ORIGINAL ARTICLE
Prevalence, management and outcomes of traumatic brain injurypatients admitted to an Irish intensive care unit
S. Frohlich • P. Johnson • J. Moriarty
Received: 7 October 2010 / Accepted: 5 January 2011 / Published online: 11 February 2011
� Royal Academy of Medicine in Ireland 2011
Abstract
Background Traumatic brain injury is one of the leading
causes of death and disability among young people.
However outcomes from traumatic brain injury can be
improved by use of parameters such as intracranial pres-
sure monitoring (ICP) to guide treatment, early surgical
intervention and management of these patients in a neu-
rosurgical centre.
Aims To examine the incidence of traumatic brain injury,
compliance with best practice guidelines and outcomes in
patients admitted to an intensive care unit in a major
teaching hospital in Ireland.
Methods Retrospective chart review.
Results Forty-six patients were admitted over a 3-year
period, half of whom had GCS \8. Medical management
was appropriate but only two patients were transferred to a
neurosurgical centre and none received ICP monitoring.
Overall mortality of 37% was higher than international
norms.
Conclusions Irish patients with severe head injury do not
currently receive care in accordance with international
evidence-based guidelines.
Keywords Traumatic brain injury � Intracranial pressure
monitoring � Neurosurgery � Outcomes
Introduction
Traumatic brain injury (TBI) is a major cause of death,
disability and economic cost to Irish society. One of the
central concepts emerging from research into traumatic
brain injury is that all neurological damage from TBI does
not occur at the time of impact, but evolves over the
ensuing hours and days [1]. Improved outcomes result
when these secondary, delayed insults resulting in reduced
cerebral perfusion to the injured brain are prevented or
overcome. This is reflected in the progressive reduction in
mortality from severe TBI from 50% to under 25% over the
last 30 years, even when adjusted for injury severity, age
and other prognostic factors [2]. The trend in reduced
mortality and improved outcomes is, in part due to evi-
dence-based protocols that emphasize monitoring and
maintaining adequate cerebral perfusion [3, 4]. The most
comprehensive available guidelines produced by a collab-
oration between the Brain Trauma Foundation, American
Association of Neurological Surgeons (AANS) and Con-
gress of Neurological Surgeons (CNS) have been widely
adopted by intensive care units in Europe and the USA.
The third edition of the evidence-based guidelines for the
Management of Severe Traumatic Brain Injury were pub-
lished in 2007, following the first and second edition in
1995 and 2000 [5, 6]. The guidelines address key topics
useful for the management of severe TBI in patients with a
Glasgow Coma Score of 3–8. Studies suggest that the
consistent application of ICU-based protocols improves
outcomes and reduces mortality and length of stay [7–9].
Our retrospective clinical audit was performed in a
S. Frohlich (&)
National SpR Academic Fellowship Programme,
Mater Misercordiae Hospital, Dublin 7, Ireland
e-mail: [email protected]
P. Johnson
Anaesthesia and Intensive Care Medicine,
Our Ladies Hospital for Sick Children, Dublin 12, Ireland
J. Moriarty
Intensive Care Medicine, St James’s University Hospital,
Dublin 8, Ireland
123
Ir J Med Sci (2011) 180:423–427
DOI 10.1007/s11845-011-0674-8
University teaching hospital in Ireland. Our aims were to
determine the incidence, demographics and outcomes of
patients with severe traumatic brain injury admitted to the
intensive care unit, examine our compliance with the Brain
Trauma Foundation Guidelines and identify areas for
improvement.
Methods
A retrospective clinical audit was undertaken examining
ICU admissions over the 3-year period, 2005–2007.
Patients who were admitted to ICU due to traumatic brain
injury were identified from the Intensive Care admission
register. Though some patients had ancillary injuries, only
patients in whom TBI was the main diagnosis were
included for audit purposes. A chart review was undertaken
for each admission. Demographic data, clinical informa-
tion, radiological findings, treatments received, monitoring
received and Glasgow Outcome Score were recorded.
Treatment given was compared with best international
practice, as per the Brain Trauma Foundation guidelines,
and compliance with the guidelines recorded.
Results
A total of 46 patients were admitted to the intensive care
unit over the 3-year study period with a primary diag-
nosis of traumatic brain injury; 89% were admitted
directly from the hospital’s emergency department and
11% were transferred from other hospitals. Of the
patients, 80% were male with a mean age of 43 years
(±17). The most common aetiology was assault (37%),
with road traffic accidents (33%) and falls (24%) also
common. Positive blood alcohol levels were recorded in
26% of patients.
GCS at the time of hospital admission ranged from 3 to
14, with a mean of 7.93 (±4.46). Of the patients, 56% were
classified as having severe traumatic brain injury (admis-
sion GCS 3–8). All patients underwent CT scanning prior
to ICU admission and 98% of the patients were intubated at
the time of ICU admission.
The mean length of stay in the ICU was 5.45 days
(range 1–30 days). Survivors had a shorter length of stay
(4.15 days) than non-survivors (7.25 days). Mean hospital
length of stay was 26 days (range 2–287 days). The severe
traumatic brain injury group (GCS 3–8) had a much longer
hospital stay (mean = 44 days) than the moderate trau-
matic brain injury group (GCS 8–15), which had a mean
length of stay of 10.9 days. In 93% of cases, a neurosur-
gical opinion was sought. Two patients were transferred to
a neurosurgical centre for further treatment.
Good compliance was achieved with the guidelines for
medical management as set out by the Brain Trauma
Foundation (Table 1). All patients complied with guide-
lines for oxygenation and blood pressure control. All
patients received appropriate thromboprophylaxis and
32% of the patients who fulfilled criteria for seizure
prophylaxis received the same. Appropriate ventilation to
normocapnia occurred in 91% of the cases. Mannitol was
used in 11% of cases, though in the absence of ICP
monitoring it was difficult to assess compliance with the
guidelines. As much as 64% of the patients fulfilled
Brain Trauma Foundation guidelines for ICP monitoring,
but due to unavailability of ICP monitoring facilities no
patient received ICP monitoring. All patients received
appropriate nutritional support. Periprocedural antibio-
tics at the time of intubation are recommended, but
received in only 29% of patients. The role of prophy-
lactic hypothermia is uncertain and was not used in any
of our patients.
A total of 15 (37%) patients fulfilled the Brain Trauma
Foundation guidelines for surgical intervention. (Table 2)
Indications were due to subdural haematoma or traumatic
parenchymal lesions. There was no incidence of epidural
haematoma or posterior fossa lesions requiring surgery.
Two patients in this group were transferred to a neuro-
surgical centre for further treatment. The mortality rate in
the group who fulfilled criteria for surgical intervention
was 67%.
The overall mortality was 37%. Of those who survived,
62% made a complete recovery with the remainder suf-
fering varying degrees of neurological impairment. In the
severe TBI group, mortality was significantly higher (54%)
than in the moderate (15%) group (P \ 0.05, Fisher’s test).
Additionally complete recovery was less likely in the
severe TBI group (23%) than in the moderate TBI group
(65%). (P \ 0.05, Fisher’s test) (Tables 3, 4).
Discussion
Traumatic brain injury in Ireland remains mainly an
affliction of the young male population. Criminal assault
and alcohol are factors in a large number of injuries.
Though the majority of patients were admitted from the
hospital’s emergency department, the transfer of four
patients with a primary diagnosis of TBI from an outside
hospital to a non-neurosurgical centre is a cause for
concern.
Medical management of TBI patients in the ICU was
broadly appropriate and in compliance with international
guidelines. All patients underwent timely CT imaging
(within 1 h of request). Appropriate blood pressure and
oxygenation parameters and ventilator strategy were
424
123
employed in almost all cases. The low use of seizure
prophylaxis (32%) is at odds with best practice guidelines.
Prophylactic anticonvulsants can decrease the incidence of
early posttraumatic seizures from 14.2 to 3.6% [10]. Low
level of mannitol use was acceptable in the absence of ICP
monitoring.
Table 1 Compliance with medical guidelines
Clinical parameters Guidelines Numbers Compliance (%)
Blood pressure BP should be monitored and hypotension (systolic
BP \ 90 mmHg) avoided (Level 2)
43 93
Oxygenation Oxygenation should be monitored and hypoxia
(PaO2 \ 60 mmHg) avoided (Level 3)
46 100
DVT prophylaxis Graduated compression stockings or mechanical compression
stockings should be used until mobile (Level 3)
46 100
Seizure prophylaxis Anticonvulsants are indicated to decrease the incidence of
early posttraumatic seizures (within 7 days of injury)
8 32
Ventilation Prophylactic hyperventilation (PaCO2 \ 25 mmHg) is not
recommended (Level 2)
41 89
Mannitol use Mannitol (dose 0.25–1 g/kg) is effective for control of raised
ICP. Arterial hypotension should be avoided (Level 2)
Restrict mannitol use prior to ICP monitoring to patients with
signs of transtentorial herniation or progressive neurological
deterioration (Level 3)
5 n/a
Steroid use The use of steroids is not recommended 0 100
ICP monitoring Intracranial pressure (ICP) should be monitored in all
salvageable patients with a severe traumatic brain injury and
an abnormal CT scan. (Level 2)
ICP is indicated in patients with severe TBI with a normal CT
scan if over 40 years, unilateral/bilateral motor posturing or
SBP \ 90 mmHg (Level 2)
0 0
Nutrition Patients should be fed to gain full caloric replacement by day 7
postinjury
46 46
Infection prophylaxis Periprocedural antibiotics for intubation should be
administered to reduce the incidence of pneumonia (Level 2)
13 29
Prophylactic hypothermia Pooled data indicate that prophylactic hypothermia is not
significantly associated with decreased mortality. It is,
however, associated with higher Glasgow Outcome Scores
(Level 3)
0 n/a
Table 2 Compliance with surgical guidelines
Clinical condition Consensus guidelines Numbers Compliance (%)
Acute epidural haematoma EDH [30 cm3 should be evacuated regardless of GCS
EDH \30 cm3 with \15 mm midline thickness and \5 mm midline
shift with GCS [8 with no focal deficit can be managed
conservatively in a neurosurgical centre
0 n/a
Acute subdural haematoma Thickness [10 mm or midline shift [5 mm should be managed
surgically
All patients with acute SDH and GCS \9 should undergo ICP
monitoring
If GCS \9 and does not meet the criteria above should undergo
surgery if ICP exceeds 20 mmHg
6
2
17
0
Traumatic parenchymal lesions Neurological deterioration related to lesion, refractory ICP or mass
effect on CT
Any lesion[50cm3 in volume or[20 cm3 in frontal or temporal lobe
with [5 mm midline shift and GCS \8
5
2
20
0
Posterior fossa mass lesions Mass effect on CT or neurological compromise referable to the lesion 0 n/a
425
123
None of our patients had intracranial pressure monitor-
ing (ICP). Brain Trauma Foundation guidelines dictate that
intracranial pressure should be monitored in all salvageable
patients who present with a GCS score of 3–8 after
resuscitation, and who have an abnormal CT scan [1].
Additionally, ICP monitoring may be indicated in patients
over 40 years, with severe TBI and a normal CT scan, who
have other features of severe injury such as unilateral or
bilateral motor posturing or systolic blood pressure
\90 mmHg [1]. The main objective of intracranial pres-
sure monitoring is to maintain adequate cerebral perfusion
and oxygenation and avoid secondary injury. Cerebral
perfusion pressure (CPP), an indirect measure of cerebral
perfusion, incorporates mean arterial pressure (MAP) and
ICP parameters. CPP values below 50 are associated with
poor outcome. The only way to reliably determine CPP and
cerebral hypoperfusion is to continuously monitor ICP and
blood pressure [11–13]. Protocols that incorporate ICP
monitoring and other advanced monitoring have demon-
strated improved outcomes when compared with earlier
time periods without a protocol [14, 15]. Additionally, the
frequency of ICP monitoring in trauma centres has been
reported to be associated with improved outcomes [16].
Intracranial pressure monitoring is not available in Ireland
outside of existing neurosurgical centres, limiting the
option of ICP-guided therapy for patients with traumatic
brain injury.
Analysis of the radiological and clinical evidence and
comparison with current Brain Trauma Foundation guide-
lines suggested that 34% of our patients may have
benefitted from surgical intervention. A decision to
undertake operative intervention depends on many other
factors, which may not be borne out in a retrospective chart
review. As a result, this component of our data is inherently
inaccurate, but the figure does raise the concern that
without resource constraints more patients might receive
surgical intervention.
The finding that only two of our patients were managed
in a neurosurgical centre points to significant capacity
constraint within the neurosurgical services in Ireland. The
practice in Ireland and much of Europe is that trauma
patients are transferred to the nearest emergency depart-
ment, where they are triaged, stabilized and transferred to a
specialist hospital if their injuries require such treatment.
This contrasts sharply with the USA, where all patients
with head injuries are brought initially to a Level 1 trauma
centre, which by definition has on-site neurosurgical ser-
vices. Our practice in Ireland can delay the transport of
patients to receive neurosurgery, and transfers depend
entirely on the available capacity at our existing centres.
Odds of death for patients with severe TBI managed in a
non-neurosurgical centre are twice that of patients man-
aged in a neurosurgical centre [17]. The improved out-
comes in a neurosurgical centre relate to both surgical
intervention and institution of specialist packages of care
such as targeted control of intracranial pressures [15, 18].
Though patients with surgical lesions are typically given
preference for transfer to neurosurgical centres, patients
with non surgically treatable head injuries have a higher
mortality [19], and interventions such as decompressive
craniectomy may be beneficial [20, 21]. Additionally,
outcome after traumatic brain injury is better in high-vol-
ume centres than in those seeing fewer head-injured
patients [22]. Currently, 53% of patients with severe TBI in
the UK are transferred to receive neurosurgical care [17],
which is far greater than in our study. Both NICE (National
Institute of Clinical Excellence, UK) and the Royal College
of Surgeon guidelines advocate transfer of all patients with
serious head injuries (GCS \ 9) to neurosurgical centres,
irrespective of the need for neurosurgery [23].
The overall mortality of 37% in our study was higher
than internationally accepted norms. This figure is largely
as a result of the high mortality in the severe TBI group
(54%) and compares unfavourably with UK statistics,
where the mortality in a group of severely brain injured
patients (GCS \ 8) with similar demographics was 35%
[17]. As with other international studies, admission GCS in
our group accurately predicted outcome [24]. Though there
is no single identifiable factor that explains the higher than
predicted mortality in our group, the lack of ICP moni-
toring and lack of surgical intervention and management in
a non-specialist centre may all help account for the
observed differences.
Table 3 Outcomes as measured by the Glasgow Outcome Score
Outcomes GCS 3–8 GCS 9–14
Numbers 26 20
GOS = 1 6 13
GOS = 2 2 2
GOS = 3 1 1
GOS = 4 3 1
GOS = 5 14 3
Table 4 The Glasgow Outcome Score
Score Rating Definition
1 Good recovery Resumption of normal life
despite minor deficits
2 Moderate disability Disabled, but independent
3 Severe disability Conscious, but disabled.
Requires daily support
4 Persistent vegetative state Minimal responsiveness
5 Death Non-survival
426
123
Despite 250 randomised controlled trials, no single
therapy has been identified that would improve the out-
come in head injury [21]. Despite this lack of a ‘‘magic
bullet’’ though, the institution of packages of specialist
neurocritical care would significantly improve outcomes
[17, 18]. Our study demonstrates that specialist neurocrit-
ical care is unavailable to many severely brain injured
patients in Ireland. Despite our institution of best medical
care in a non-neurosurgical centre, the mortality rate in our
study is significantly higher than for similarly injured
patients in the UK. To improve our outcomes in this young
group of patients and comply with international best
practice, major investment will be required in both the
infrastructure and personnel in our neurosurgical services.
Perhaps the time has come for the implementation of a
national brain injury strategy.
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