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Head injury - a hard nut to crack

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Stuart Duffin is an intensive care doctor & anaesthetist working in Stockholm, Sweden. In this talk from #SWEETS17 he looks at the difficulties front line clinicians face when predicting prognisis in severe traumatic brain injury. How can we possibly be able to look reliably into the future to allow us to make the right decisions? How can we avoid falling into the fallacy of the self fullfilling prophecy and not even knowing it?

Full talk: http://scanfoam.org/prognosis-in-tbi-a-hard-nut-to-crack/

Published in: Health & Medicine
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Head injury - a hard nut to crack

  1. 1. Prognosis in brain injury A hard nut to crack Stuart Duffin Intensive Care Department Karolinska University Hospital, Solna @stuart_duffin
  2. 2. Disclosures
  3. 3. Sara
  4. 4. Sara
  5. 5. What we really want to know is... …how’s it going to go?
  6. 6. Extended Glasgow Outcome Scale (GOS-E)
  7. 7. Extended Glasgow Outcome Scale (GOS-E)
  8. 8. Extended Glasgow Outcome Scale (GOS-E)
  9. 9. It’s hard to make predictions, especially about the future -Yogi Berra
  10. 10. Glasgow Coma Scale
  11. 11. Pupils
  12. 12. Age Nelson DW et al, J Neurotrauma 2010
  13. 13. CT features
  14. 14. Compressed basal cisterns Midline shift
  15. 15. Secondary injury Hypoxia Hypotension Hypo/hyperglycemia Anemia ……………….etc
  16. 16. Biomarkers S100b
  17. 17. Thelin EP et al, Acta Neurochir (Wien). 2017 Feb;159(2):209-225
  18. 18. Beware the self fulfilling prophecy…
  19. 19. Sara A 22-year-old woman was the unrestrained driver in a roll- over motor vehicle accident during which she was ejected, and the car rolled on top of her. Her initial GCS was 3 with non-reactive pupils bilaterally. In the field she was hypotensive (BP 84/52, HR 74), with no O2 saturation documented. She was intubated and transported to a Level I Trauma Center. Here, her GCS was 3T with non- reactive pupils bilaterally. The initial trauma workup revealed an acute L parietal subdural hematoma with 12 mm midline shift and uncal herniation, diffuse axonal injury in the L thalamus and bilateral atlanto-occipital dislocation, with associated prevertebral swelling extending to C4. In addition, she had multiple facial fractures, bilateral rib fractures with a left hemo-pneumothorax, bilateral pulmonary contusions, shock bowel and several extremity fractures. Toxicology screen was positive for alcohol and marijuana. Neurocrit Care (2013) 19:347–363
  20. 20. Sara 18% of doctors recommended withdrawal of care 50% of neurosurgeons recommended withdrawal of care Neurocrit Care (2013) 19:347–363 Death 66% or 80%? GOS-E ≤ 3 79% or 90%?
  21. 21. Sara 6 months later Communicating Walking Outpatient physio Still improving… Neurocrit Care (2013) 19:347–363
  22. 22. Take homes… Early prognostication in TBI is a REALLY hard nut to crack Age, motor score, pupils, compression/midline shift most useful Beware the self fulfilling prophecy Get the basics right, always - It’s not rocket science, it’s only neurosurgery

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