Severe traumatic brain injury: Does compliance with the management guidelines affect outcomes?
Katie Krause, Lauren Kava, Brian Reed, Patrick Medado, Syed Ayaz, Brian O’Neil Department of Emergency Medicine, Wayne State University, and Detroit Medical Center
Background: Traumatic brain injury (TBI) is the leading cause of death between the ages of 1 and 45. Adherence to evidence-based guidelines has been limited primarily because of the scarcity of data that support improved neurologic outcomes.
Objectives: To examine whether compliance with the evidence-based neurosurgical guidelines within the first 24 hours after a severe TBI will influence patient outcomes between discharge and 1- to 6-month follow-up.
Methods: Patients aged 18-75 presenting to the emergency department of two large hospitals in Detroit, Michigan with blunt head trauma and a Glasgow Coma Score (GCS) between 4 and 8 were screened for this IRB-approved, prospective, observational study. Patients were excluded if presenting with penetrating brain injury, spinal cord injury, known prior cerebral injury, or history of chronic seizures. Data was collected in the web-based Evidence-Based Medicine (EBM) Care® tool for the first 24 hours post-TBI. Compliance with current guidelines entails MAP above 90mmHg, ICP below 20mmHg, and PaCO2 above 25mmHg. Patient outcome was measured by the Glasgow Outcome Scale (GOS), comparing initial injury to 1- to 6-month follow-up GOS. GOS status was defined as deteriorating, equivalent, and improving. A cross-tabular frequency comparison was performed to assess GOS status, relative to compliance level.
Results: 30 patients (mean age 36.4 years [SD±12.91]; 83.3% male; 60.0% black) were included; 6.6% had deteriorating GOS, 63.3% had an equivalent GOS, and 30% had an improved GOS score. Of the 9 patients with improved GOS scores at follow-up, 66% were treated according to the guidelines. Of the 2 patients with declining GOS scores, neither were compliant with guidelines. Of the 19 patients who had equivalent GOS scores, 47% met EBM Care measurements. The deteriorating group showed a mean change of -2.5, from initial the GOS of 5.0 to the final of 2.5. The improving group showed mean change of +1.8 from initial mean of 3.6 to 5.3.
Conclusion: Our data shows that two-thirds of the patients with improved outcomes were managed according to the guidelines, signifying the need for better adherence.
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