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.