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

1. TRAUMATIC BRAIN INJURY IN THE
REAL WORLD
Anthony Delaney MBBS MSc FACEM FCICM
Staff Specialist Malcolm Fisher Department of Intensive Care Medicine

2. The real world?
 A couple of new issues in the field
 Field intubation
 ICP monitoring
 “severe” traumatic brain injury

3. Brain trauma foundation guidelines
 Chapter 1
 Avoid SBP <90 mm Hg
 Avoid SpO2 < 90%

4.  g

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. 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. 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. Pre-hospital intubation
 Comparison:
 Oxygen at 12L/min
 BVM
 Guedells or NP airway if needed
 Morphine if combative
 Intabated at the hospital

9. Pre-hospital
intubation
 Outcome
 6 month Extended Glasgow Outcome Scale

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. 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. 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. 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. 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. 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. Intracranial pressure monitoring
 Measurement of ventricular pressure in
trauma began with Guillaume and Janny in
1951 and Lundberg in the 1960’s

18. 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

19. BEST: TRIP
 Intervention both groups
 CT at baseline, 48 hours and 5-7 days
 Mechanical ventilation, sedation and analgesia,
 Aggressively managed non-neurological
problems?

20. 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”

21. Neuroworsening?
 Dude

22. Neuroworsening?
 Stat!

23. 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

24. 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

25. BEST: TRIP
 Sample size
80% power to detect a 10% increase in good clinical
outcomes (OR 1.5)
Very complicated analysis

26. BEST: TRIP
 Internal validity:
 Follow-up

27. BEST: TRIP
 Results

28. Favourable outcome in ICP group???
 Favourable outcome

29. To rule out a favourable outcome in
ICP group???

30. ICP?
 It may not make a difference to a
complicated outcome scale in Bolivia

31. ICP?
 But it is probably important
 Further investigation of monitoring in severe
brain injury
 Probably really need treatments

32. “Severe” Traumatic brain injury
 NFL has recently settled a case brought be
ex-players for US$ 765 Million

33. “Severe” Traumatic brain injury

34. QUESTIONS ??
ADELANEY@MED.USYD.EDU.AU