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Published byKimberly Nichols Modified over 8 years ago
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Anthony Delaney MBBS MSc FACEM FCICM Staff Specialist Malcolm Fisher Department of Intensive Care Medicine
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The real world? A couple of new issues in the field Field intubation ICP monitoring “severe” traumatic brain injury
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Brain trauma foundation guidelines Chapter 1 Avoid SBP <90 mm Hg Avoid SpO2 < 90%
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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
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Pre-hospital intubation Population: Head trauma Age ≥15 GCS ≤9 Intact airway reflexes Excluded <10 minutes from hospital Allergy to RSI drugs Helicopter transport
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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 60 Cricoid pressure Pancuronium, morphine and midazolam Max 2 attempts
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Pre-hospital intubation Comparison: Oxygen at 12L/min BVM Guedells or NP airway if needed Morphine if combative Intabated at the hospital
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Pre-hospital intubation Outcome 6 month Extended Glasgow Outcome Scale
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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
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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)
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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
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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
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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.
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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
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Intracranial pressure monitoring Measurement of ventricular pressure in trauma began with Guillaume and Janny in 1951 and Lundberg in the 1960’s
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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
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BEST: TRIP Intervention both groups CT at baseline, 48 hours and 5-7 days Mechanical ventilation, sedation and analgesia, Aggressively managed non-neurological problems?
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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 PaCO 2 30-35 EVD for CSF drainage Treatments for “neuroworsening”
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Neuroworsening? Dude
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Neuroworsening? Stat!
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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
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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
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BEST: TRIP Sample size 80% power to detect a 10% increase in good clinical outcomes (OR 1.5) Very complicated analysis
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BEST: TRIP Internal validity: Follow-up
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BEST: TRIP Results
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Favourable outcome in ICP group??? Favourable outcome
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To rule out a favourable outcome in ICP group???
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ICP? It may not make a difference to a complicated outcome scale in Bolivia
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ICP? But it is probably important Further investigation of monitoring in severe brain injury Probably really need treatments
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“Severe” Traumatic brain injury NFL has recently settled a case brought be ex-players for US$ 765 Million
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“Severe” Traumatic brain injury
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