1. Management of AIS 3+ Head Injuries: Where are we going?

2. Introduction  Why are we talking about AIS 3+ head injuries  What is an AIS 3+ head injury  What is the evidence  How is national diktat influencing management  What does it mean for our patients  Where do we go from here

3. Why AIS 3+?  Recent introduction of a TQuINS measure  T14-1C-112 Management of Severe Head Injury-all patients with severe head injury (AIS 3+) within the trauma network should be managed within the neurosciences centre as specified in the NICE head injury guidance (CG176-Jan 14)

4. Why AIS 3+?  Look at CG176 and can find nothing about AIS 3+ in isolation  p31 states GCS <9 secondary to HI  Further reference mentions GCS <9 and AIS 3+

5. Why AIS 3+?  The 2007/14 NICE guidance – based on the TARN 2005 Lancet paper is that all severe TBI (GCS<9/intubated) should be (safely) transferred into neuroscience regardless of need for neurosurgery (a NICE quality standard).  The TARN data suggests this is now happening in ~80% of this severe TBI group.  The proportions transferred with AIS3+ brain injury but a higher GCS is much lower (~30% ) and the evidence base to suggest benefit is weaker in terms of reduced mortality.

6. What is an AIS 3+ head injury?  Abbreviated Injury Scale (AIS) is an anatomical-based coding system created by the Association for the Advancement of Automotive Medicine to classify and describe the severity of injuries.  Represents the threat to life associated with the injury rather than the comprehensive assessment of the severity of the injury.

7. What is an AIS 3+ head injury?  AIS 3+ (3 or greater) encompasses a whole range of pathologies (there are no age parameters)  Intracerebellar petechial and subcortical haemorrhage of 0.6-1cm is a 4  Intracerebellar petechial haemorrhage including perilesional oedema is 3  Brain swelling/oedema is a 3  Single cerebral contusion of >1cm is a 3  Multiple contusions of total volume >30ml is a 4

8. What is an AIS 3+ head injury?  Extradural of 0.6-1cm thickness is a 4  Subdural of <0.6cm is a 3, 0.6-1cm is a 4  Any pneumocephalus is a 3  Skull base fracture with or without a CSF leak is a 3  Any compound skull fracture depressed <2cm is a 3

9. Evidence

10.  There is limited evidence supporting a strategy of secondary transfer of severe non- surgical traumatic brain injury patients to specialist neuroscience centres. Randomised controlled trials powered to detect clinically plausible treatment effects should be considered to definitively investigate effectiveness.

11. Evidence  LOW RATE OF TRAUMATIC BRAIN INJURY IN HEAD INJURED ADULTS BYPASSING NEAREST HOSPITAL – FINDINGS OF THE HEAD INJURY TRANSPORTATION STRAIGHT TO NEUROSURGERY (HITS-NS) RANDOMISED FEASIBILITY TRIAL

12. Evidence  Current NHS England practice of bypassing suspected TBI patients to neuroscience centres typically gives an over triage ratio of 13:1 for neurosurgical intervention and 4:1 for traumatic brain injury. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using a randomised design and highlights the challenge of reliably identifying TBI at the scene of injury.

13. A national diktat  Stable TBI patients are more likely to get appropriate neurorehab in an MTC (depending on local service configuration)  “ Your network needs to ensure that the mortality rates in direct admissions to the MTC for TBI are similar to those in TBI patients who remain in TUs”

14. Case Study

15. What it means for our patients?

18. Where do we go from here?  Measure set to stay  Impact on patients, relatives and carers (measurable? reportable?)  Impact on MTCs, TUs and ambulance services

19. Any questions?