ICP?
It may not make a difference to a complicated outcome scale in Bolivia
ICP?
But it is probably important
Further investigation of monitoring in severe brain injury
Probably really need treatments
“Severe” Traumatic brain injury
NFL has recently settled a case brought be ex-players for US$ 765 Million
“Severe” Traumatic brain injury
QUESTIONS [email protected]