Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

Nathanson, Michael H.; Andrzejowski, J.; Dinsmore, J.; Eynon, C Andy; Ferguson, K.; Hooper, Tim; Kashyap, A.; Kendall, Jason; McCormack, Victoria; Shinde, Sandeep; Smith, Andrew F.; Thomas, E.

doi:10.1111/anae.14866

Cited by 37 publications

(16 citation statements)

References 21 publications

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“…In this study, the mean hospital arrival ETCO 2 was 4.1 (±0.7) kPa (30.7 mm Hg), which suggests that the prehospital providers adhered closely to the extant guidelines. Despite this, the mean PaCO 2 was 5.8 (±1.1) kPa (43.3 mm Hg)—far in excess of the target of 4.5–5.0 kPa, 24 owing to a mean ETCO 2 –PaCO 2 gradient of 1.7 (±1.0) kPa (12.8 mm Hg). The result of this is that when relying on ETCO 2 as a surrogate, providers may not achieve an optimal prehospital PaCO 2 .…”

Section: Discussionmentioning

confidence: 90%

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price¹,

Sandbach²,

Ercole

et al. 2020

Emerg Med J

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ObjectivesIn the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0–4.5 kPa (30.0–33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2–PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2–PaCO2 gradient of TBI patients at hospital arrival.MethodsA retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2–PaCO2 gradient data were compared with a two-tailed, unpaired, t-test.Results107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and −0.2 (95% CI −0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2–PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg).ConclusionThere is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.

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Section: Discussionmentioning

confidence: 90%

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price¹,

Sandbach²,

Ercole

et al. 2020

Emerg Med J

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“…Several organisations have produced guidelines for the management of TBI [7–9]. Key elements of the most commonly used are summarised in Table 1.…”

Section: Introductionmentioning

confidence: 99%

“…As a result, more patients with TBI have comorbid medical conditions which are associated with an increase in all-cause mortality rates [6]. Several organisations have produced guidelines for the management of TBI [7][8][9]. Key elements of the most commonly used are summarised in Table 1.…”

Section: Introductionmentioning

confidence: 99%

Management of traumatic brain injury: a narrative review of current evidence

Wiles

2022

Anaesthesia

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Globally, approximately 70 million people sustain traumatic brain injury each year and this can have significant physical, psychosocial and economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the management of traumatic brain injury in order to promote best clinical practice. The use of tranexamic acid in the management of traumatic brain injury has been the focus of several studies, with one large randomised controlled trial suggesting a reduction in all-cause mortality within 24 h of injury. The use of therapeutic hypothermia does not improve neurological outcomes and maintenance of normothermia remains the optimal management strategy. For seizure management, levetiracetam appears to be as effective as phenytoin, but the optimal dose remains unclear. There has been a lack of clear outcome benefit for any individual osmotherapy agent, with no difference in mortality or neurological recovery. Early tracheostomy (< 7 days from injury) for patients with traumatic brain injury is associated with a reduction in the incidence of ventilator-associated pneumonia and duration of mechanical ventilation, critical care and hospital stay. Further research is needed in order to determine the optimal package of care and interventions. There is a need for research studies to focus on patient-centred outcome measures such as long-term neurological recovery and quality of life.

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“…While some had recognised this should change [4], and national guidelines and safety reports had recommended improvements [5][6][7], funding and resources were lacking. This landscape was the situation within which Huq et al [8] found themselves at the beginning of the COVID-19 pandemic.…”

mentioning

confidence: 99%

“…Before the COVID‐19 pandemic, dedicated services were operational, or in development, in the devolved nations of Northern Ireland, Scotland and Wales, but no provision had been made in England outside extracorporeal membrane oxygenation retrieval services. While some had recognised this should change [ 4 ], and national guidelines and safety reports had recommended improvements [ 5 , 6 , 7 ], funding and resources were lacking. This landscape was the situation within which Huq et al.…”

mentioning

confidence: 99%

Developments in adult critical care transfer in England: a positive legacy of the COVID‐19 pandemic

Grier¹,

Browne²

2022

Anaesthesia

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Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

Cited by 37 publications

References 21 publications

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Management of traumatic brain injury: a narrative review of current evidence

Developments in adult critical care transfer in England: a positive legacy of the COVID‐19 pandemic

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