BCC4: Anthony Delaney on Traumatic Brain Injury in the Real World

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%

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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 ??ADELANEY@MED.USYD.EDU.AU