THREE HUNDRED AND ten TBI patients with a

Size: px
Start display at page:

Download "THREE HUNDRED AND ten TBI patients with a"

Transcription

1 Acute Medicine & Surgery 2014; 1: doi: /ams2.5 Original Article Outcome prediction model for severe traumatic brain injury Jiro Iba, 1 Osamu Tasaki, 2 Tomohito Hirao, 2 Tomoyoshi Mohri, 3 Kazuhisa Yoshiya, 4 Koichi Hayakawa, 6 Tadahiko Shiozaki, 4 Toshimitsu Hamasaki, 5 Yasushi Nakamori, 6 Satoshi Fujimi, 7 Hiroshi Ogura, 4 Yasuyuki Kuwagata, 6 and Takeshi Shimazu 4 1 Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka; 2 Department of Emergency Medicine, Unit of Clinical Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki; 3 Emergency and Critical Care Center, Hyogo Prefectural Nishinomiya Hospital, Hyogo; Departments of 4 Traumatology and Acute Critical Medicine, and 5 Biomedical Statistics, Osaka University Graduate School of Medicine, Osaka; 6 Department of Emergency and Critical Care Medicine, Kansai Medical University Hirakata Hospital, Osaka; and 7 Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan Aim: Treatment of severe traumatic brain injury is aided by better prediction of outcomes. The purpose of the present study was to develop and validate a prediction model using retrospective analysis of prospectively collected clinical data from two tertiary critical care medical centers in Japan. Methods: Data were collected from 253 patients with a Glasgow Coma Scale score of <9. Within 24 h of their admission, 15 factors possibly related to outcome were evaluated. The dataset was randomly split into training and validation datasets using the repeated random subsampling method. A logistic regression model was fitted to the training dataset and predictive accuracy was assessed using the validation data. Results: The best model included the variables age, pupillary light reflex, extensive subarachnoid hemorrhage, intracranial pressure, and midline shift. The estimated area under the curve for the model development data was 0.957, with a 95% confidence interval of , and that for validation data was 0.947, with a 95% confidence interval of Conclusion: Our predictive model was shown to have high predictive value. It will be useful for review of treatment, family counseling, and efficient allocation of resources for patients with severe traumatic brain injury. Key words: Glasgow Coma Scale, logistic regression, outcome prediction, repeated random subsampling method, severe traumatic brain injury INTRODUCTION SEVERE TRAUMATIC BRAIN injury (TBI) is a major cause of death and severe disability after trauma. 1,2 Outcome prediction is useful for family counseling, evaluation of treatment effectiveness, efficient use of limited medical resources, and efficient design and conduct of randomized clinical trials. Although numerous investigators have proposed prognostic models for TBI, a mathematical model with high predictive value has not yet been established. 1 6 Previously, we developed a prediction model with high predictive value using multivariate logistic Corresponding: Osamu Tasaki, MD, PhD, Department of Emergency Medicine, Unit of Clinical Medicine, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto, Nagasaki, , Japan. tasaki-o@nagasaki-u.ac.jp. Received 17 Jul, 2013; accepted 17 Sep, 2013 regression. 7 However, this model was limited in that it was derived from a single institute and was not subjected to validation analysis. The purpose of the present study was to develop an improved prediction model using data from two tertiary critical care medical centers and to examine its predictive value using a sophisticated statistical method. METHODS Patients THREE HUNDRED AND ten TBI patients with a Glasgow Coma Scale (GCS) score of <9 within 12 h after injury were registered in our database during the period June 1997 October Of these 310 patients, 57 were excluded from the study due to: >2 h transport time to the critical care centers (n = 17); alcohol-induced coma (n = 14); circulation collapse due to hemorrhagic shock (n = 11); neurologically dead upon admission (n = 10); and no intracranial pressure (ICP) monitor indwelling due to minor 31

2 32 J. Iba et al. Acute Medicine & Surgery 2014; 1: injury (n = 5). Thus, the study group comprised 253 patients from two tertiary critical care medical centers. This study was carried out according to the principles of the Declaration of Helsinki and approved by the institutional review board at Osaka University Hospital (approval number: 12220). The board waived the need for informed consent because this was a retrospective study using clinical data. Initial management All patients received the same initial standardized treatment protocol, which included appropriate resuscitation and stabilization in accordance with the Advanced Trauma Life Support Guidelines 8 and immediate neurologic evaluation (GCS score, pupil size and reactivity, and neurologic deficits). Patients were examined by computed tomography (CT) as soon after stabilization as possible. According to CT findings, patients were taken either to the operating room for surgical evacuation of significant space-occupying lesions or directly to the intensive care unit. Computed tomography scanning was repeated 6 and 24 h after injury, as well as immediately after surgery, or when a patient s level of consciousness deteriorated. An ICP monitor was inserted in each patient. A ventricular catheter was used if available; otherwise, a parenchymal or subdural monitoring system was used. Arterial blood samples were taken on admission for blood gas analysis and cell counts. Treatment of intracranial hypertension Cerebrospinal fluid drainage was used as a first option for ICP elevation. If cerebrospinal fluid drainage was ineffective in controlling ICP or was not available, barbiturate therapy and then mild hypothermia was provided according to a published protocol. 9 Craniectomy was not carried out routinely for refractory intracranial hypertension that was not controllable with mild hypothermia and barbiturate therapy, although it was considered when requested by a patient s family. Outcome In all cases, the outcome was assessed prospectively at 6 months after injury according to the Glasgow Outcome Scale. 10 Good recovery and moderate disability were considered to be favorable outcomes. Severe disability, persistent vegetative state, and death were considered unfavorable. Statistical analyses The present study involved retrospective analysis of prospectively collected clinical data. We considered a total of 15 candidate prognostic variables possibly related to outcome: age, sex, GCS score, pupillary light reflex (LR), ICP, cerebral perfusion pressure (CPP), base deficit, body temperature, PaO 2 (hypoxia), PaCO 2 (hypocapnia or hypercapnia), hypotension, and three features on the CT scan (absence of the cisterns, midline shift, extensive traumatic subarachnoid hemorrhage [Ext-SAH]) (Table 1). Age, GCS score, LR, body temperature, and systolic blood pressure were recorded on admission. Base deficit, hypoxia, and hypocapnia or hypercapnia were also evaluated on admission by arterial blood gas analysis. Both ICP and CPP were recorded immediately after patients were admitted to the intensive care unit. We calculated CPP by subtracting ICP from mean arterial pressure. The CT features were identified on scans obtained within 24 h of injury, and the most serious findings were recorded. Cistern absence was defined as absence of the basal cisterns including the suprasellar cisterns, ambient Table 1. Grades and definitions of variables related to outcomes in 253 patients with severe traumatic brain injury Variable Grades and definition Variable Grades and definition Age Years Hypoxia PaO 2 <60 mmhg Sex Male or female Hypocapnia PaCO 2 <35 mmhg GCS score 3 15 Hypercapnia PaCO 2 >45 mmhg LR 1: Bi/unilaterally present 0: Bilaterally absent Absent cisterns 0: Basal cistern present 1: Basal cistern absent Hypotension Systolic blood pressure <90 mmhg ICP mmhg Midline shift mm CPP mmhg Ext-SAH 0: Absent 1: Present BD meq/l BT C BD, base deficit; BT, body temperature; CPP, cerebral perfusion pressure; ext-sah, extensive subarachnoid hemorrhage; GCS, Glasgow Coma Scale; ICP, intracranial pressure; LR, pupillary light reflex.

3 Acute Medicine & Surgery 2014; 1: Outcome prediction of brain injury 33 Table 2. Glasgow Outcome Scale in 253 patients 6 months after severe traumatic brain injury Glasgow Outcome Scale n (%) Death 115 (45.5) Persistent vegetative state 40 (15.8) Severe disability 37 (14.6) Moderate disability 26 (10.3) Good recovery 35 (13.8) cisterns, and quadrigeminal cisterns. Extensive traumatic subarachnoid hemorrhage was defined as the presence of a high density area both in the basal cisterns and over the convexity on the CT scan. Midline shift was measured at the level of the septum pellucidum. Statistical analyses were carried out using SAS version for Windows (SAS Institute, Cary, NC, USA) and in-house validated Fortran programs. The repeated random subsampling method was used to build a substantially predictable and robust model to an independent dataset. The dataset was first randomly split into training and validation datasets. Then, for each such split, a logistic regression model was fitted to the training dataset and predictive accuracy was assessed using the validation data. To assess predictive accuracy, positive predictive value, negative predictive value, total predictive value, and sensitivity and specificity were calculated. In addition to the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC) and its 95% confidence interval (CI) were calculated. These are commonly used as a summary measure of a model s predictive accuracy. The subset of variables with the largest value of AUC was selected as the most predictive. RESULTS PATIENT OUTCOMES AT 6 months after injury are shown in Table 2. Seventy-six percent of 253 patients had an unfavorable outcome, and 24% had a favorable outcome. The results of univariate analysis with logistic regression are shown in Table 3. Age, GCS score, LR, ICP, CPP, hypercapnea, cistern absence, midline shift, and Ext- SAH were significantly associated with outcome (P < 0.05). The variables selected by repeated random subsampling validation were age, Ext-SAH, LR, ICP, and midline shift. The results of the repeated random subsampling validation analysis are shown in Table 4. The odds ratios for each these variables were 1.072, 11.95, 0.157, 1.043, and 1.087, respectively. According to these results, a statistical model for outcome prediction was developed as: Pu = exp (B)/1 + exp (B), where Pu is the probability of an unfavorable outcome, and exp (B) is the exponential function of B, where B = age (years) ICP (mmhg) midline shift (mm) ext-sah (1 or 0) LR (1 or 0) Table 3. Univariate analysis of variables related to outcomes in 253 patients with severe traumatic brain injury Variable Median (range) Percent OR (95%CI) P-value Age 49 (0 91) ( ) Sex (male) ( ) GCS score 6 (3 15) ( ) LR (present) ( ) ICP 18 ( ( ) BD 2 ( 9 21) ( ) CPP 64 (0 120) ( ) BT 36 (29 40) ( ) Hypoxia ( ) Hypocapnia ( ) Hypercapnia ( ) Hypotension ( ) Absent cisterns ( ) Midline shift 5 (0 29) ( ) Ext-SAH ( ) 0.000, not applicable. BD, base deficit; BT, body temperature; CI, confidence interval; CPP, cerebral perfusion pressure; Ext-SAH: extensive subarachnoid hemorrhage; GCS, Glasgow Coma Scale; ICP, intracranial pressure; LR, pupillary light reflex; OR, odds ratio.

4 34 J. Iba et al. Acute Medicine & Surgery 2014; 1: Table 4. Results of repeated random subsampling validation analysis of factors possibly related to outcome in patients with severe traumatic brain injury (n = 253) Covariate Coeff(β) SE(β) P value OR 95%CI Age Ext-SAH LR ICP Midline shift CI, confidence interval; Coeff(β), coefficient; Ext-SAH, extensive subarachnoid hemorrhage; ICP, intracranial pressure; LR, pupillary light reflex; OR, odds ratio; SE(β), standard error of coefficient. Fig. 1. Probability of an unfavorable outcome (Pu) in 253 patients with severe traumatic brain injury. Each circle represents one patient. Fig. 2. Receiver operating characteristic curve of our predictive model for all patients with severe traumatic brain injury (n = 253). Both the model development data and validation data had considerably high AUC values. The AUC for model development data was estimated to be 0.957, with a 95% CI of , and the AUC for validation data was 0.947, with a 95% CI of The probability of an unfavorable outcome for all the patients (n = 253) with favorable and unfavorable outcomes is shown in Figure 1. If the cut-off value was imposed at 0.517, the positive predictive value of this model was 94.7% (180/190), negative predictive value was 81.0% (51/63), and total predictive value was 91.3% (231/253). Sensitivity was 93.8% (180/192), and specificity was 83.6% (51/61). The ROC curve is shown in Figure 2. The AUC for the model was 0.956, with a 95% CI of DISCUSSION OUR PREVIOUS MODEL was limited in that it was derived from a single institute and was not subjected to validation analysis. Therefore, in the present study, we developed an improved prediction model using data from two tertiary critical care medical centers and examined its predictive value using a sophisticated statistical method. Five indicators (age, Ext-SAH, LR, ICP, midline shift) were shown to be powerful prognostic indicators with a high predictive value. These findings are consistent with, and build upon, our previous study model, which had the same selected variables, although coefficients are a little different (age, versus 0.11; Ext-SAH, versus 3.44; LR, versus 4.09; ICP, versus 0.12; midline shift, versus 0.16). Recently, two prediction models have been developed based on large datasets. One is published by the Medical Research Council (MRC) corticosteroid randomization after significant head injury (CRASH) trial, 3 and the other is by the International Mission for Prognosis and Analysis of Clinical Trials in traumatic brain injury (IMPACT) project. 4 The MRC

5 Acute Medicine & Surgery 2014; 1: Outcome prediction of brain injury 35 CRASH study included patients with mild to severe traumatic brain injury (GCS 14), used variables assessed within a few hours of admission, and developed a prediction model of unfavorable outcome at 6 months after injury. External validation for unfavorable outcome at 6 months in high income countries showed an AUC of In the model derived from the IMPACT project, patients with moderate to severe traumatic brain injury (GCS 12) were included, admission characteristics were used for model development, and unfavorable outcome at 3 or 6 months was predicted. The authors reported that external validation confirmed the discriminative ability of the model to be adequate (AUC 0.80). Due to the fact that many factors influence prognosis, it has been difficult to develop an all-round predictive model for all degrees of traumatic brain injury. In the present study, we focused on severe traumatic brain injury defined as GCS <9 within 12 h of injury. We also excluded several patient categories: those who had more than 2 h transport time to the centers; an alcohol-induced coma; circulation collapse due to hemorrhagic shock; and those who were neurologically dead upon admission. Another feature of our model was that predictions were made 24 h after injury. There are some reports of outcome prediction using patient characteristics on admission or variables within a few hours of injury. 4,5 However, those models were not strongly predictive. This may be because there are considerable numbers of patients who deteriorate rapidly after admission. In 20 cases (7.9%) out of 253 patients in the present study, GCS on admission was 9, but decreased thereafter (data not shown). Therefore, to improve the predictive value, we selected possible prognostic indicators within 24 h after injury. The model is likely to provide a more accurate prediction of outcomes as more patients were included in the study and from multiple centers. However, with an increased number of patients and participating institutes it may be more difficult to collect precise and detailed parameters. Although we collected data from only two institutes in this study, we were able to collect such data as ICP, CPP, CT findings, and blood gases because both centers had the same level of facilities and shared the same treatment algorithm. One way of developing the best prediction model may be to choose robust indicators based on a small but well-examined study, and then use these to calibrate coefficients in a large cohort study. Limitations There are several limitations to the present study. First, differences in emergency medical services (EMS) might have influenced the results of the study. For example, in Japan, EMS is not permitted to intubate the trachea except in cases of cardiopulmonary arrest. Although this is unlikely to affect the utility of the five predictive indicators (age, Ext-SAH, LR, ICP, midline shift), the model may have to be adjusted for different EMS procedures. Second, even if the prognostic value is high, it is still difficult to make a decision to continue or withdraw the treatment of a patient with severe traumatic brain injury. In our model, 22 patients out of 253 were not correctly predicted. The discrimination of severe and moderate disability was especially difficult. 11 The Pu values of 13 (59%) out of the 22 patients were between 0.40 and 0.80 (data not shown). This may highlight a limitation of using a dichotomous classification such as favorable and unfavorable outcome. Finally, although we carried out cross-validation using a repeated random subsampling method, external validation based on a completely different dataset is yet to be performed. There is also the possibility that our model was over fitting because the sample size was relatively small and the treatment algorithm was identical in the two institutes. However, erroneous omission of predictors with weaker effect may occur in small samples such as this, due to a lack of power. To examine the true quality of the present model, a validation study in a large cohort will be required. CONCLUSION WE DEVELOPED AND validated a predictive model of severe traumatic brain injury. Five indicators age, Ext-SAH, LR, ICP, and midline shift were detected, consistent with our previous study. As this new model has a high predictive value, further validation studies in a large patient cohort are warranted. CONFLICT OF INTEREST N ONE. ACKNOWLEDGMENTS OSAMU TASAKI RECEIVED a grant from The General Insurance Association of Japan; Tadahiko Shiozaki received a Grant-in Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technology of Japan (no ). REFERENCES 1 Husson EC, Ribbers GM, Willemse-van Son AH, Verhagen AP, Stam HJ. Prognosis of six-month functioning after moderate to severe traumatic brain injury: A systematic review of prospective cohort studies. J. Rehabil. Med. 2010; 42:

6 36 J. Iba et al. Acute Medicine & Surgery 2014; 1: Menon DK, Zahed C. Prediction of outcome in severe traumatic brain injury. Curr. Opin. Crit. Care. 2009; 15: MRC CRASH Trial Collaborators, Perel P, Arango M et al. Predicting outcome after traumatic brain injury: Practical prognostic models based on large cohort of international patients. BMJ. 2008; 336: Steyerberg EW, Mushkudiani N, Perel P et al. Predicting outcome after traumatic brain injury: Development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008; 5: e Hukkelhoven CW, Steyerberg EW, Habbema JD et al. Predicting outcome after traumatic brain injury: Development and validation of a prognostic score based on admission characteristics. J. Neurotrauma. 2005; 22: Meric E, Gunduz A, Turedi S, Cakir E, Yandi M. The prognostic value of neuron-specific enolase in head trauma patients. J. Emerg. Med. 2010; 38: Tasaki O, Shiozaki T, Hamasaki T et al. Prognostic indicators and outcome prediction model for severe traumatic brain injury. J. Trauma. 2009; 66: American College of Surgeons Committee on Trauma. Advanced trauma life support program for doctors: Student course manual. Chicago: American College of Surgeons, Shiozaki T, Hayakata T, Tasaki O et al. Cerebrospinal fluid concentration of anti-inflammatory mediators in early-phase severe traumatic brain injury. Shock 2005; 23: Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975; 1: Choi SC, Narayan RK, Anderson RL, Ward JD. Enhanced specificity of prognosis in severe head injury. J. Neurosurg. 1988; 69:

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8 PRACTICE GUIDELINE Effective Date: 9-1-2012 Manual Reference: Deaconess Trauma Services TITLE: TRAUMATIC BRAIN INJURY GUIDELINE OBJECTIVE: To provide practice management guidelines for traumatic brain

More information

Moron General Hospital Ciego de Avila Cuba. Department of Neurological Surgery

Moron General Hospital Ciego de Avila Cuba. Department of Neurological Surgery Moron General Hospital Ciego de Avila Cuba Department of Neurological Surgery Early decompressive craniectomy in severe head injury with intracranial hypertension Angel J. Lacerda MD PhD, Daisy Abreu MD,

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Cooper DJ, Nichol A, Bailey M, et al. Effect of early sustained prophylactic hypothermia on neurologic outcomes among patients with severe traumatic brain injury: the POLAR

More information

Marshall Scale for Head Trauma Mark C. Oswood, MD PhD Department of Radiology Hennepin County Medical Center, Minneapolis, MN

Marshall Scale for Head Trauma Mark C. Oswood, MD PhD Department of Radiology Hennepin County Medical Center, Minneapolis, MN Marshall Scale for Head Trauma Mark C. Oswood, MD PhD Department of Radiology Hennepin County Medical Center, Minneapolis, MN History of Marshall scale Proposed by Marshall, et al in 1991 to classify head

More information

Case 1. Case 5/30/2013. Traumatic Brain Injury : Review, Update, and Controversies

Case 1. Case 5/30/2013. Traumatic Brain Injury : Review, Update, and Controversies Case 1 Traumatic Brain Injury : Review, Update, and Controversies Shirley I. Stiver MD, PhD 32 year old male s/p high speed MVA Difficult extrication Intubated at scene Case BP 75 systolic / palp GCS 3

More information

Update on Guidelines for Traumatic Brain Injury

Update on Guidelines for Traumatic Brain Injury Update on Guidelines for Traumatic Brain Injury Current TBI Guidelines Shirley I. Stiver MD, PhD Department of Neurosurgery Guidelines for the management of traumatic brain injury Journal of Neurotrauma

More information

Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm

Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm Original Article Print ISSN: 2321-6379 Online ISSN: 2321-595X DOI: 10.17354/ijss/2017/300 Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm Raja S Vignesh

More information

Head injuries. Severity of head injuries

Head injuries. Severity of head injuries Head injuries ED Teaching day 23 rd October Severity of head injuries Minor GCS 14-15 Must not have any of the following: Amnesia 10min Neurological sign or symptom Skull fracture (clinically or radiologically)

More information

Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics

Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics Ewout W. Steyerberg 1*, Nino Mushkudiani 1, Pablo Perel

More information

Early Treatment of TBI A Prospective Study from Austria

Early Treatment of TBI A Prospective Study from Austria Early Treatment of TBI A Prospective Study from Austria Walter Mauritz MD, PhD Dept. of Anaesthesiology & Critical Care Trauma Hospital XX, 1200 Vienna, Austria International Neurotrauma Research Organisation,

More information

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients Emergency 2016; 4 (4): 196-201 ORIGINAL RESEARCH Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients Behrooz Hashemi 1, Mahnaz Amanat 1,

More information

Do Prognostic Models Matter in Neurocritical Care?

Do Prognostic Models Matter in Neurocritical Care? Do Prognostic Models Matter in Neurocritical Care? Alexis F. Turgeon MD MSc FRCPC Associate Professor and Director of Research Department of Anesthesiology and Critical Care Medicine Division of Critical

More information

Standardize comprehensive care of the patient with severe traumatic brain injury

Standardize comprehensive care of the patient with severe traumatic brain injury Trauma Center Practice Management Guideline Iowa Methodist Medical Center Des Moines Management of Patients with Severe Traumatic Brain Injury (GCS < 9) ADULT Practice Management Guideline Contact: Trauma

More information

Traumatic Brain Injuries

Traumatic Brain Injuries Traumatic Brain Injuries Scott P. Sherry, MS, PA-C, FCCM Assistant Professor Department of Surgery Division of Trauma, Critical Care and Acute Care Surgery DISCLOSURES Nothing to disclose Discussion of

More information

Traumatic Brain Injury:

Traumatic Brain Injury: Traumatic Brain Injury: Changes in Management Across the Spectrum of Age and Time Omaha 2018 Trauma Symposium June 15, 2018 Gail T. Tominaga, M.D., F.A.C.S. Scripps Memorial Hospital La Jolla Outline Background

More information

Session 7: The Sliding Dichotomy 7.1 Background 7.2 Principles 7.3 Hypothetical example 7.4 Implementation 7.5 Example: CRASH Trial

Session 7: The Sliding Dichotomy 7.1 Background 7.2 Principles 7.3 Hypothetical example 7.4 Implementation 7.5 Example: CRASH Trial Session 7: The Sliding Dichotomy 7.1 Background 7.2 Principles 7.3 Hypothetical example 7.4 Implementation 7.5 Example: CRASH Trial Session 7 1 7.1 The Sliding Dichotomy: Background The sliding dichotomy

More information

PREDICTION OF PROGNOSIS IN PATIENTS OF DIFFUSE BRAIN INJURY USING PROGNOSTIC PREDICTIVE MODEL DEVELOPED BY NIMHANS

PREDICTION OF PROGNOSIS IN PATIENTS OF DIFFUSE BRAIN INJURY USING PROGNOSTIC PREDICTIVE MODEL DEVELOPED BY NIMHANS PREDICTION OF PROGNOSIS IN PATIENTS OF DIFFUSE BRAIN INJURY USING PROGNOSTIC PREDICTIVE MODEL DEVELOPED BY NIMHANS Devendra Singh Dhaker, Yogendra Singh Bhakuni, Ashish Kumar Dwivedi, A. K. Chaurasia,

More information

Imaging Biomarkers Significance S100B NSE. Admitted within 6 hours of injury and CT scan occurred after initial examination. N = 1,064 CT+ N = 50 4.

Imaging Biomarkers Significance S100B NSE. Admitted within 6 hours of injury and CT scan occurred after initial examination. N = 1,064 CT+ N = 50 4. Concussion Guidelines Step 1: Systematic Review of Prevalent Indicators Supplemental Content 7 Evidence Table. Included Studies For Key Question 4 Imaging and Biomarker Publications Medium Potential for

More information

Prognostic Value of Secondary Insults in Traumatic Brain Injury: Results from the IMPACT Study ABSTRACT

Prognostic Value of Secondary Insults in Traumatic Brain Injury: Results from the IMPACT Study ABSTRACT JOURNAL OF NEUROTRAUMA Volume 24, Number 2, 2007 Mary Ann Liebert, Inc. Pp. 287 293 DOI: 10.1089/neu.2006.0031 Prognostic Value of Secondary Insults in Traumatic Brain Injury: Results from the IMPACT Study

More information

Outcome of severe traumatic brain injury at a critical care unit: a review of 87 patients

Outcome of severe traumatic brain injury at a critical care unit: a review of 87 patients Original Article Outcome of severe traumatic brain injury at a critical care unit: a review of 87 patients E.A. Opondo, MBChB, MMed (Surg), General surgeon, North Kinangop Mission Hospital, Surgery Department

More information

The application of adult traumatic brain injury models in a pediatric cohort

The application of adult traumatic brain injury models in a pediatric cohort clinical article J Neurosurg Pediatr 18:558 564, 2016 The application of adult traumatic brain injury models in a pediatric cohort Adam M. H. Young, MRCS, 1 Mathew R. Guilfoyle, MRCS, 1 Helen Fernandes,

More information

1st Turku Traumatic Brain Injury Symposium Turku, Finland, January 2014

1st Turku Traumatic Brain Injury Symposium Turku, Finland, January 2014 The TBIcare decision support tool aid for the clinician Jyrki Lötjönen & Jussi Mattila, VTT Technical Research Centre of Finland Validation of the decision support tool Ari Katila University of Turku 1st

More information

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury*

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury* J Neurosurg 92:1 6, 2000, Click here to return to Table of Contents Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury*

More information

Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer

Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer Vavilala MS, et al Retrospective multicenter cohort study Prehospital Arena ED OR - ICU Each 1% increase in adherence was associated

More information

Traumatic Brain Injury Pathways for Adult ED Patients Being Admitted to Trauma Service

Traumatic Brain Injury Pathways for Adult ED Patients Being Admitted to Trauma Service tic Brain Injury Pathways for Adult ED Patients Being Admitted to Service Revision Team Tyler W. Barrett, MD, MSCI Elizabeth S. Compton, NP Bradley M. Dennis, MD Oscar D. Guillamondegui, MD, MPH Michael

More information

How should clinical trials in brain injury be designed

How should clinical trials in brain injury be designed How should clinical trials in brain injury be designed Alexis F. Turgeon MD MSc FRCPC Associate Professor and Director of Research Department of Anesthesiology and Critical Care Medicine Division of Critical

More information

Pressure reactivity: Relationship between ICP and arterial blood pressure (ABP). Pressure-reactivity index, computational methods. Clinical examples.

Pressure reactivity: Relationship between ICP and arterial blood pressure (ABP). Pressure-reactivity index, computational methods. Clinical examples. Pressure reactivity: Relationship between ICP and arterial blood pressure (ABP). Pressure-reactivity index, computational methods. Clinical examples. Optimization of cerebral perfusion pressure: Relationship

More information

Study the Prognostic Value of Computed Tomographic Characteristics in Cases of Traumatic Brain Injury

Study the Prognostic Value of Computed Tomographic Characteristics in Cases of Traumatic Brain Injury Study the Prognostic Value of Computed Tomographic Characteristics in Cases of Traumatic Brain Injury Tamer Abdullah Helmy 1, Mohammed Nasr-Eldeen Elsayd 1, Mamdoh Ahmed Zidan 2, Mohamed Farid 3 (1) Critical

More information

Traumatic brain Injury- An open eye approach

Traumatic brain Injury- An open eye approach Traumatic brain Injury- An open eye approach Dr. Sunit Dr Sunit, Apollo children's hospital Blah blah Lots of head injury Lot of ill children Various methods of injury Various mechanisms of brain damage

More information

Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth. Objectives 11/7/2017

Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth. Objectives 11/7/2017 Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth Objectives 1. Be able to discuss brain anatomy and physiology as it applies to

More information

INTRACRANIAL PRESSURE -!!

INTRACRANIAL PRESSURE -!! INTRACRANIAL PRESSURE - Significance raised ICP main cause of death in severe head injury main cause of morbidity in moderate and mild head injury main target and prognostic indicator in the ITU setting

More information

Management of Severe Traumatic Brain Injury

Management of Severe Traumatic Brain Injury Guideline for North Bristol Trust Management of Severe Traumatic Brain Injury This guideline describes the following: Initial assessment and management of the patient with head injury Indications for CT

More information

Perioperative Management of Traumatic Brain Injury. C. Werner

Perioperative Management of Traumatic Brain Injury. C. Werner Perioperative Management of Traumatic Brain Injury C. Werner Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical

More information

HEAD INJURY. Dept Neurosurgery

HEAD INJURY. Dept Neurosurgery HEAD INJURY Dept Neurosurgery INTRODUCTION PATHOPHYSIOLOGY CLINICAL CLASSIFICATION MANAGEMENT - INVESTIGATIONS - TREATMENT INTRODUCTION Most head injuries are due to an impact between the head and another

More information

PROPOSAL FOR MULTI-INSTITUTIONAL IMPLEMENTATION OF THE BRAIN INJURY GUIDELINES

PROPOSAL FOR MULTI-INSTITUTIONAL IMPLEMENTATION OF THE BRAIN INJURY GUIDELINES PROPOSAL FOR MULTI-INSTITUTIONAL IMPLEMENTATION OF THE BRAIN INJURY GUIDELINES INTRODUCTION: Traumatic Brain Injury (TBI) is an important clinical entity in acute care surgery without well-defined guidelines

More information

8/29/2011. Brain Injury Incidence: 200/100,000. Prehospital Brain Injury Mortality Incidence: 20/100,000

8/29/2011. Brain Injury Incidence: 200/100,000. Prehospital Brain Injury Mortality Incidence: 20/100,000 Traumatic Brain Injury Almario G. Jabson MD Section Of Neurosurgery Asian Hospital And Medical Center Brain Injury Incidence: 200/100,000 Prehospital Brain Injury Mortality Incidence: 20/100,000 Hospital

More information

SUBJECT: Clinical Practice Guideline for the Management of Severe Traumatic Brain Injury

SUBJECT: Clinical Practice Guideline for the Management of Severe Traumatic Brain Injury ASPIRUS WAUSAU HOSPITAL, INC. Passion for excellence. Compassion for people. Effective Date: December 1, 2005 Proposed By: Samuel Picone III, MD, Trauma Medical Director Approval and Dates: Dr. Bunch,

More information

Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury

Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury J Med Dent Sci 2010; 57: 133-138 Original Article Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury Hiroyuki Masaoka Department of Neurosurgery,

More information

Prediction tree for severely head-injured patients

Prediction tree for severely head-injured patients J Neurosurg 75:251-255, 1991 Prediction tree for severely head-injured patients SUNG C. ClIoI, P]I.D., JAN P. MUIZELAAR, M.D., PH.D., TIIOMAS Y. BARNES, M.S., ANTIIONY M.,XRMAROU, PH.D., DANNV M. BROOKS,

More information

Traumatic brain injury (TBI) is a heterogeneous disease

Traumatic brain injury (TBI) is a heterogeneous disease JOURNAL OF NEUROTRAUMA 29:1306 1312 (May 1, 2012) ª Mary Ann Liebert, Inc. DOI: 10.1089/neu.2011.1988 Predicting 14-Day Mortality after Severe Traumatic Brain Injury: Application of the IMPACT Models in

More information

Outcomes after severe traumatic brain injury (TBI)

Outcomes after severe traumatic brain injury (TBI) CLINICAL ARTICLE J Neurosurg 129:234 240, 2018 Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury Aditya Vedantam,

More information

11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome?

11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome? 11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome? Critical levels of CPP, ICP and PRx Percentage of patients in outcome

More information

IMPACT Recommendations for Improving the Design and Analysis of Clinical Trials in Moderate to Severe Traumatic Brain Injury

IMPACT Recommendations for Improving the Design and Analysis of Clinical Trials in Moderate to Severe Traumatic Brain Injury Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics IMPACT Recommendations for Improving the Design and Analysis of Clinical Trials in Moderate to Severe Traumatic

More information

Medical Management of Intracranial Hypertension. Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center

Medical Management of Intracranial Hypertension. Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center Medical Management of Intracranial Hypertension Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center Anatomic and Physiologic Principles Intracranial compartments Brain 80% (1,400

More information

11/27/2017. Stroke Management in the Neurocritical Care Unit. Conflict of interest. Karel Fuentes MD Medical Director of Neurocritical Care

11/27/2017. Stroke Management in the Neurocritical Care Unit. Conflict of interest. Karel Fuentes MD Medical Director of Neurocritical Care Stroke Management in the Neurocritical Care Unit Karel Fuentes MD Medical Director of Neurocritical Care Conflict of interest None Introduction Reperfusion therapy remains the mainstay in the treatment

More information

Traumatic Brain Injury Pathway, GCS 15 Closed head injury

Traumatic Brain Injury Pathway, GCS 15 Closed head injury Traumatic Brain Injury Pathway, GCS 15 Closed head injury Plus Any One of the Following Mild TBI 2010 Consensus Definition of TBI from CDC, NINDS, NIDDR, VA, DVBIC, DCoE Plus Any One of the Following New

More information

Predicting the need for operation in the patient with an occult traumatic intracranial hematoma

Predicting the need for operation in the patient with an occult traumatic intracranial hematoma J Neurosurg 55:75-81, 1981 Predicting the need for operation in the patient with an occult traumatic intracranial hematoma SAM GALBRAITH, M.D., F.R.C.S., AND GRAHAM TEASDALE, M.R.C.P., F.R.C.S. Department

More information

Rerupture of intracranial aneurysms: a clinicoanatomic study

Rerupture of intracranial aneurysms: a clinicoanatomic study J Neurosurg 67:29-33, 1987 Rerupture of intracranial aneurysms: a clinicoanatomic study ALBERT HIJDRA, M.D., MARINUS VERMEULEN, M.D., JAN VAN GIJN, M.D., AND HANS VAN CREVEL, M.D. Departments ~[ Neurology.

More information

x = ( A) + (3.296 B) (0.070 C) (1.006 D) + (2.426 E) Receiver Operating Characteristic ROC

x = ( A) + (3.296 B) (0.070 C) (1.006 D) + (2.426 E) Receiver Operating Characteristic ROC 7 1... 4. 5. 6. 7. 8. 9. 1. 000 1 01 11 006 01 1 11 6 Glasgow outcome scale GOS GOS 4 n=477 55 A C D 5 ph B E = 1/(1 + e x) x = ( 0.0 A) + (.96 B) (0.070 C) (1.006 D) + (.46 E) 19.489 estimated probability

More information

Severe traumatic brain injury. Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre

Severe traumatic brain injury. Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre Severe traumatic brain injury Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre Primary focus of care Prevent ischemia, hypoxia and hypoglycemia Nutrient & oxygen supply Limited

More information

THOMAS G. SAUL, M.D., THOMAS B. DUCKER, M.D., MICHAEL SALCMAN, M.D., AND ERIC CARRO, M.D.

THOMAS G. SAUL, M.D., THOMAS B. DUCKER, M.D., MICHAEL SALCMAN, M.D., AND ERIC CARRO, M.D. J Neurosurg 54:596-600, 1981 Steroids in severe head injury A prospective randomized clinical trial THOMAS G. SAUL, M.D., THOMAS B. DUCKER, M.D., MICHAEL SALCMAN, M.D., AND ERIC CARRO, M.D. Department

More information

HHS Public Access Author manuscript Neurocrit Care. Author manuscript; available in PMC 2017 February 01.

HHS Public Access Author manuscript Neurocrit Care. Author manuscript; available in PMC 2017 February 01. Derivation of a Predictive Score for Hemorrhagic Progression of Cerebral Contusions in Moderate and Severe Traumatic Brain Injury Randall Z. Allison 1, Kazuma Nakagawa 2,3, Michael Hayashi 4,5, Daniel

More information

Efficient analysis of ordinal functional outcome scales

Efficient analysis of ordinal functional outcome scales Efficient analysis of ordinal functional outcome scales Gordon D Murray University of Edinburgh Outline of presentation Functional outcome scales Ordinal analysis Case study: SCAST Results Points to consider

More information

Early prediction of outcome after severe traumatic brain injury: a simple and practical model

Early prediction of outcome after severe traumatic brain injury: a simple and practical model Rizoli et al. BMC Emergency Medicine (2016) 16:32 DOI 10.1186/s12873-016-0098-x RESEARCH ARTICLE Open Access Early prediction of outcome after severe traumatic brain injury: a simple and practical model

More information

ICP. A Stepwise Approach. Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System

ICP. A Stepwise Approach. Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System ICP A Stepwise Approach Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System ICP: Basic Concepts Monroe-Kellie doctrine: skull = fixed volume

More information

Brain under pressure Managing ICP. Giuseppe

Brain under pressure Managing ICP. Giuseppe Brain under pressure Managing ICP Giuseppe Citerio giuseppe.citerio@unimib.it @Dr_Cit Intro Thresholds Treating HICP Conclusions NO COI for this presentation Produces pressure gradients: herniation HIGH

More information

Head injury in children

Head injury in children Head injury in children Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison #1 cause of death and disability Bimodal distribution 62,000 hospitalization 564,000 ED visits

More information

Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury

Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury J Neurosurg 95:560 568, 2001 Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury CHARLES F. CONTANT, PH.D., ALEX B. VALADKA, M.D., SHANKAR P. GOPINATH,

More information

Predicting Outcome after Traumatic Brain Injury: Development and Validation of a Prognostic Score Based on Admission Characteristics

Predicting Outcome after Traumatic Brain Injury: Development and Validation of a Prognostic Score Based on Admission Characteristics JOURNAL OF NEUROTRAUMA Volume 22, Number 10, 2005 Mary Ann Liebert, Inc. Pp. 1025 1039 Predicting Outcome after Traumatic Brain Injury: Development and Validation of a Prognostic Score Based on Admission

More information

Update sulle lesioni emorragiche posttraumatiche

Update sulle lesioni emorragiche posttraumatiche Update sulle lesioni emorragiche posttraumatiche Corrado Iaccarino Neurochirurgia-Neurotraumatologia AOU Parma Neurochirurgia d'urgenza IRCCS ASMN Reggio Emilia LAW UPDATING This document provides recommendations

More information

Sequential changes in Rotterdam CT scores related to outcomes for patients with traumatic brain injury who undergo decompressive craniectomy

Sequential changes in Rotterdam CT scores related to outcomes for patients with traumatic brain injury who undergo decompressive craniectomy clinical article J Neurosurg 124:1640 1645, 2016 Sequential changes in Rotterdam CT scores related to outcomes for patients with traumatic brain injury who undergo decompressive craniectomy Kenji Fujimoto,

More information

Resource Utilization in Helicopter Transport of Head-Injured Children

Resource Utilization in Helicopter Transport of Head-Injured Children Resource Utilization in Helicopter Transport of Head-Injured Children Clay M. Elswick MD, Deidre Wyrick MD, Lori Gurien MD, Mallik Rettiganti PhD, Marie Saylors MS, Ambre Pownall APRN, Diaa Bahgat MD,

More information

Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand

Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand Evidence Pathophysiology Why? Management Non-degenerative, Non-congenital insult

More information

Cerebral autoregulation is a complex intrinsic control. Time course for autoregulation recovery following severe traumatic brain injury

Cerebral autoregulation is a complex intrinsic control. Time course for autoregulation recovery following severe traumatic brain injury J Neurosurg 111:695 700, 2009 Time course for autoregulation recovery following severe traumatic brain injury Clinical article Gi l l E. Sv i r i, M.D., M.Sc., 1 Ru n e Aa s l i d, Ph.D., 2 Co l l e e

More information

Changing Demographics in Death After Devastating Brain Injury

Changing Demographics in Death After Devastating Brain Injury Changing Demographics in Death After Devastating Brain Injury Andreas H. Kramer MD MSc FRCPC Departments of Critical Care Medicine & Clinical Neurosciences Foothills Medical Center, University of Calgary

More information

Clinical malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months

Clinical malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months Original Article Indian Journal of Neurotrauma (IJNT) 35 2007, Vol. 4, No. 1, pp. 35-39 Clinical malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months SS Dhandapani

More information

Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan

Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan DOI 10.1186/s40064-016-1781-9 RESEARCH Open Access Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan Daddy Mata Mbemba 1,2,

More information

Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases

Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases 31 Original Article Indian Journal of Neurotrauma (IJNT) 2006, Vol. 3, No. 1, pp. 31-36 Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases Deepak Kumar Gupta

More information

Neurological Prognosis after Cardiac Arrest Guideline

Neurological Prognosis after Cardiac Arrest Guideline Neurological Prognosis after Cardiac Arrest Guideline I. Associated Guidelines and Appendices 1. Therapeutic Hypothermia after Cardiac Arrest 2. Hypothermia after Cardiac Arrest Algorithm II. Rationale

More information

INCREASED INTRACRANIAL PRESSURE

INCREASED INTRACRANIAL PRESSURE INCREASED INTRACRANIAL PRESSURE Sheba Medical Center, Acute Medicine Department Irene Frantzis P-Year student SGUL 2013 Normal Values Normal intracranial volume: 1700 ml Volume of brain: 1200-1400 ml CSF:

More information

Midline Shift is Unrelated to Subjective Pupillary Reactivity Assessment on Admission in Moderate and Severe Traumatic Brain Injury

Midline Shift is Unrelated to Subjective Pupillary Reactivity Assessment on Admission in Moderate and Severe Traumatic Brain Injury Neurocrit Care (2018) 29:203 213 https://doi.org/10.1007/s12028-018-0526-8 ORIGINAL ARTICLE Midline Shift is Unrelated to Subjective Pupillary Reactivity Assessment on Admission in Moderate and Severe

More information

Correspondence should be addressed to Sorayouth Chumnanvej;

Correspondence should be addressed to Sorayouth Chumnanvej; Neurology Research International Volume 2016, Article ID 2737028, 7 pages http://dx.doi.org/10.1155/2016/2737028 Research Article Assessment and Predicting Factors of Repeated Brain Computed Tomography

More information

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank Sweeney et al. World Journal of Emergency Surgery (2015) 10:23 DOI 10.1186/s13017-015-0017-6 WORLD JOURNAL OF EMERGENCY SURGERY RESEARCH ARTICLE Prediction of neurosurgical intervention after mild traumatic

More information

Pre-hospital Response to Trauma and Brain Injury. Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center

Pre-hospital Response to Trauma and Brain Injury. Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center Pre-hospital Response to Trauma and Brain Injury Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center Traumatic Brain Injury is Common 235,000 Americans hospitalized for non-fatal TBI

More information

BACKGROUND AND SCIENTIFIC RATIONALE. Protocol Code: ISRCTN V 1.0 date 30 Jan 2012

BACKGROUND AND SCIENTIFIC RATIONALE. Protocol Code: ISRCTN V 1.0 date 30 Jan 2012 BACKGROUND AND SCIENTIFIC RATIONALE Protocol Code: ISRCTN15088122 V 1.0 date 30 Jan 2012 Traumatic Brain Injury 10 million killed or hospitalised every year 90% in low and middle income countries Mostly

More information

ORIGINAL ARTICLE. Hypotension, Hypoxia, and Head Injury

ORIGINAL ARTICLE. Hypotension, Hypoxia, and Head Injury Hypotension, Hypoxia, and Head Injury Frequency, Duration, and Consequences ORIGINAL ARTICLE Geoffrey Manley, MD, PhD; M. Margaret Knudson, MD; Diane Morabito, RN, MPH; Susan Damron, MS, RN; Vanessa Erickson,

More information

The Nottingham Head Injury Register: a survey of 1,276 adult cases of moderate and severe traumatic brain injury in a British neurosurgery centre

The Nottingham Head Injury Register: a survey of 1,276 adult cases of moderate and severe traumatic brain injury in a British neurosurgery centre The Intensive Care Society 2011 Audits and surveys The Nottingham Head Injury Register: a survey of 1,276 adult cases of moderate and severe traumatic brain injury in a British neurosurgery centre G Fuller,

More information

Stroke & Neurovascular Center of New Jersey. Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center

Stroke & Neurovascular Center of New Jersey. Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center Stroke & Neurovascular Center of New Jersey Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center Past, present and future Past, present and future Cerebral Blood Flow Past, present and future

More information

Optimum sodium levels in children with brain injury. Professor Sunit Singhi, Head, Department of Pediatrics, Head, Pediatric

Optimum sodium levels in children with brain injury. Professor Sunit Singhi, Head, Department of Pediatrics, Head, Pediatric India Optimum sodium levels in children with brain injury Professor Sunit Singhi, Head, Department of Pediatrics, Head, Pediatric Sodium and brain Sodium - the major extracellular cation and most important

More information

Management of Post Cardiac Arrest Syndrome

Management of Post Cardiac Arrest Syndrome Management of Post Cardiac Arrest Syndrome Wilhelm Behringer Associated Professor of Emergency Medicine Medical University of Vienna, Austria Patients % What happens after ROSC? 35 30 25 20 15 10 5 ROSC

More information

Multimodal monitoring to individualize care in TBI

Multimodal monitoring to individualize care in TBI Multimodal monitoring to individualize care in TBI Critical Care Canada Forum 2017 October 4 th, 2017 Donald Griesdale MD MPH Associate Professor Department of Anesthesiology, Pharmacology & Therapeutics

More information

10. Severe traumatic brain injury also see flow chart Appendix 5

10. Severe traumatic brain injury also see flow chart Appendix 5 10. Severe traumatic brain injury also see flow chart Appendix 5 Introduction Severe traumatic brain injury (TBI) is the leading cause of death in children in the UK, accounting for 15% of deaths in 1-15

More information

Determinants of Health: Effects of Funding on Quality of Care for Patients with severe TBI

Determinants of Health: Effects of Funding on Quality of Care for Patients with severe TBI Determinants of Health: Effects of Funding on Quality of Care for Patients with severe TBI Facts about traumatic brain injury Definitions & Outcomes Methods Results Conclusions Facts about TBI TBI (traumatic

More information

Correlation of Computed Tomography findings with Glassgow Coma Scale in patients with acute traumatic brain injury

Correlation of Computed Tomography findings with Glassgow Coma Scale in patients with acute traumatic brain injury Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-2 ABSTRACT OBJECTIVE To correlate Computed Tomography (CT) findings with Glasgow Coma Scale (GCS) in patients with acute traumatic brain injury

More information

Early Indicators of Prognosis in Traumatic Brain Injury and their Association with Outcome

Early Indicators of Prognosis in Traumatic Brain Injury and their Association with Outcome IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-issn: 2279-0853, p-issn: 2279-0861.Volume 16, Issue 6 Ver. IV (June. 2017), PP 44-48 www.iosrjournals.org Early Indicators of Prognosis in Traumatic

More information

Improving TBI outcome

Improving TBI outcome Improving TBI outcome Dr Peter Smielewski ps10011@cam.ac.uk 20/10/2017 Division of Neurosurgery, Department of Clinical Neurosciences Background Stein, S. C., Georgoff, P., et al. (2010). Journal of Neurotrauma

More information

Correlation of D-Dimer level with outcome in traumatic brain injury

Correlation of D-Dimer level with outcome in traumatic brain injury 2014; 17 (1) Original Article Correlation of D-Dimer level with outcome in traumatic brain injury Pradip Prasad Subedi 1, Sushil Krishna Shilpakar 2 Email: Abstract Introduction immense. The major determinant

More information

www.yassermetwally.com MANAGEMENT OF CEREBRAL HAEMORRHAGE (ICH): A QUICK GUIDE Overview 10% of strokes is caused by ICH. Main Causes: Less than 40 years old: vascular malformations and illicit drug use.

More information

Effect of post-intubation hypotension on outcomes in major trauma patients

Effect of post-intubation hypotension on outcomes in major trauma patients Effect of post-intubation hypotension on outcomes in major trauma patients Dr. Robert S. Green Professor, Emergency Medicine and Critical Care Dalhousie University Medical Director, Trauma Nova Scotia

More information

Outcome Evaluation of Chronic Subdural Hematoma Using Glasgow Outcome Score

Outcome Evaluation of Chronic Subdural Hematoma Using Glasgow Outcome Score Outcome Evaluation of Chronic Subdural Hematoma Using Glasgow Outcome Score Mehdi Abouzari, Marjan Asadollahi, Hamideh Aleali Amir-Alam Hospital, Medical Sciences/University of Tehran, Tehran, Iran Introduction

More information

Stayin Alive: Pediatric Advanced Life Support (PALS) Updated Guidelines

Stayin Alive: Pediatric Advanced Life Support (PALS) Updated Guidelines Stayin Alive: Pediatric Advanced Life Support (PALS) Updated Guidelines Margaret Oates, PharmD, BCPPS Pediatric Critical Care Specialist GSHP Summer Meeting July 16, 2016 Disclosures I have nothing to

More information

Simplifying the use of prognostic information in traumatic brain injury. Part 2: Graphical presentation of probabilities

Simplifying the use of prognostic information in traumatic brain injury. Part 2: Graphical presentation of probabilities CLINICAL ARTICLE J Neurosurg 128:1621 1634, 2018 Simplifying the use of prognostic information in traumatic brain injury. Part 2: Graphical presentation of probabilities Gordon D. Murray, MA, PhD, 1 Paul

More information

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury Eur J Trauma Emerg Surg (2013) 39:285 292 DOI 10.1007/s00068-013-0269-3 ORIGINAL ARTICLE Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic

More information

Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report

Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report 214 Balasa et al - Acute cerebral MCA ischemia Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report D. Balasa 1, A. Tunas 1, I. Rusu

More information

9/19/2011. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center. Epidural Hematoma: Lens Shaped.

9/19/2011. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center. Epidural Hematoma: Lens Shaped. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center Epidural Hematoma: Lens Shaped. 1 Epidural Hematoma Subdural Hematoma: Crescent-shaped Subdural Hematoma 2 Cerebral Contusion Cause of

More information

Post-Arrest Care: Beyond Hypothermia

Post-Arrest Care: Beyond Hypothermia Post-Arrest Care: Beyond Hypothermia Damon Scales MD PhD Department of Critical Care Medicine Sunnybrook Health Sciences Centre University of Toronto Disclosures CIHR Physicians Services Incorporated Main

More information

Blood pressure and total cholesterol level are critical risks especially for hemorrhagic stroke in Akita, Japan.

Blood pressure and total cholesterol level are critical risks especially for hemorrhagic stroke in Akita, Japan. Blood pressure and total cholesterol level are critical risks especially for hemorrhagic stroke in Akita, Japan. Manabu Izumi, Kazuo Suzuki, Tetsuya Sakamoto and Masato Hayashi Jichi Medical University

More information

Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity

Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity CLINICAL ARTICLE Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity Paul M. Brennan, MBBChir, FRCS, PhD, 1 Gordon

More information

Prognosis in moderate and severe traumatic brain injury: External validation of the IMPACT models and the role of extracranial injuries

Prognosis in moderate and severe traumatic brain injury: External validation of the IMPACT models and the role of extracranial injuries ORIGINAL ARTICLE Prognosis in moderate and severe traumatic brain injury: External validation of the IMPACT models and the role of extracranial injuries Hester Lingsma, PhD, Teuntje M.J.C. Andriessen,

More information