Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39461.643438.25 (Published 21 February 2008) Cite this as: BMJ 2008;336:425
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The CRASH trialists and the editorial by Godlee draw attention to the very important public health issue of traumatic brain injury 1. A recent review of 749 patients by Schneider et al reported that of 35% had a degree of post-traumatic hypopituitarism 2. Hypopituitarism can be subclinical or overt and severe in its onset. Deficiency of adrenocorticotroph hormone and antidiuretic hormone may potentially be life threatening and requires prompt management. Symptoms can be mask by other effects of the traumatic brain injury. Chronic pituitary deficiencies may complicate rehabilitation.
Bondanelli et al in a small series of 72 patients following moderate to severe traumatic brain injury suggest that pituitary function (assessed by growth hormone response to dynamic stimuli) predicts functional and cognitive outcome 3.
Doctors treating patients with traumatic brain injury should remember the possibility of deficiency of pituitary hormones in both the acute and late phase including rehabilitation. Testing of pituitary function using simple screening algorithms is advised in selected patients4.
References:
1. MRC CRASH Trial Collaborators. Predicting oucome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ, doi:10.1136/bmj.39461.643438.25 (12 February 2008).
2. Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E. Hypopituitarism. Lancet. 2007 Apr 28;369(9571):1461-70
3. Bondanelli M, Ambrosio MR, Cavazzini L, Bertocchi A, Zatelli MC, Carli A, Valle D, Basaglia N, Uberti EC. Anterior pituitary function may predict functional and cognitive outcome in patients with traumatic brain injury undergoing rehabilitation. J Neurotrauma. 2007 Nov;24(11):1687-97
4. Agha A, Thompson CJ. Anterior pituitary dysfunction following traumatic brain injury (TBI). Clin Endocrinol (Oxf). 2006 May;64(5):481-8.
Competing interests: None declared
Competing interests: No competing interests
The MRC CRASH trial collaborators have produced a simple prognostic model, which can be used to predict outcomes in patients with traumatic brain injury [1]. Although their prognostic model considered time from injury to randomisation, the time at which the patient presented to the hospital was not considered as a potential independent prognostic variable. This is important because provision of key aspects of hospital trauma services such as staffing, access to operating theatres and interventional radiology is reduced after normal working hours.
In the United Kingdom (UK) a recent study examined the process of care for 795 severely injured patients of whom 493 sustained a head injury [2]. The majority of these patients presented to the accident and emergency department out of hours (18.00-07.59 hours or weekends). Initial management of the patient was inappropriate in 23.5% of cases where a senior house officer was the team leader/first reviewer compared to 3.1% where a consultant performed this role. Consultant involvement was highest during the day (39.6%) of cases and fell over the evening and into the night (11.5% of cases presenting at night). The trend for involvement of junior doctors was in the opposite direction, being highest during the night. In addition to a lack of senior medical staff to coordinate management out of hours, immediate intervention for more specialised injuries was often unavailable.
Organisational deficiencies in out of hours care is not unique to the UK and similar problems are likely to exist in low, middle and high-income countries. Moreover this problem is not restricted to the provision of trauma care; increased mortality out of hours has also been identified in patients with myocardial infarcts undergoing primary coronary intervention [3], cardiac arrest [4] and discharge from intensive care [5].
Out of hours presentation to hospital may be associated with treatment delays and adverse outcomes. We suggest that the time of hospital presentation should have been considered in the MRC CRASH collaborators prognostic model for predicting outcome after traumatic brain injury.
Paul Frost, Consultant in Intensive Care Medicine, Critical Care Directorate, University Hospital of Wales, Cardiff CF14 4XW
Paul.Frost@CardiffandVale.wales.nhs.uk
Matt P Wise. Consultant in Intensive Care Medicine
Competing interests: None Declared
References
1. MRC CRASH Trial Collaborators Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008;336:425-9
2. Findlay G, Martin IC, Carter S, Smith N, Weyman D, Mason M. Trauma who cares? A report of the National Confidential Enquiry into Patient Outcome and Death. 2007. www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf
3. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE, for the Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group. Weekend versus Weekday Admission and Mortality from Myocardial Infarction. N Engl J Med 2007; 356:1099-1109
4. Peberdy MA, Ornato JP, Larkin GL, Braithwaite RS, Kashner MT, Carey SM; et al, for the National Registry of Cardiopulmonary Resuscitation Investigators. Survival From In-Hospital Cardiac Arrest During Nights and Weekends. JAMA 2008;299(7):785-792.
5. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet 2000; 355: 1138-1142.
Competing interests: None declared
Competing interests: No competing interests
The recent study published by MRC CRASH Trial Collaborators in BMJ,1 in which our group participated, developed an interesting prognosis model for patients with traumatic brain injury (TBI). The most important thing we consider that it has is pragmatism, so necessary for doctors directly related to daily medical practice. Our comment will be focused on the dichotomy between high or low-middle income countries and their relation to the management of TBI in Cuba. We have commented previously on two diseases that have an important burden in mortality: acute myocardial infarction2 and stroke3 (1st and 3rd cause of death).
Trauma takes the fourth place in the death causes and the main burden is due to TBI. Ten years ago in our intensive care unit 47% of trauma admissions were TBI and the mortality rate was 88%.4 In the last years, 25% of all the patients admited with trauma have a head injury and 10% of them have severe TBI (8 points or less on the Glasgow Come Scale [GCS]). The risk of death is double in patients with GCS between 3-5 points compared with those that have 6-8 points, taking GCS at the admission and after non quirurgic reanimation. On the other hand, we can relate the decrease of points in GCS in the time have a worse prognosis.
Through the years, we have been working to reduce our mortality rate and we have ben able to lower it to 40-45%.5 In this reduction take place many factors, one of the most important is the application of neuromonitoring because it can show us the intracranial pressure (ICP) and brain metabolic variables like venous jugular oxygen saturation (SvjO2). Other factors that helped us are the possibility of imaging 24 hours a day: computer tomography (CT scan) and resonance imaging (MRI). We have too, the possibility to modify medical or surgery treatment because we have clinical practice guidelines that help us to avoid secondary lessions and to mantain the best conditions to recover the brain from the primary lession. Is very important to evacuate the lesions that take space like haematomas higher than 20 ml and the practice of decompressive craniectomy with wide duramadre flap. This procedure can improve brain compliance in severe brain injury. In our experience, extracranial injury is related to mortality when low blood pressure (systolic pressure below 90 mm Hg) and hypoxemic events (oxygen arterial pressure below 60 mmHg) are present.
The management of patients with TBI is complicated because it needs a qualified team and enough conditions to offer patients quality care, but our results show that it is possible to do this in low or middle income countries.
References
1. MRC CRASH Trial Collaborators. Predicting oucome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ, doi:10.1136/bmj.39461.643438.25 (published 12 February 2008).
2. Orduñez PO, Iraola MD, La Rosa Y. Experience in Cuba shows optimising thrombolysis may reduce death rates in poor countries. BMJ 2005; 330: 1271-1272.
3. Orduñez PO, Iraola MD, Bembibre R. Cuba better care for stroke. BMJ 2006; 332: 551.
4. Iraola MD, Rodríguez R, Santana A, Pons F. Valor del indice de trauma en la unidad de cuidados intensivos. Rev Cubana Med Int Emerg 2003; 2: 15-20.
5. Pons F. Mortalidad por trauma craneoencefalico en la provincia de Cienfuegos. Conferencia presentada en la Primera Jornada Territorial de Medicina Intensiva. Matanzas, 23 de octubre 2007.
Competing interests: None declared
Competing interests: No competing interests
Niels Bohr wasn't the first
In the commentary following this remarkable piece of prognostic research a famous Danish joke is quoted: "It is difficult to prophesy -- especially when the future is involved." The saying, which has been popular in Denmark since the 1950s, was attributed to Niels Bohr (1885- 1962). He may well have used it. Most Danes, however, ascribe it to his contemporary Robert Storm-Petersen, known as 'Storm P.' (comedian, cartoonist, painter, writer, 1882-1949).
In actual fact it is not a joke at tall but a slip of the tongue, committed by an anonymous member of the Danish parliament in the late 1930s and recollected by a fellow politician (K. K. Steincke, 1880-1963, known as the father of modern welfare legislation)in his 1948 memoirs.
At least this is what I have been able dig up by consulting various domestic sources of information.
Competing interests: None declared
Competing interests: No competing interests