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

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

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)

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

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

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)

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

Emergency department care Prehospital care Emergency department care

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

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.

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

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

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

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

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 2010-2015 1990-2000 2000-2010 2007 ＪＮＴＥＣ 2003 ＪＰＴＥＣ 2002 ＪＡＴＥＣ 2015 5th edition Standardization of initial treatment for TBI

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

Results of multiple trauma including TBI P-value Year 1998-2001 2004-2006 2009-2013 - 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

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%)

b=b0 + b1×RTS + b2×ISS + b3×Age Formula for RTS and Ps (TRISS Method) Revised Trauma Score (RTS) RTS=0.9368×（GCS）+0.7326×（SBP)+0.2908×（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 -1.2470 0.9544 -0.0768 -1.9052 Penetrating -0.6029 1.1430 -0.1516 -2.6676

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

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

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