There is no such thing as mild, moderate and severe TBI - by Andrew Udy
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Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
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There is no such thing as mild, moderate and severe TBI - by Andrew Udy
- 2. There is no such thing as mild, moderate, and severe TBI Andrew Udy
- 3. Context
- 5. EtOH / Illicit drugs Timing (seizures) Baseline function Type of injury
- 9. • Patient focused • Not simply GCS • Biomarkers • Clinical spectrum Conclusions
Editor's Notes
- I am thrilled to argue the affirmative in this debate. My learned friend will (no doubt) try to dazzle you with imaging, and physiological data. He will suggest to you that this historical, and out-dated categorization is necessary.. But he is sadly wrong.. Similar to the reports I hear about when he inserts a central line, he is simply “out of touch”.. I’m going to suggest that we need to change the language we use, when referring to TBI
- The use of arbitrary cut-offs has ben become engrained in TBI literature / conversations Even the most recent publications from learned colleagues, still refer to the traditional ‘tri-chotomisation’ of GCS. But I would ask you to consider the following: 1. On what basis was such categorisation proposed? 2. Do these really inform management and prognosis? 3. Are these distinctions patient and/or care giver orientated? What do they mean to a TBI survivor? If I have a mild TBI, does that mean I will be OK?
- Let’s look at the original GCS… First proposed Teasdale and Jennett – N/Surgeons working in Glasgow, Scotland Principally for the purposes of assessing the depth and duration of impaired consciousness and coma. Widespread uptake over the remainder of the 80’s and 90’s.. But.. Teasdale and Jennett never intended for the GCS to be the sole arbiter of brain injury severity, or to for use in predicting outcome
- This is a CT scan of a 55 year old man on warfarin for AF who has fallen from standing height while intoxicated. Anterior head strike. Reviewed in ED by the ICU SR ICU admission required Mild, moderate or severe TBI???
- Significant risks: - under-recognition by staff - reduced access to diagnostic / therapeutic strategies - impact on processes of care and access to specialist services (including managing longer term risk) post injury - dis-ingenuous for patients / families -> what does mild or moderate mean to them? - outcomes from TBI are measured at 6-12 months – how can we really know the impact on the patient (in terms of function, etc) at the time of injury?
- GFP – glial fibrillary acid protein TRACK-TBI observational cohort study Patients 17 years and older, who are evaluated for TBI at 18 US Level 1 trauma centres All patients receive a head CT This paper: All patients had day of injury plasma samples for GFAP (commercially available assay) and completed 6-months GOSE 1696 participants between Feb 2014 and Aug 2018 120 died, 235 had a GOSE </= 4, 1135 (67%) had incomplete recovery Those with a GCS of 13-15 constituted 46 (~20%) of the 235 who had an unfavourable outcome All patients predicting mortality or unfavourable outcome – GFAP AUROC 0.86 Improved discrimination vs IMPACT score in patients with GCS 3-12