1. Evidence based guidelines for prehospital and acute hospital care in Japan
Eiichi Suehiro, Michiyasu Suzuki
Department of Neurosurgery,
Yamaguchi University School of Medicine
Ube, Japan

2. Secondary brain injury
Begin immediately after trauma
Occur on both
microscopic cellular level (e.g. as a result of
hypoxemia)
macroscopic level (e.g. a subdural hematoma)
Determine patient outcome
Can be prevented and/or controlled

3. Prehospital treatment
Spinal precautions
Airway management
Oxygen supply to maintain oxygen saturation > 90%
Normal breathing should be maintained
Maintain blood pressure (BP) > 90 mmHg (systoric)

4. 2003~ JPTEC (Japan Prehospital Trauma Evaluation and Care)
Guideline for evaluation and care quickly at prehospital .

5. JPTEC protocol
First, a head should be fixed at neutral position for prevending spinal injury.
The judgement should be performed within 15 seconds, whether danger of the life is tangible or not with…
Initial evaluation
Conscious
Normal breathing (airway, respiration)
BP maintenance or shock

6. JPTEC protocol “load and go”
When there is abnormality in the initial evaluation, leader declares “load and go”.
“load and go”
1. Perform the treatment essential for life support
securing the airway and ventilation
Hypotension: obtain intravenous access and fluid administration
2. promptly transport the patients to an
appropriate medical facility (Trauma-bypass)

7. JPTEC protocol within 2 minutes The whole body observation
Head palpation
Maxillary and jaw palpation
Cervical inspection, palpation
Chest inspection, palpation, auscultation
Abdominal inspection and palpation
The pelvis palpation
Extremity inspection, palpation
Neurological examination
Initial evaluation and the whole body observation should be performed
within 2 minutes

8. Emergency department care
Prehospital care
Emergency department care

9. 2002~ JATEC (Japan Advanced Trauma Evaluation and Care)
Guideline for evaluation and care quickly at emergency department .

10. JATEC protocol Primary survey:
Evaluation and care for maintenance and recovery of the physiological function for life support based on ABCDE approach
Secondary survey:
After confirming the problem directly connected with life support in a primary survey, anatomical evaluation and care systemically for damage of whole body.

11. JATEC protocol Primary survey A: airway evaluation and securement
cervical protection
B: evaluation of breathing
treatment for critical chest injury
C: evaluation and resuscitation of
circulation and hemostasis
D: evaluation of brain herniation
E: body temperature management

12. Main site of injury pointed out in primary survey
step
treatment
Airway obstruction
A/B
Airway management
Flail chest B
Airway management/positive pressure ventilation
Tension pneumothorax
B/C
Thoracic drainage
Open pneumothorax
Wound closure/Thoracic drainage
Massive hemothorax
Thoracic drainage/hemostasis
tamponade C
pericardiocentesis
hemoperitoneum
hemostasis
Retroperitoneal bleeding
Hemostasis/external skeletal fixation
Brain herniation D
Stabilization of ABC
hypothermia E
warming

13. Guidelines for the Management of Severe Head Injury from the Japan Society of Neurotraumatology
2nd edition
English ver
3rd edition
March 15, 2001
February 15, 2007
March 1, 2013
Neurol Med Chir (Tokyo) 52: 1-30, 2012

14. Contents
Emergency care system and Neurosurgical department (Neurosurgeons)
Initial treatment to protect the brain
Imaging diagnosis
ICU management
Surgical indications and procedures
Management of craniofacial injuries
Management of pediatric and geriatric patients
Management of mild and moderate head injuries
Appendix
1. sports head injury
2. higher brain dysfunction after TBI
3. intracranial hypotension syndrome

15. Standardization of a treatment series for Prehospital care、Emergency Department Care, and Neurosurgical treatment
JNTDB
Project 2004
Project
1998
Project 2009
Project 2015
2006
Guidelines for the management of severe TBI
2nd edition
2013
3rd edition
2000
Guidelines for the management of severe head injury
2007
ＪＮＴＥＣ
2003
ＪＰＴＥＣ
2002
ＪＡＴＥＣ
2015
5th edition
Standardization of initial treatment for TBI

16. Japan Neurotrauma Data Bank
Inclusion Criteria
severe traumatic brain injury（GCS score 3-8 at admission)
deterioration to that level within 48h of impact
craniotomy for traumatic hematomas（GCS score 9-15 at admission， including of ICP sensor）
all age

17. Results of multiple trauma including TBI
P-value
Year -
Total number of cases
1002
1101
1091
No of Pts.
136
140
195
Age
41.6±22.1*
42.4±21.7✝
50.3±22.5*✝
0.0003
Gender (M/F, M%）
107/29
（78.7%）
103/37
(73.6%)
136/59
(69.7%)
0.1939
Transportation time
31.0±14.9*✝
39.3±11.0*
38.7±11.0✝
0.0001
Initial GCS
6.0±2.6*
6.6±3.0
6.9±3.8*
0.0334
ISS　
36.0±9.4
37.6±12.4
38.0±9.1
0.1994
Systolic BP
129.9±44.4
122.8±40.3
128.6±37.2
0.2790
Pulse Rate
101.2±30.7
100.0±29.2
99.7±29.4
0.8922
Resp. Rate
23.5±8.8
23.9±7.9*
21.8±8.3*
0.0377
PaO2(mmHg)
168.1±146.9*✝
214.6±144.3*
218.8±139.7✝
0.0100

18. Result: outcome NS 0.2570 0.9968 Good 30 (22.1%) 43 (30.7%) 50 (25.6%)
GOS at Discharge
P1998
N=136
P2004
N=140
P2009
N=195
P-value
Good
30 (22.1%)
43 (30.7%)
50 (25.6%)
0.2570
Unfavorable
106 (77.9%)
97 (69.3%)
145 (74.4%)
GOS on
6-month
P1998
N=125
P2004
N=98
P2009
N=162
P-value
Good
40 (32.0%)
31 (31.6%)
52 (32.1%)
0.9968
Unfavorable
85 (68.0%)
67 (68.4%)
110 (67.9%)

19. b=b0 + b1×RTS + b2×ISS + b3×Age
Formula for RTS and Ps (TRISS Method)
Revised Trauma Score (RTS)
RTS=0.9368×（GCS） ×（SBP) ×（RR）
Value
GCS
SBP RR 4
13-15
>89
10-29 3
9-12
76-89
>29 2
6-8
50-75
6-9 1
4-5
1-49
1-5
Probability of survival (Ps)
Ps = 1/(1 + e-b)
b=b0 + b1×RTS + b2×ISS + b3×Age
Age=0 ; <55y.o, Age=1 ; ≧55y.o
Type of injury b0 b1 b2 b3
Blunt
0.9544
Penetrating
1.1430

20. Unexpected death (Ps>0.5)
Result: Percentage of unexpected death
P1998
P2004
P2009
P-value
Total No. of patients
136
140
195
Revised
Trauma
Score
5.2±1.2✝
5.3±1.4*
3.9±2.8*✝
0.0001 Ps
0.55±0.29✝
0.57±0.31*
0.39±0.36*✝
Total No. of Dead
69(50.7%)
48(34.3%)
80(41.0%)
0.0507
Unexpected death (Ps>0.5)
29(42.0%)
16(33.3%)
19(23.7%)
0.0307

21. Neurosurgical treatment
Seamless collaboration in trauma care from prehospital care to neurosurgical treatment
Rate of favorable outcome
mortality
no change
Rate of unexpected death
improved
JATEC
Emergency department
Neurosurgical treatment
JPTEC
Prehospital care

22. Thank you for your attension!