PURPOSE: To prevent secondary brain injury by implementing protocol based management in emergency department, operating room and intensive care unit.
METHODS: Protocol was driven from the Guidelines for the management of Severe Traumatic Brain Injury (STBI) published by Brain Trauma Foundation in 2007. Inclusion criteria: adult with STBI, Glasgow Coma Scale (GCS) 3-8 and abnormal Computed Tomography (CT) scan of the brain. Exclusion criteria: GCS 3, fixed dilated pupils and CT scan brain findings consistent with brain herniation.Data was collected for events of hypotension (Systolic Blood Pressure <90mmHg), hypoxia (Partial arterial oxygen pressure <60 mmHg or Arterial oxygen saturation <90%) and Cerebral Perfusion Pressure (CPP<60mmHg) from the time of ED arrival, till Intra Cranial Pressure (ICP) monitoring catheter was removed. Each event was considered as an episode per patient. Primary outcome indicators were mortality, GCS≥10 and Glasgow outcome Score (GOS) ≥3 at 6 weeks.
RESULTS: Between July-December 2009 total of 57 patients were presented with STBI in the ED. 51 patients were included in the protocol. 82% were males; mean age was 37. Motor vehicle accident was the most common mode of injury, followed by fall. All 51 patients had ICP catheter inserted as per protocol. 34(67%) patients were managed medically and 17 (33%) patients had decompressive craniotomy (DC) performed. 11 patients had DC within 4 hours of arrival, while 6 had DC within 72 hours. 34 (67%) patients had total of 59 episodes, while 17 (33%) patients didn't have any episode. 24(70%) patients who had episodes survived, while all 17(33%) patients without episodes also survived. Among all the survivors 29(57%) patients had GCS≥10 and GOS≥3 at 6 weeks. Total of 10(19.8%) patients died and all patients who expired had one of these episode.
CONCLUSION: Protocol based management may not reduce the total number of episodes, but can prevent further clinical deterioration once identified, which may explain improved neurological and functional outcome in our study group.
CLINICAL IMPLICATIONS: Systemic hypotension can more reliably predict worst neurologic outcome.
DISCLOSURE: Jawed Abubaker, No Financial Disclosure Information; No Product/Research Disclosure Information