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

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Delaney helps highlight recent research into pre-hospital intubation and intracranial pressure monitoring for patients with TBI. This talk was recorded at Bedside Critical Care Conference 4 and is available with the Intensive Care Network on Libsyn and on www.intensivecarenetwork.com

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

  1. 1. TRAUMATIC BRAIN INJURY IN THE REAL WORLD Anthony Delaney MBBS MSc FACEM FCICM Staff Specialist Malcolm Fisher Department of Intensive Care Medicine
  2. 2. The real world?  A couple of new issues in the field  Field intubation  ICP monitoring  “severe” traumatic brain injury
  3. 3. Brain trauma foundation guidelines  Chapter 1  Avoid SBP <90 mm Hg  Avoid SpO2 < 90%
  4. 4.  g
  5. 5. 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
  6. 6. Pre-hospital intubation  Population:  Head trauma  Age ≥15  GCS ≤9  Intact airway reflexes  Excluded  <10 minutes from hospital  Allergy to RSI drugs  Helicopter transport
  7. 7. 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
  8. 8. Pre-hospital intubation  Comparison:  Oxygen at 12L/min  BVM  Guedells or NP airway if needed  Morphine if combative  Intabated at the hospital
  9. 9. Pre-hospital intubation  Outcome  6 month Extended Glasgow Outcome Scale
  10. 10. 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
  11. 11. 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)
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. 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
  16. 16. Intracranial pressure monitoring  Measurement of ventricular pressure in trauma began with Guillaume and Janny in 1951 and Lundberg in the 1960’s
  17. 17. BEST: TRIP Benchmark 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
  18. 18. BEST: TRIP  Intervention both groups  CT at baseline, 48 hours and 5-7 days  Mechanical ventilation, sedation and analgesia,  Aggressively managed non-neurological problems?
  19. 19. 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”
  20. 20. Neuroworsening?  Dude
  21. 21. Neuroworsening?  Stat!
  22. 22. 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
  23. 23. 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
  24. 24. BEST: TRIP  Sample size 80% power to detect a 10% increase in good clinical outcomes (OR 1.5) Very complicated analysis
  25. 25. BEST: TRIP  Internal validity:  Follow-up
  26. 26. BEST: TRIP  Results
  27. 27. Favourable outcome in ICP group???  Favourable outcome
  28. 28. To rule out a favourable outcome in ICP group???
  29. 29. ICP?  It may not make a difference to a complicated outcome scale in Bolivia
  30. 30. ICP?  But it is probably important  Further investigation of monitoring in severe brain injury  Probably really need treatments
  31. 31. “Severe” Traumatic brain injury  NFL has recently settled a case brought be ex-players for US$ 765 Million
  32. 32. “Severe” Traumatic brain injury
  33. 33. QUESTIONS ?? ADELANEY@MED.USYD.EDU.AU

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