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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Open Access 01-12-2015 | Original research

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

Authors: Alexandra Brazinova, Marek Majdan, Johannes Leitgeb, Helmut Trimmel, Walter Mauritz, Austrian Working Group on Improvement of Early TBI Care

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2015

Abstract

Background

Existing evidence concerning the management of traumatic brain injury (TBI) patients underlines the importance of appropriate treatment strategies in both prehospital and early in-hospital care. The objectives of this study were to analyze the current state of early TBI care in Austria with its physician-based emergency medical service. Subsequently, identified areas for improvement were transformed into treatment recommendations. The proposed changes were implemented in participating emergency medical services and hospitals and evaluated for their effect.

Methods

14 Austrian centers treating TBI patients participated in the study. Between 2009 and 2012 all patients with Glasgow Coma Scale score < 13 and/or AIS head > 2 within 48 h after the accident, were enrolled. Data were collected in 2 phases: in the first phase data of 408 patients were analyzed. Based on this, a set of recommendations expected to improve outcomes was developed by the study group and implemented in participating centers. Recommendations included time factors (transport to appropriate trauma center, avoiding secondary transfer), adequate treatment strategies (prehospital fluid and airway management, anesthesia, ventilation), monitoring (pulse oximetry and blood pressure monitoring in all patients, capnography in ventilated patients) for prehospital treatment. In the emergency department focus was on first CT scan as soon as possible, short interval between CT scan and surgery and early use of thrombelastometry to optimize coagulation. Following implementation of these recommendations, data on 325 patients were collected and analyzed in phase 2. Final analysis investigated the impact of the recommendations on patient outcomes.

Results

Patients in both data collection phases showed comparable demographic and injury severity characteristics. Treatment changes, especially in terms of fluid management, monitoring and normoventilation as well as thrombelastometry measurements were implemented successfully in phase 2, and led to significant improvement of patient outcomes. Hospital mortality was reduced from 31 % to 23 %. We found a lower rate of unfavorable outcomes, a significant increase in unexpected survivors and more patients with unexpected favorable outcomes as well.

Conclusions

The results of this study clearly demonstrate that the outcomes of TBI patients can be improved with appropriate early care.

Ghajar J. Traumatic brain injury. Lancet. 2000;356(9233):923–9. doi:10.1016/s0140-6736(00)02689-1.PubMedCrossRef

Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochir (Wien). 2006;148(3):255–68. doi:10.1007/s00701-005-0651-y. discussion 68.CrossRef

Ackery A, Hagel BE, Provvidenza C, Tator CH. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Inj Prev. 2007;13(6):368–75. doi:10.1136/ip.2007.017285.PubMedCentralPubMedCrossRef

Auman KM, Kufera JA, Ballesteros MF, Smialek JE, Dischinger PC. Autopsy study of motorcyclist fatalities: the effect of the 1992 Maryland motorcycle helmet use law. Am J Public Health. 2002;92(8):1352–5.PubMedCentralPubMedCrossRef

Bowman SM, Aitken ME, Helmkamp JC, Maham SA, Graham CJ. Impact of helmets on injuries to riders of all-terrain vehicles. Inj Prev. 2009;15(1):3–7. doi:10.1136/ip.2008.019372.PubMedCrossRef

Steudel WI, Cortbus F, Schwerdtfeger K. Epidemiology and prevention of fatal head injuries in Germany--trends and the impact of the reunification. Acta Neurochir. 2005;147(3):231–42. doi:10.1007/s00701-004-0441-y. discussion 42.PubMedCrossRef

WHO. World Report on Road Traffic Injury Prevention. Geneva: World Health Organization; 2004.

Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7(8):728–41. doi:10.1016/s1474-4422(08)70164-9.PubMedCrossRef

Stocchetti N, Paterno R, Citerio G, Beretta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma. 2012;29(6):1119–25. doi:10.1089/neu.2011.1995.PubMedCrossRef

10.

Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ. Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med. 2002;30(8):1870–6.PubMedCrossRef

11.

Fakhry SM, Trask AL, Waller MA, Watts DD. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004;56(3):492–9. discussion 9-500.PubMedCrossRef

12.

Bullock R, Chesnut RM, Clifton G, Ghajar J, Marion DW, Narayan RK, et al. Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med. 1996;3(2):109–27.PubMedCrossRef

13.

Rusnak M, Janciak I, Majdan M, Wilbacher I, Mauritz W. Severe traumatic brain injury in Austria VI: effects of guideline-based management. Wien Klin Wochenschr. 2007;119(1-2):64–71. doi:10.1007/s00508-006-0765-0.PubMedCrossRef

14.

Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma. 2002;19(1):111–74.PubMedCrossRef

15.

Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir. 1976;34(1-4):45–55.PubMedCrossRef

16.

Bull JP. Measures of severity of injury. Injury. 1978;9(3):184–7.PubMedCrossRef

17.

Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma. 1998;15(8):573–85.PubMedCrossRef

18.

Perel P, Arango M, Clayton T, Edwards P, Komolafe E, Poccock S, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. Br Med J. 2008;336(7641):425–9. doi:10.1136/bmj.39461.643438.25.CrossRef

19.

Majdan M, Lingsma HF, Nieboer D, Mauritz W, Rusnak M, Steyerberg EW. Performance of IMPACT, CRASH and Nijmegen models in predicting six months outcome of patients with severe or moderate TBI: an external validation study. Scand J Trauma Resusc Emerg Med. 2014;22(1):68. doi:10.1186/s13049-014-0068-9.PubMedCentralPubMedCrossRef

20.

Tohme S, Delhumeau C, Zuercher M, Haller G, Walder B. Prehospital risk factors of mortality and impaired consciousness after severe traumatic brain injury: an epidemiological study. Scand J Trauma Resusc Emerg Med. 2014;22:1. doi:10.1186/1757-7241-22-1.PubMedCentralPubMedCrossRef

21.

Hartl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma. 2006;60(6):1250–6. doi:10.1097/01.ta.0000203717.57821.8d. discussion 6.PubMedCrossRef

22.

Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern B, et al. Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center. J Trauma. 2007;62(3):584–91. doi:10.1097/01.ta.0000221797.46249.ee.PubMedCrossRef

23.

Fung Kon Jin PH, Penning N, Joosse P, Hijdra AH, Bouma GJ, Ponsen KJ, et al. The effect of the introduction of the Amsterdam Trauma Workflow Concept on mortality and functional outcome of patients with severe traumatic brain injury. J Neurotrauma. 2008;25(8):1003–9. doi:10.1089/neu.2007.0463.PubMedCrossRef

24.

Helm M, Schuster R, Hauke J, Lampl L. Tight control of prehospital ventilation by capnography in major trauma victims. Br J Anaesth. 2003;90(3):327–32.PubMedCrossRef

25.

Warner KJ, Cuschieri J, Garland B, Carlbom D, Baker D, Copass MK, et al. The utility of early end-tidal capnography in monitoring ventilation status after severe injury. J Trauma. 2009;66(1):26–31. doi:10.1097/TA.0b013e3181957a25.PubMedCrossRef

26.

Myburgh J, Cooper DJ, Finfer S, Bellomo R, Norton R, Bishop N, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–84. 357/9/874.PubMedCrossRef

27.

Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004;291(11):1350–7. doi:10.1001/jama.291.11.1350.PubMedCrossRef

28.

Lier H, Krep H, Schochl H. Coagulation management in the treatment of multiple trauma. Anaesthesist. 2009;58(10):1010–26. doi:10.1007/s00101-009-1595-z.PubMedCrossRef

29.

Schochl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care. 2010;14(2):R55. doi:10.1186/cc8948.PubMedCentralPubMedCrossRef

30.

Schochl H, Solomon C, Traintinger S, Nienaber U, Tacacs-Tolnai A, Windhofer C, et al. Thromboelastometric (ROTEM) findings in patients suffering from isolated severe traumatic brain injury. J Neurotrauma. 2011;28(10):2033–41. doi:10.1089/neu.2010.1744.PubMedCrossRef

31.

Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H, Farrell B, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365(9475):1957–9. doi:10.1016/S0140-6736(05)66552-X.PubMedCrossRef

32.

Masson F, Thicoipe M, Aye P, Mokni T, Senjean P, Schmitt V, et al. Epidemiology of severe brain injuries: a prospective population-based study. J Trauma. 2001;51(3):481–9.PubMedCrossRef

33.

Baker SP, O'Neill B, Haddon Jr W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96.PubMedCrossRef

Title: Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria
Authors: Alexandra Brazinova
Marek Majdan
Johannes Leitgeb
Helmut Trimmel
Walter Mauritz
Austrian Working Group on Improvement of Early TBI Care
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine / Issue 1/2015
Electronic ISSN: 1757-7241
DOI: https://doi.org/10.1186/s13049-015-0133-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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