TBI Debate - Mild, moderate and severe categories work
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Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
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TBI Debate - Mild, moderate and severe categories work
- 1. “There is no such thing as mild, moderate, or severe TBI”
- 2. Agenda
- 3. TBI or not…
- 5. Same?
- 6. Is there a difference? MILD • GCS 13-15 • Mortality 0.1% MODERATE • GCS 9-12 • Mortality 10% SEVERE • GCS < 9 • Mortality 40%
- 10. Brain injury is… “a puzzle, all the pieces are there but in the wrong order.”
- 11. Treatment
- 12. “There IS mild, moderate, & severe TBI”
- 13. Thank You
Editor's Notes
- My name is Andrew Chow (aka Chowie to those who know me), and I’d like to thank Oli and the organisers for the opportunity to participate in this debarcle (ahem, I mean debate). I have no conflicts of interest, except that I believe there is such a thing as mild, moderate and severe TBI.
- Friends, esteemed colleagues, neurosurgeons and finally Andrew Udy… I beg to differ… I’ve been set the challenge to preach to the already converted, you, my fellow educated, neurocentric intellectuals! Despite the eloquent soliloquy from Udy, if you’ll allow me, over the next few minutes, I’d like to remind you of the of what we currently understand, why it helps, and how we put this “arbitrary classification” into good use.
- To be brain injured, or not? That is the question… Udy will try to convince you you either have a TBI, or you don’t. (Kind of like being pregnant – either you are or you’re not!) Could I be provocative and to say to Udy or not to Udy?
- Categorisation isn’t arbitrary… GCS has been the mainstay of cut-offs between categories, and this is with good reasons that I’ll get to shortly. Under the Udy classification, is concussion included as a mild TBI? Both the Centers for Disease Control and Prevention and the World Health Organization agree that mild TBI is due to a blunt or mechanical force that results in: some type of transient confusion, disorientation or loss of consciousness lasting not more than 30 minutes; possibly associated with transient neurobehavioral deficits; and a GCS no worse than 13.
- These are not the same. All TBI is not the same. The GCS has been used extensively to classify TBI into levels of severity and prognosis. After TBI, there is an inverse relationship between the GCS score and the incidence of positive findings on computed tomography (CT); the rate of intracranial injury (ICI) and need for neurosurgical intervention doubles when the GCS drops from 15 to 14
- Mild TBI: GCS 13-15; mortality 0.1% Moderate TBI: GCS 9-12; mortality 10% Severe TBI: GCS <9; mortality 40%. Many clinicians recommend that patients with a GCS of 13 be classified as having moderate TBI instead of mild, due to the higher incidence of ICI and poor outcomes in these patients (compared with those with a GCS of >13).[9][10][11]
- List faculty and talk briefly about each one and how we each use mild, moderate and severe classification! Neurosurgeon Amal, Little Intensivist Flower, Udy, Yartsev, Jeffcote, Weedon Research Nasrallah Rehab/spinal Lee, Browne Social work Whitfield, Sayers When you use the words severe TBI, we all know what is meant.
- March 27, 2021 ESICM Talk is a new 20-minute podcasts series on noteworthy intensive care topics – available online In this first episode, NEXT Committee Member Dr Rahul Costa-Pinto interviews Prof Andrew Udy, principal investigator of the BONANZA study (Brain Oxygen Neuromonitoring in Australia and New Zealand Assessment Trial). Short term memory loss…. Hmmmm…
- Clinical guidelines in Australia recognize the increased morbidity associated with a GCS of 13, and limit the classification of mild TBI to those patients with a GCS of 14 or 15.[12] As an alternative, we could consider the Mayo classification system for TBI classifies patients with TBI into definite, probable, and possible, based on the patient’s clinical and CT findings.[13]. However this needs explaining.
- So it’s clear we need this arbitrary classification system so that families aka the “layperson” understands the concept. It’s embedded in medical lingo as much as small, medium and large is in common vernacular. People know what they are getting when they order a medium big mac meal, and people understand mild, moderate and severe traumatic brain injury. As a clinician, how many times during family meetings or conversations have we used the words “severe head injury” to convey the message? There’s also a flip side to this as well, when providing somewhat better news, that a mild TBI
- Should we treat them as different entities? In my humble institution at John Hunter Hospital, (akin to the NHS) with constant ICU bed pressure, lack of capacity and a hospital system under strain, as much as I would love to admit all TBI patients to the intensive care unit, this is simply not possible. Thus, classifying the TBI into mild, moderate and severe categories helps both intrinsic and extrinsic decision making, with the relative risk of clinical deterioration needing ICU level care increasing with severity of the injury. I would love to hear if in the golden halls of The Alfred, funded by the panacea that is the Victoria Health, that Professor Andrew Udy practices intensive care medicine by admitting all TBI’s (including mild ones) into the ICU? Surely this practice would be outside what would count as social norms? Should we treat each of these as separate entities? We already do, in keeping with evidence-based practice. See Brain Trauma Foundation guidelines. The follow-on effects relate to ICP monitoring and then onto Tiered levels management based on each arbitrarily classified severity of TBI… but alas, time does not permit us to delve into these depths this time.
- Yes, TBI is a spectrum, it’s not simply a have or have not like Udy would like you to think. So despite this classification being somewhat arbitrary, it simply works, and hopefully you’ll all agree with me, that there is mild, moderate and severe TBI!