Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation (original) (raw)
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The journal of trauma and acute care surgery, 2014
It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients ...
The journal of trauma and acute care surgery, 2013
Neurosurgical services are a limited resource and effective use of them would improve the health care system. Acute care surgeons (ACS) are accustomed to treating mild traumatic brain injury (TBI) including those with minor radiographic intracranial injuries. We hypothesized that ACS safely manage mild TBI with intracranial hemorrhage (ICH) on head computed tomographic (CT) scan without neurosurgical consultation (NC). We performed a retrospective analysis on all TBI patients with positive findings on head CT scan managed without NC during a 2-year period. Propensity scoring matched NC to no-NC patients on a 1:2 ratio for Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (h-AIS) score, neurological examination, age, Injury Severity Score (ISS), findings of initial head CT scan including type and size of ICH. A total of 270 patients with mild TBI and positive CT scan findings were included (90 with NC and 180 without NC). Sixty-three percent were male, and mean (SD) age w...
2015
Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity worldwide, especially in low and middle income countries. The outcome of TBI does not only depend on the initial trauma, but is also affected by secondary neurological damage that follows the trauma. These secondary effects can be reduced by implementing an evidence based protocol of management for TBI. Aim: To evaluate the effect of TBI management protocol on short term outcome. Methods: retrospective evaluation of medical records of severe TBI patients admitted to ICU during three months prior to implementing the protocol for short term outcome (group 1), then prospective observation of short term outcome of patients with severe TBI admitted to ICU, and managed with the TBI protocol for three months. Results: there was statistically significant difference between the two groups regarding the GCS after 7 days (p=0.017), the length of ICU stay (p=0.009) and the duration of mechanical ventilation (p=...
Background Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. Methods A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). Results The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. This article is part of the Topical Collection on Brain trauma
Emergency Access to Neurosurgical Care for Patients with Traumatic Brain Injury
Journal of the American College of Surgeons, 2014
Background Traumatic brain injury (TBI) is an important public health problem in Ethiopia and worldwide. TBI can lead to lifelong issues that not only affect the lives of individuals and their families but also have a significant impact on society and the economy, especially where there is poor pre-hospital care, proper intensive care unit and rehabilitation centres. The aim of the study is to assess the functional outcome of patients after neurosurgical intervention following traumatic brain injury performed by general surgeons. Methods This was a single hospital based prospective study on the functional outcomes of patients following neurosurgery at Soddo Christian Hospital (SCH), representing a rural hospital in Ethiopia from January 2015 to January 2017. Outcome was described by using the Extended Glasgow Outcome Score (GOSE). Descriptive statistics and non-parametric methods were used for data analysis. Results Ninety patients underwent neurosurgical intervention. The ages ranged from 2 to 76 years, with a male predominance of 84.4%. Head injury was severe in 23%, moderate in 17% and mild in 60% of patients. Thirty-seven patients had chronic subdural hematomas (CSDH), 28 had epidural hematomas (EDH), 18 had depressed skull fractures (DSF), 4 had EDH and DSF, and acute subdural hematoma (ASDH) was seen in 3 patients. Functional outcomes based on GOSE were as follows: 61 (67.8%) had upper good recovery, 15 (16.7%) lower good recovery, 6 (2.2%) upper moderate disability, and 1(1.1%) lower moderate disability score. Overall mortality was 12.2% (n-11). Conclusions Neurosurgical interventions for intracranial haemorrhage and depressed skull fractures can be done safely by general surgeons with good functional outcomes, and acceptable morbidity and mortality rates.
World Journal of Emergency Surgery
Background Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. Methods A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. Results A total of 28 statements were proposed and discussed. Conse...
Marked reduction in mortality in patients with severe traumatic brain injury
Journal of Neurosurgery, 2013
Object In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p < 0.0001), a...
J Neurosci Rural Pract, 2020
Background: Traumatic brain injury (TBI) is a global public health problem. In Colombia, it is estimated that 70% of deaths from violence and 90% of deaths from road traffic accidents are TBI related. In the year 2014, the Ministry of Health of Colombia funded the development of a clinical practice guideline (CPG) for the diagnosis and treatment of adult patients with severe TBI. A critical barrier to the widespread implementation was identified—that is, the lack of a specific protocol that spans various levels of resources and complexity across the four treatment phases. The objective of this article is to present the process and recommendations for the management of patients with TBI in various resource environments, across the treatment phases of prehospital care, emergency department (ED), surgery, and intensive care unit. Methods: Using the Delphi methodology, a consensus of 20 experts in emergency medicine, neurosurgery, prehospital care, and intensive care nationwide developed recommendations based on 13 questions for the management of patients with TBI in Colombia. Discussion: It is estimated that 80% of the global population live in developing economies where access to resources required for optimum treatment is limited. There is limitation for applications of CPGs recommendations in areas where there is low availability or absence of resources for integral care. Development of mixed methods consensus, including evidence review and expertise points of good clinical practices can fill gaps in application of CPGs. BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) is intended to be a practical handbook for care providers to use to treat TBI patients with whatever resources are available. Results: Stratification of recommendations for interventions according to the availability of the resources on different stages of integral care is a proposed method for filling gaps in actual evidence, to organize a better strategy for interventions in different real-life scenarios. We develop 10 algorithms of management for building TBI protocols based on expert consensus to articulate treatment options in prehospital care, EDs, neurological surgery, and intensive care, independent of the level of availability of resources for care.