The observation that patients with haemorrhagic trauma in military and civilian settings do better if they receive coagulation factors and platelets is yet to be replicated in a randomised trial. It has been suggested that the effect may in part be a consequence of survivor bias – ie. that if a patient lives long enough to received some thawed fresh frozen plasma, then they were already more likely to be a survivor and therefore more survivors will be represented in the ‘FFP’ groups vs a ‘no-FFP’ comparison group.
An attempt to eliminate survivor bias was made in the PROMMTT study, which documented the timing of transfusions during active resuscitation and patient outcomes in adult trauma patients who received a transfusion of at least 1 unit of RBCs within 6 hours of admission.
Increased ratios of plasma:RBCs and platelets:RBCs were independently associated with decreased 6-hour mortality, when haemorrhagic death predominated. In the first 6 hours, patients with ratios less than 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher.
A prospective trial is underway to identify the optimal ratio of blood products, in the PROPPR study, in which 1:1:1 ratio of plasma:platelets:RBC will be compared with 1:1:2.
The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study
Arch Surg. 2012 Oct 15:1-10
Objective: To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios.
Design: Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models.
Setting: Ten US level I trauma centers.
Patients: Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group).
Main Outcome Measure: In-hospital mortality.
Results: Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P < .001 for both). In a multivariable time-dependent Cox model, increased ratios of plasma:RBCs (adjusted hazard ratio = 0.31; 95% CI, 0.16-0.58) and platelets:RBCs (adjusted hazard ratio = 0.55; 95% CI, 0.31-0.98) were independently associated with decreased 6-hour mortality, when hemorrhagic death predominated. In the first 6 hours, patients with ratios less than 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from nonhemorrhagic causes prevailed.
Conclusions: Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.
Sydney HEMS physician Dr Brian Burns talks about the prehospital care of trauma in this 20 minute audio podcast recorded at SMACC 2013
Further talks from the SMACC conference are available for free download on iTunes.
Here are the accompanying slides:
A small pilot study on a convenience sample of children presenting to the emergency department with acute limb injury pain evaluated the use of intranasal ketamine(1).
Initial dose averaged 0.84 mg/kg and a third of the patients required a top up dose at 15 minutes, resulting in a total dose of about 1.0 mg/kg to provide adequate analgesia by 30 min for most patients. The authors suggest that this could guide investigators on an appropriate dose of IN ketamine for use in clinical trials.
Adverse events were all transient and mild.
Prior to administration, the ketamine was diluted with saline to a total volume of 0.5 mL and was administered as 0.25 mL per nare using a Mucosal Atomiser Device (MAD, Wolfe Tory Medical, Salt Lake City, UT, USA). According to the protocols in my Service, this device requires 0.1 ml to prime its dead space(2). It is unclear whether this factor may have affected the total dose delivered to the patient in this study.
1. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: A pilot study
Emerg Med Australas. 2013 Apr;25(2):161-7
OBJECTIVE: The present study aims to conduct a pilot study examining the effectiveness of intranasal (IN) ketamine as an analgesic for children in the ED.
METHODS: The present study used an observational study on a convenience sample of paediatric ED patients aged 3-13 years, with moderate to severe (≥6/10) pain from isolated limb injury. IN ketamine was administered at enrolment, with a supplementary dose after 15 min, if required. Primary outcome was change in median pain rating at 30 min. Secondary outcomes included change in median pain rating at 60 min, patient/parent satisfaction, need for additional analgesia and adverse events being reported.
RESULTS: For the 28 children included in the primary analysis, median age was 9 years (interquartile range [IQR] 6-10). Twenty-three (82.1%) were male. Eighteen (64%) received only one dose of IN ketamine (mean dose 0.84 mg/kg), whereas 10 (36%) required a second dose at 15 min (mean for second dose 0.54 mg/kg). The total mean dose for all patients was 1.0 mg/kg (95% CI: 0.92-1.14). The median pain rating decreased from 74.5 mm (IQR 60-85) to 30 mm (IQR 12-51.5) at 30 min (P < 0.001, Mann-Whitney). For the 24 children who contributed data at 60 min, the median pain rating was 25 mm (IQR 4-44). Twenty (83%) subjects were satisfied with their analgesia. Eight (33%) were given additional opioid analgesia and the 28 reported adverse events were all transient and mild.
CONCLUSIONS: In this population, an average dose of 1.0 mg/kg IN ketamine provided adequate analgesia by 30 min for most patients
2. Case report: prehospital use of intranasal ketamine for paediatric burn injury
Emerg Med J. 2011 Apr;28(4):328-9
In this study, the administration of an intravenous ketamine formulation to the nasal mucosa of a paediatric burn victim is described in the prehospital environment. Effective analgesia was achieved without the need for vascular or osseous access. Intranasal ketamine has been previously described for chronic pain and anaesthetic premedication. This case highlights its potential as an option for prehospital analgesia.
A team from Los Angeles (including the great Kenji Inaba) has published a study on penetrating cardiac wounds in the pediatric population. This is one of the largest studies on this thankfully rare event.
The outcome was poor which may be due to the high proportion of patients arriving at hospital without signs of life (SOL).
What I like about the paper is the discussion of their liberal policy for the use of resuscitative ED thoracotomy:
…we do not rely heavily on prehospital data regarding the precise timing of loss of SOL. Thus, at the discretion of the attending trauma surgeon, every penetrating injury to the chest with SOL lost during patient transport will be considered for ED thoracotomy.
In cases when a perfusing cardiac rhythm is regained, the patient will receive all operative and critical care support as standard of care. If the patient progresses to brain death, aggressive donor management will be implemented in accordance with consent obtained by the organ procurement organization.
In a recent publication, we observed two pediatric patients who underwent ED thoracotomy that subsequently became organ donors after brain death was declared . A total of nine organs were recovered for transplantation. This contemporary outcome measure is of paramount importance in the current era of significant organ shortage.
When such aggressive resuscitative procedures are attempted on arrested trauma patients, there is a temptation to justify inaction on the grounds of futility or the risk of ‘creating a vegetable’. This paper reminds us that other outcome benefits may arise from attempted resuscitation even if the patient does not survive.
These benefits include the saving of other lives through organ donation. In addition to this, there is the opportunity for family members to be with their loved one on the ICU, to hold their warm hand for the last time, to hear the news broken by a team they have gotten to know and trust, to enact any spiritual or religious rites that may provide a source of comfort and closure, and to be there during withdrawal of life sustaining therapies after diagnosis of brain stem death. That will never be pleasant, but on the bleak spectrum of parental torture it may be better than being told the devastating news in the ED relatives’ room by a stranger they’ve never met but will remember forever.
The ED thoracotomy may at the very least remove any doubt that everything that could have been done, was done.
1. Penetrating cardiac trauma in adolescents: A rare injury with excessive mortality
Journal of Pediatric Surgery (2013) 48, 745–749
Background Penetrating cardiac injuries in pediatric patients are rarely encountered. Likewise, the in-hospital outcome measures following these injuries are poorly described.
Methods All pediatric patients (<18years) sustaining penetrating cardiac injuries between 1/2000 and 12/2010 were retrospectively identified using the trauma registry of an urban level I trauma center. Demographic and admission variables, operative findings, and hospital course were extracted. Outpatient follow-up data were obtained through chart reviews and cardiac-specific imaging studies.
Results During the 11-year study period, 32 of the 4569 pediatric trauma admissions (0.7%) sustained penetrating cardiac injuries. All patients were male and the majority suffered stab wounds (81.2%). The mean systolic blood pressure on admission was 28.8±52.9mmHg and the mean ISS was 46.9±27.7. Cardiac chambers involved were the right ventricle (46.9%), the left ventricle (43.8%), and the right atrium (18.8%). Overall, 9 patients (28.1%) survived to hospital discharge. Outpatient follow-up echocardiography was available for 4 patients (44.4%). An abnormal echocardiography result was found in 1 patient, demonstrating hypokinesia and tricuspid regurgitation.
Conclusions Penetrating cardiac trauma is a rare injury in the pediatric population. Cardiac chambers predominantly involved are the right and left ventricles. This injury is associated with a low in-hospital survival (<30%).
2. Organ donation: an important outcome after resuscitative thoracotomy
J Am Coll Surg. 2010 Oct;211(4):450-5
BACKGROUND: The persistent shortage of transplantable organs remains a critical issue around the world. The purpose of this study was to investigate outcomes, including organ procurement, in trauma patients undergoing resuscitative emergency department thoracotomy (EDT). Our hypothesis was that potential organ donor rescue is one of the important outcomes after traumatic arrest and EDT.
STUDY DESIGN: Retrospective study at Los Angeles County and University of Southern California Medical Center. Patients undergoing resuscitative EDT from January 1, 2006 through June 30, 2009 were analyzed. Primary outcomes measures included survival. Secondary outcomes included organ donation and the brain-dead potential organ donor.
RESULTS: During the 42-month study period, a total of 263 patients underwent EDT. Return of a pulse was achieved in 85 patients (32.3%). Of those patients, 37 (43.5%) subsequently died in the operating room and 48 (56.5%) survived to the surgical intensive care unit. Overall, 5 patients (1.9%) survived to discharge and 11 patients (4.2%) became potential organ donors. Five of the 11 potential organ donors had sustained a blunt mechanism injury. Of the 11 potential organ donors, 8 did not donate: 4 families declined consent, 3 because of poor organ function, and 1 expired due to cardiopulmonary collapse. Eventually 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel) were harvested from 3 donors. Two of the 3 donors had sustained blunt injury and 1 penetrating mechanism of injury.
CONCLUSIONS: Procurement of organs is one of the tangible outcomes after EDT. These organs have the potential to alter the survival and quality of life of more recipients than the number of survivors of the procedure itself.
Ever heard anyone spout dogma along the lines of: “it’s a traumatic cardiac arrest – resuscitation is futile as the outcome is hopeless: survival is close to zero per cent”?
I have. Less frequently in recent years, I’ll admit, but you still hear it spout forth from the anus of some muppet in the trauma team. Here’s some recent data to add to the existing literature that challenges the ‘zero per cent survival’ proponents. A Spanish study retrospectively analysed 167 traumatic cardiac arrests (TCAs). 6.6% achieved a complete neurological recovery (CNR), which increased to 9.4% if the first ambulance to arrive contained an advanced team including a physician. Rhythm and age were important: CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole; survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly.
Since traumatic arrest tends to affect a younger age group than medical arrests, the authors suggest:
“Avoiding the potential decrease in life expectancy in this kind of patient justifies using medical resources to their utmost potential to achieve their survival “
Since 2.7% of the asystolic patients achieved a CNR, the authors challenge the practice proposed by some authors that Advanced Life Support be withheld in TCA patients with asystole as the initial rhythm:
“had that indication been followed, three of our patients who survived neurologically intact would have been declared dead on-scene.”
I’d like to know what interventions were making the difference in these patients. They describe what’s on offer as:
In our EMS, all TCA patients receive ALS on-scene, which includes intubation, intravenous access, fluid and drug therapy, point-of-care blood analysis, and procedures such as chest drain insertion, pericardiocentesis, or Focused Assessment with Sonography for Trauma ultrasonography to improve the treatment of the cause of the TCA.
It appears that crystalloids and colloids are their fluid therapy of choice; unlike many British and Australian physician-based prehospital services they made no mention of the administration of prehospital blood products.
Traumatic cardiac arrest: Should advanced life support be initiated?
J Trauma Acute Care Surg. 2013 Feb;74(2):634-8
BACKGROUND: Several studies recommend not initiating advanced life support in traumatic cardiac arrest (TCA), mainly owing to the poor prognosis in several series that have been published. This study aimed to analyze the survival of the TCA in our series and to determine which factors are more frequently associated with recovery of spontaneous circulation (ROSC) and complete neurologic recovery (CNR).
METHODS: This is a cohort study (2006-2009) of treatment benefits.
RESULTS: A total of 167 TCAs were analyzed. ROSC was obtained in 49.1%, and 6.6% achieved a CNR. Survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly (p < 0.05). There was no significant difference in ROSC according to which type of ambulance arrived first, but if the advanced ambulance first, 9.41% achieved a CNR, whereas only 3.7% if the basic ambulance first. We found significant differences between the response time and survival with a CNR (response time was 6.9 minutes for those who achieved a CNR and 9.2 minutes for those who died). Of the patients, 67.5% were in asystole, 25.9% in pulseless electrical activity (PEA), and 6.6% in VF. ROSC was achieved in 90.9% of VFs, 60.5% of PEAs, and 40.2% of those in asystole (p < 0.05), and CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole (p < 0.05). The mean (SD) quantity of fluid replacement was greater in ROSC (1,188.8 [786.7] mL of crystalloids and 487.7 [688.9] mL of colloids) than in those without ROSC (890.4 [622.4] mL of crystalloids and 184.2 [359.3] mL of colloids) (p < 0.05).
CONCLUSION: In our series, 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm and that a rapid response time and aggressive fluid replacement are the keys to the survival of these patients.
The group usually considered the universal donor for fresh frozen plasma because it contains no anti-A or anti-B antibodies is Type AB. Due to its limited availability the trauma service of the Mayo Clinic in Minnesota has been issuing thawed group A plasma to its flight crews who retrieve major trauma casualties from rural centres. This is given with packed group O red cells to patients who meet their prehospital massive transfusion protocol criteria. Some patients will inevitably receive ABO-incompatible plasma (namely patients with Group B or AB blood) which could theoretically give rise to haemolytic transfusion reactions, in which donor antibodies bind host red cells, activate complement, and give rise to anaemia, disseminated intravascular coagulation, acute kidney injury, and death. However:
- the transfusion of platelets containing ABO-incompatible plasma is common, with up to 2 units of incompatible plasma per apheresis platelet unit, whereas haemolytic reactions to platelets are rare (1 in 9,000 incompatible platelet transfusions);
- all reports of haemolytic reactions are caused by products that contain Group O plasma and there has never been a documented case of haemolysis as a result of products containing Group A plasma
A retrospective review showed no increased rates of adverse events with Type A compared with AB or ABO-compatible plasma. Since only a small absolute number of patients received an ABO-incompatible plasma transfusion, it could be argued that the study is underpowered (a point acknowledged by the authors). However this is very important and useful information for resource-limited settings.
Emergency use of prethawed Group A plasma in trauma patients
J Trauma Acute Care Surg. 2013 Jan;74(1):69-74
BACKGROUND: Massive transfusion protocols lead to increased use of the rare universal plasma donor, Type AB, potentially limiting supply. Owing to safety data, with a goal of avoiding shortages, our blood bank exploited Group A rather than AB for all emergency release plasma transfusions. We hypothesized that ABO-incompatible plasma transfusions had mortality similar to ABO-compatible transfusions.
METHODS: Review of all trauma patients receiving emergency release plasma (Group A) from 2008 to 2011 was performed. ABO compatibility was determined post hoc. Deaths before blood typing were eliminated. p < 0.05 was considered statistically significant.
RESULTS: Of the 254 patients, 35 (14%) received ABO-incompatible and 219 (86%) received ABO-compatible transfusions. There was no difference in age (56 years vs. 59 years), sex (63% vs. 63% male), Injury Severity Score (ISS) (25 vs. 22), or time spent in the trauma bay (24 vs. 26.5 minutes). Median blood product units transfused were similar: emergency release plasma (2 vs. 2), total plasma at 24 hours (6 vs. 4), total red blood cells at 24 hours (5 vs. 4), plasma-red blood cells at 24 hours (1.3:1 vs. 1.1:1), and plasma deficits at 24 hours (2 vs. 1). Overall complications were similar (43% vs. 35%) as were rates of possible transfusion-related acute lung injury (2.9% vs. 1.8%), acute lung injury (3.7% vs. 2.5%), adult respiratory distress syndrome (2.9% vs. 1.8%), deep venous thrombosis (2.9% vs. 4.1%), pulmonary embolism (5.8% vs. 7.3%), and death (20% vs. 22%). Ventilator (6 vs. 3), intensive care unit (4 vs. 3), and hospital days (9 vs. 7) were similar. There were no hemolytic reactions. Mortality was significantly greater for the patients who received incompatible plasma if concurrent with a massive transfusion (8% vs. 40%, p = 0.044). Group AB plasma use was decreased by 96.6%.
CONCLUSION: Use of Group A for emergency release plasma resulted in ABO-incompatible transfusions; however, this had little effect on clinical outcomes. Blood banks reticent to adopt massive transfusion protocols owing to supply concerns may safely use plasma Group A, expanding the pool of emergency release plasma donors.
LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.
A study on data from traumatic brain injury patients from the the TARN database examined the prognostic value of various scoring and classification systems and pathologies.
Contusion and haemorrhage appeared to be less signiﬁcant predictors of outcome than the presence of brain swelling in this British dataset.
The brainstem was the most significant location of cerebral injury.
Prognostic value of various intracranial pathologies in traumatic brain injury
European Journal of Trauma and Emergency Surgery February 2012, Volume 38, Issue 1, pp 25-32
Objective Various intracranial pathologies in traumatic brain injury (TBI) can help to predict patient outcomes.
These pathologies can be categorised using the Marshall Classiﬁcation or the Abbreviated Injury Scale (AIS) dictionary or can be described through traditional descriptive terms such as subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural haemorrhage (EDH) etc. The purpose of this study is to assess the prognostic value of AIS scores, the Marshall Classiﬁcation and various intracranial pathologies in TBI.
Methods A dataset of 802 TBI patients in the Trauma Audit and Research Network (TARN) database was analysed using logistic regression. First, a baseline model was constructed with age, Glasgow Coma Scale (GCS), pupillary reactivity, cause of injury and presence/absence of extracranial injury as predictors and survival at discharge as the outcome. Subsequently, AIS score, the Marshall Classiﬁcation and various intracranial pathologies such as haemorrhage, SAH or brain swelling were added in order to assess the relative predictive strength of each variable and also to assess the improvement in the performance of the model.
Results Various AIS scores or Marshal classes did not appear to signiﬁcantly affect the outcome. Among traditional descriptive terms, only brain stem injury and brain swelling signiﬁcantly inﬂuenced outcome [odds ratios for survival: 0.17 (95% conﬁdence interval [CI]; 0.08–0.40) and 0.48 (95% CI; 0.29–0.80), respectively].
Neither haemorrhage nor its subtypes, such as SAH, SDH and EDH, were signiﬁcantly associated with outcome. Adding AIS scores, the Marshall Classiﬁcation and various
intracranial pathologies to the prognostic models resulted in an almost equal increase in the predictive performance of the baseline model.
Conclusions In this relatively recent dataset, each of the brain injury classification systems enhanced equally the performance of an early mortality prediction model in traumatic brain injury patients. The significant effect of brain swelling and brain stem injury on the outcome in comparison to injuries such as SAH suggests the need to improve therapeutic approaches to patients who have sustained these injuries.
Two popular pelvic compression devices are the SAM Pelvic Sling II and the T-POD®.
In a direct comparison 50 health care volunteers secured both devices correctly 100% of the time.
The SAM Pelvic Sling II was quicker to apply, but participants preferred the T-POD®.
The authors conclude that very little separates the devices.
Pelvic circumferential compression devices (PCCDs): a best evidence equipment review
Eur J Trauma Emerg Surg (2012) 38:439–442
Purpose Traumatic disruption of the pelvis can lead to significant morbidity and mortality. ATLS® guidance advocates temporary stabilisation or ‘closure’ of the disrupted pelvis with a compression device or sheet. We undertook a best evidence equipment review to assess the ease and efficacy of the application of two leading commercially available devices, the T-POD® and the SAM Pelvic Sling™ II.
Methods Fifty health care professionals and medical students participated in pelvic circumferential compression device (PCCD) education and assessment. Participants received a 10-min lecture on the epidemiology and aetiology of pelvic fractures and the principles of circumferential compression, followed by a practical demonstration. Three volunteers acted as trauma victims. Assessment included the time taken to secure the devices and whether this was achieved correctly. All participants completed a post-assessment survey.
Results Both devices were applied correctly 100% of the time. The average time taken to secure the SAM Pelvic Sling™ II was 18 s and for the T-POD®, it was 31 s (p ≤ 0.0001). Forty-four participants (88%) agreed or strongly agreed that the SAM Pelvic Sling™ II was easy to use compared to 84% (n = 42) for the T-POD®. Thirty-nine participants (78%) reported that they preferred and, given the choice in the future, would select the T-POD® over the SAM Pelvic Sling™ II (n = 11, 22%).
Conclusions The results of this study indicate that both PCCDs are easy and acceptable to use and, once learned, can be applied easily and rapidly. Participants applied both devices correctly 100% of the time, with successful application taking, on average, less than 60 s.
High intensity focused ultrasound (HIFU) was hailed as the ‘surgery of the future’ a few years ago(1). As it’s now the future, where is it?
HIFU uses ultrasound to increase the heat within tissues at a specific area, causing local necrosis and cautery without injuring surrounding tissues. It is used to treat some cancers, but has shown promise in haemorrhage control. In animal studies it reduced or stopped bleeding in liver(2), spleen(3), and vascular injuries(4).
It has been proposed to offer a promising method for hemorrhage control in both civilivan and miltary trauma(5). Automated systems have been developed and tested that identify bleeding using Doppler ultrasound techniques that then allow targeting of the HIFU beam to the bleeding tissue(6). The United States Army has identified the need for a such systems and has designed a remotely operated robotic haemostatic system to save lives of soldiers. This was presented in 2006(7).
I would love to know where we are with this technology, and why nothing seems to have appeared about it in the literature for the last few years. If you have any information, please fill us in via the comments box.
1. High intensity focused ultrasound: surgery of the future?
Br J Radiol. 2003 Sep;76(909):590-9 Full text
2. Liver hemostasis using high-intensity focused ultrasound
Ultrasound Med Biol. 1997;23(9):1413-20
3. Control of splenic bleeding by using high intensity ultrasound
J Trauma. 1999 Sep;47(3):521-5
4. Hemostasis of punctured blood vessels using high-intensity focused ultrasound
Ultrasound Med Biol. 1998 Jul;24(6):903-10
5. Hemorrhage control using high intensity focused ultrasound
Int J Hyperthermia. 2007 Mar;23(2):203-11
6. Focused ultrasound: concept for automated transcutaneous control of hemorrhage in austere settings.
Aviat Space Environ Med. 2009 Apr;80(4):391-4
7. Remotely Operated Robotic High Intensity Focused Ultrasound (HIFU) Manipulator System for Critical Systems for Trauma and Transport (CSTAT)
Presented at the IEEE Ultrasonics Symposium, October 3-6, 2006, Vancouver, Canada – Full Text Here
A South American randomised controlled trial has demonstrated no improvement in mortality when traumatic brain injured patients had therapy targeted at keeping intracranial pressure below or equal to 20 mmHg as measured by an intraparenchymal monitor. The control group’s management was guided by neurologic examination and serial CT imaging(1).
Editorialist Dr Ropper summarises what we should do with this information well(2):
“[The authors]…do not advocate abandoning the treatment of elevated intracranial pressure any more than the authors of studies on wedge pressure reject the administration of fluid boluses in the treatment of shock”
Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed.
We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging–clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance).
There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging–clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging–clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging–clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging–clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups.
For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination
1. A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury
N Eng J Med 367;26:2471-2381 Full Text
2. Brain in a Box
N Eng J Med DOI: 10.1056/NEJMe1212289 Full Text