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Gil-Jardiné C, Payen JF, Bernard R, Bobbia X, Bouzat P, Catoire P, Chauvin A, Claessens YE, Douay B, Dubucs X, Galanaud D, Gauss T, Gauvrit JY, Geeraerts T, Glize B, Goddet S, Godier A, Le Borgne P, Rousseau G, Sapin V, Velly L, Viglino D, Vigue B, Cuvillon P, Frasca D, Claret PG. Management of patients suffering from mild traumatic brain injury 2023. Anaesth Crit Care Pain Med 2023; 42:101260. [PMID: 37285919 DOI: 10.1016/j.accpm.2023.101260] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop a multidisciplinary French reference that addresses initial pre- and in-hospital management of a mild traumatic brain injury patient. DESIGN A panel of 22 experts was formed on request from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesiology and Critical Care Medicine (SFAR). A policy of declaration and monitoring of links of interest was applied and respected throughout the process of producing the guidelines. Similarly, no funding was received from any company marketing a health product (drug or medical device). The expert panel had to respect and follow the Grade® (Grading of Recommendations Assessment, Development and Evaluation) methodology to evaluate the quality of the evidence on which the recommendations were based. Given the impossibility of obtaining a high level of evidence for most of the recommendations, it was decided to adopt a "Recommendations for Professional Practice" (RPP) format, rather than a Formalized Expert Recommendation (FER) format, and to formulate the recommendations using the terminology of the SFMU and SFAR Guidelines. METHODS Three fields were defined: 1) pre-hospital assessment, 2) emergency room management, and 3) emergency room discharge modalities. The group assessed 11 questions related to mild traumatic brain injury. Each question was formulated using a PICO (Patients Intervention Comparison Outcome) format. RESULTS The experts' synthesis work and the application of the GRADE® method resulted in the formulation of 14 recommendations. After two rounds of rating, strong agreement was obtained for all recommendations. For one question, no recommendation could be made. CONCLUSION There was strong agreement among the experts on important, transdisciplinary recommendations, the purpose of which is to improve management practices for patients with mild head injury.
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Affiliation(s)
- Cédric Gil-Jardiné
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Service des Urgences-Adultes, Population Health, INSERM U1219, équipe aHeAD, Université de Bordeaux, Bordeaux, France.
| | - Jean-François Payen
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Rémy Bernard
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Xavier Bobbia
- Montpellier University, UR UM 103 (IMAGINE), Department of Emergency Medicine, CHU Montpellier, Montpellier, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Pierre Catoire
- Emergency Consultant, Academic Clinical Fellow (Pitié-Salpétrière University, General Emergency Department, Paris) - Tactical Ultrasound Course for Ukraine (TUSC-UA) Course Director - Mehad, France
| | - Anthony Chauvin
- Service d'Accueil des Urgences/SMUR, CHU Lariboisière, Université de Paris - Inserm U942 MASCOT, Université de Paris, Paris, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse Grace, Avenue Pasteur, MC-98002, Monaco
| | - Bénédicte Douay
- SMUR/Service des Urgences, Hôpital Beaujon, AP-HP Nord, Clichy, France
| | - Xavier Dubucs
- Emergency Departement, Centre Hospitalo-Universitaire de Toulouse, Place du Docteur Baylac, 31300 Toulouse, France
| | - Damien Galanaud
- Service de Neuroradiologie, GH Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Jean-Yves Gauvrit
- Service de Neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Thomas Geeraerts
- Pole Anesthesie Réanimation et INSERM Tonic, CHU de Toulouse et Universite Toulouse 3, Toulouse, France
| | - Bertrand Glize
- PMR Department, CHU de Bordeaux, ACTIVE Team, BPH INSERM U1219, University of Bordeaux, France
| | - Sybille Goddet
- Samu-21, CHU de Dijon, SAU-Smur, CH du Creusot, Dijon, France
| | - Anne Godier
- Université Paris Cité, APHP, Hôpital Européen Georges Pompidou, Service d'anesthésie Réanimation and Inserm UMRS_1140, Paris, France
| | - Pierrick Le Borgne
- Emergency Department, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France - INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médecine, Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg Cedex, France
| | | | - Vincent Sapin
- Service de Biochimie et de Génétique Moléculaire, Centre de Biologie, CHU de Clermont-Ferrand, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Damien Viglino
- University Grenoble-Alpes, Emergency Department, CHU Grenoble-Alpes, Grenoble, France - HP2 Laboratory INSERM U1300, Grenoble, France
| | - Bernard Vigue
- Département d'Anesthésie Réanimation, Hôpital Universitaire de Bicêtre, Le Kremlin Bicêtre, France
| | - Philippe Cuvillon
- EA 2992 IMAGINE, Prévention et Prise en Charge de la Défaillance Circulatoire des Patients en état de Choc, Anaesthesiology Department, CHU Nîmes, University Montpellier, 30000 Nîmes, France
| | - Denis Frasca
- Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France, Service d'Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France, INSERM U1246, Methods in Patients-Centered Outcomes and Health Research - SPHERE, Nantes, France
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Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J Neurotrauma 2018; 35:703-718. [PMID: 29324173 PMCID: PMC5831640 DOI: 10.1089/neu.2017.5259] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - William Townend
- Emergency Department, Hull and East Yorkshire NHS Trust, Hull, United Kingdom
| | - Aditya Borakati
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Forlì, Italy
| | - Trevor A. Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Center, Heslington, York, United Kingdom
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Hill JH, Bonner P, O’Mara MS, Wood T, Lieber M. Delayed intracranial hemorrhage in the patient with blunt trauma on anticoagulant or antiplatelet agents: routine repeat head computed tomography is unnecessary. Brain Inj 2018; 32:735-738. [DOI: 10.1080/02699052.2018.1441442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Joshua H. Hill
- Grant Medical Center, Trauma, an OhioHealth Hospital, Columbus, OH, USA
| | - Paul Bonner
- Doctor’s Hospital, PGY-2 General Surgery, an OhioHealth Hospital, Columbus, OH, USA
| | - M Shay O’Mara
- Grant Medical Center, Trauma, an OhioHealth Hospital, Columbus, OH, USA
| | - Teresa Wood
- Grant Medical Center, Trauma, an OhioHealth Hospital, Columbus, OH, USA
| | - Michael Lieber
- Grant Medical Center, Trauma, an OhioHealth Hospital, Columbus, OH, USA
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Factors associated with adverse outcomes in patients with traumatic intracranial hemorrhage and Glasgow Coma Scale of 15. Am J Emerg Med 2017; 35:875-880. [PMID: 28143693 DOI: 10.1016/j.ajem.2017.01.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 02/04/2023] Open
Abstract
Patients with mild traumatic brain injury (mTBI) with associated intracranial injury, or complicated mTBI, are at risk of deterioration. Clinical management differs within and between institutions. We conducted an exploratory analysis to determine which of these patients are unlikely to have an adverse outcome and may be future targets for less resource intensive care. This single center retrospective cohort study included patients presenting to the ED with blunt complicated mTBI between January 2001 and December 2010. Patients with a Glasgow coma score (GCS) of 15, an initial head CT with a traumatic abnormality, and a repeat head CT within 24h were eligible. We defined the composite adverse outcome as death within two weeks, neurosurgical procedure within two weeks, hospitalization >48h, and worsened second head CT. Classification and Regression Tree methodology was used to identify factors associated with adverse outcomes. Of 1011 patients with two head CTs performed in a 24-h period, 240 (24%) had complicated mTBI and GCS 15. Of these, 56 (23%) experienced the composite adverse outcome defined above. Age, headache, and subarachnoid hemorrhage, correctly classified 93% of patients with an adverse outcome. No instance of death or neurosurgical procedure was missed. Our analysis highlighted three factors associated with adverse outcomes in persons who have complicated mTBI but a GCS of 15. Absence of these risk factors suggests low risk of adverse outcomes, and may suggest that a patient is safe for discharge home. Additional research is required before utilizing these findings in clinical practice.
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Bardes JM, Turner J, Bonasso P, Hobbs G, Wilson A. Delineation of Criteria for Admission to Step down in the Mild Traumatic Brain Injury Patient. Am Surg 2016. [DOI: 10.1177/000313481608200121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients that suffer a mild traumatic brain injury (TBI) with intracranial hemorrhage are commonly admitted to an intensive care unit with repeat imaging in 12 to 24 hours. This is costly to the health-care system. This study aimed to evaluate this practice and to identify criteria to triage patients to lower levels of monitored care. A retrospective review was performed at a university-based Level I trauma center. Patients with mild TBI were included. Data were collected on demographics, neurological status at 6, 12, and 24 hours, CT scan results, and medical or surgical interventions were required. A total of 389 patients were evaluated, 53 had a documented neurological decline while being admitted. Factors found to be associated with a neurological decline included Glasgow Coma Scale (GCS) < 15 ( P = 0.002), age greater than 55 ( P < 0.001), and warfarin use ( P = 0.039). Aspirin and Plavix were not associated with neurological decline. No patient age <55 with a GCS of 15 had a documented decline. Several risk factors were found to be associated with neurological decline after mild TBI. These include age, GCS < 15, and warfarin use. Patients aged <55 with GCS 15, posed minimal risk for deterioration. Patients aged <55 and with a GCS of 15 can be admitted to a monitored step-down bed with less frequent neurological checks.
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Affiliation(s)
- James M. Bardes
- From the Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jason Turner
- From the Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Patrick Bonasso
- From the Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Gerald Hobbs
- From the Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- From the Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia
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Early magnetic resonance imaging is unnecessary in patients with traumatic brain injury. ACTA ACUST UNITED AC 2009; 66:1008-12; discussion 1012-4. [PMID: 19359907 DOI: 10.1097/ta.0b013e31819adba2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Computed tomography (CT) is routinely performed in traumatic brain injury (TBI). Magnetic resonance imaging (MRI) is considered more sensitive than CT for subtle abnormalities. Because CT does not always explain the posttraumatic neurologic examination, MRI is being performed with increasing frequency. Although MRI at a later stage may be of significant prognostic value, the role of early MRI is questionable. Our objective was to evaluate the role of early MRI in the initial management of patients with TBI. METHODS This is a 3-year prospective study (January 2005-December 2007) of adult patients with TBI who, in addition to CT, had MRI of the head within 48 hours of admission to the hospital. The findings from the two imaging studies were compared. The outcome was any change in management based on MRI findings. RESULTS We identified 123 trauma patients who had MRI within 18 hours +/- 14.5 hours of CT (median: 12 hours). In 82 (67%) patients, the findings of CT and MRI were identical. In the remaining 41 patients there were discrepancies between CT and MRI: 35 patients had slight differences in the location or size of the lesions found and six had minor brain lesion detected by MRI and not CT. Compared with patients who had identical CT and MRI, those who showed differences in the two tests had higher severity of head injury, lower initial blood pressure, and a higher rate of intubation. Based on CT findings, 78 (63%) patients received TBI-related interventions: 8 craniotomies, 12 intracranial pressure monitoring catheters, 14 mannitol infusions, and 72 antiepileptic medications. There was no change in treatment because of MRI. CONCLUSION Early MRI may be superior to CT in describing subtle TBI findings, but this information does not affect management. Head CT is the only imaging test necessary in the first 48 hours after TBI.
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Durham SR, Liu KC, Selden NR. Utility of serial computed tomography imaging in pediatric patients with head trauma. J Neurosurg Pediatr 2006; 105:365-9. [PMID: 17328259 DOI: 10.3171/ped.2006.105.5.365] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to evaluate the risk of progression of traumatic intracranial lesions in children by comparing initial and subsequent computed tomography (CT) scans. Reserving repeated CT imaging for patients who harbor higher-risk lesions may reduce overall radiation exposure, the need for sedative agents, and cost. METHODS The authors performed a retrospective cohort study in 268 patients younger than 18 years of age who underwent repeated CT scanning within 24 hours of their initial CT scanning procedure. The risk of progression between the initial and repeated CT scanning sessions and the need for delayed neurosurgical intervention were determined for each lesion type. In 54 patients (20.1%) the normal findings on the initial CT study did not change on subsequent imaging. In 61 (28.5%) of the 214 patients in whom abnormal findings were present on the initial scan, progression was demonstrated. Patients with epidural hematoma (EDH; odds ratio [OR] 12.29), subdural hematoma (SDH; OR 3.18), cerebral edema (OR 9.34), and intraparenchymal hemorrhage (IPH; OR 18.3) were found to be at a significantly increased risk for progression and to require delayed neurosurgical intervention (OR 11.91). No significantly increased risk was found for patients with subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), diffuse axonal injury (DAI), or skull fracture. CONCLUSIONS Repeated CT imaging in children with high-risk lesions such as EDH, SDH, cerebral edema, and IPH is recommended. However, in children with low-risk lesions, such as SAH, IVH, DAI, and isolated skull fractures but no sign of clinical deterioration, repeated imaging may be less likely to alter the clinical management scheme. The limited benefits of undertaking repeated imaging in these patients should be weighed against the risks of radiation exposure, sedation, intrahospital transportation, and patient monitoring.
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MESH Headings
- Adolescent
- Brain Edema/diagnostic imaging
- Brain Edema/etiology
- Brain Edema/surgery
- Cerebral Hemorrhage/diagnostic imaging
- Cerebral Hemorrhage/etiology
- Cerebral Hemorrhage/surgery
- Child
- Child, Preschool
- Cohort Studies
- Craniocerebral Trauma/complications
- Craniocerebral Trauma/diagnostic imaging
- Craniocerebral Trauma/surgery
- Disease Progression
- Female
- Hematoma, Epidural, Cranial/diagnostic imaging
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Epidural, Cranial/surgery
- Hematoma, Subdural, Intracranial/diagnostic imaging
- Hematoma, Subdural, Intracranial/etiology
- Hematoma, Subdural, Intracranial/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Neurosurgical Procedures
- Retrospective Studies
- Risk Assessment
- Time Factors
- Tomography, X-Ray Computed
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Affiliation(s)
- Susan R Durham
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA.
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