Anthony Delaney MBBS MSc FACEM FCICM Staff Specialist Malcolm Fisher Department of Intensive Care Medicine

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

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

Pre-hospital intubation  Population:  Head trauma  Age ≥15  GCS ≤9  Intact airway reflexes  Excluded  <10 minutes from hospital  Allergy to RSI drugs  Helicopter transport

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

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

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

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

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)

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

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

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.

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

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

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   Population:  >13 years  GCS 3-8 (Motor 1-5 if intubated), within 48 hours of injury  Exclusion  Bilateral fixed dilated pupils  Unsurvivable injury

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

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  EVD for CSF drainage  Treatments for “neuroworsening”

Neuroworsening?  Dude

Neuroworsening?  Stat!

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

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

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

BEST: TRIP  Internal validity:  Follow-up

BEST: TRIP  Results

Favourable outcome in ICP group???  Favourable outcome

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

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

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

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

“Severe” Traumatic brain injury