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Survey of Management of Severe Head Injury in Canada

Published online by Cambridge University Press:  02 December 2014

Michael J. Jacka
Affiliation:
The Department of Anesthesiology, Division of Critical Care, University of Alberta, Edmonton
David Zygun
Affiliation:
Department of Critical Care Medicine, Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Abstract

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Objective:

To determine: 1. the degrees of consensus and disagreement among Canadian critical care clinicians regarding the appropriateness (benefit exceeding risk) of common therapeutic manoeuvres in patients with severe closed head injury (CHI), and 2. the frequency with which clinicians employed these manoeuvres.

Methods:

The study design was a systematic scenario-based survey of all neurosurgeons and critical care physicians treating patients with severe CHI in Canada.

Results:

In the scenario of acute epidural hematoma with mass effect, respondents agreed very strongly that surgery was appropriate. Clinicians reported mannitol and hypertonic saline as appropriate. Beyond these two interventions, agreement was less strong, and the use of the extraventricular drain (EVD), phenytoin, cooling, hyperventilation, nimodipine, and jugular venous oximetry (JVO) were of uncertain appropriateness. Steroids were considered inappropriate. In a scenario of diffuse axonal injury (DAI), clinicians agreed strongly that fever reduction, early enteral feeding, intensive glucose control, and cerebral perfusion pressure (CPP)-directed management were appropriate. The use of mannitol, hypertonic saline, EVD, JVO, narcotics and propofol were also appropriate. Neuromuscular blockade, surgery, and hyperventilation were of uncertain appropriateness. The appropriateness ratings of the interventions considered in the scenario of an intracranial contusion mirrored the DAI scenario. In general, correlations between the reported appropriateness and frequency of use of each intervention were very high. An exception noted was the use of the JVO. The correlation between CPP-guided therapy and the use of the EVD was weak.

Conclusions:

This survey has described current practice with regard to treatment of patients with severe CHI. Areas of variation in perceived appropriateness were identified that may benefit from further evaluation. Suggested priorities for evaluation include the use of osmotic diuretics, anticonvulsants, and intracranial manometry.

Résumé:

RÉSUMÉ:

Enquête sur le traitement du traumatisme cérébral sévère au Canada.

Objectif :

Nous voulions déterminer le degré de consensus ou de désaccord entre les médecins réanimateurs concernant la pertinence (bénéfices/risques) de traitements couramment utilisés dans la prise en charge des traumatismes crâniens fermés sévères (TCF) et la fréquence d'utilisation de ces traitements.

Methods:

Méthodes : Nous avons effectué une enquête systématique basée sur des scénarios auprès de tous les neurochirurgiens et médecins réanimateurs qui traitent des patients atteints de TCF au Canada.

Résultats :

Les répondants étaient fortement d'accord que la chirurgie était indiquée chez les patients porteurs d'un hématome épidural aigu avec effet de masse. Les médecins réanimateurs considéraient que le mannitol et le salin hypertonique étaient des traitements appropriés. Au-delà de ces deux interventions, le consensus était moins marqué, particulièrement quant à l'utilisation du drain extraventriculaire (DEV), de la phénytoï, de l'hypothermie, de l'hyperventilation, de la nimodipine et de l'oxymétrie veineuse par voie jugulaire (OVJ). L'administration de stéroïs était considérée comme inappropriée. En ce qui concerne le traumatisme axonal diffus (TAD), les médecins réanimateurs considéraient comme très appropriés une diminution de la fièvre, une alimentation entérale précoce, un contrôle glycémique serré et le rétablissement ou le maintien de la pression de perfusion cérébrale. L'utilisation du mannitol, du salin hypertonique, du DEV, de l'OVJ, des narcotiques et du propofol étaient aussi considérées comme appropriées. La pertinence de l'utilisation de substances myorésolutives, de la chirurgie et de l'hyperventilation étaient considérées comme incertaines. Les taux de pertinence des interventions envisagées dans le scénario d'une contusion intracrânienne reflétaient le scénario du TAD. En général, les corrélations entre la pertinence rapportée et la fréquence d'utilisation de chaque intervention étaient très élevées, à l'exception de l'utilisation de l'OVJ. La corrélation entre le traitement guidé par la pression de perfusion cérébrale et l'utilisation du DEV était faible.

Conclusions :

Cette enquête décrit les pratiques en vigueur dans le traitement des patients présentant un TCF. Nous avons identifié des variations dans la perception de la pertinence de certains traitements qui pourraient faire l'objet d'une évaluation plus poussée. Nous suggérons les priorités d'évaluation suivantes: l'utilisation de diurétiques osmotiques, d'anticonvulsivants et de la manométrie intracrânienne.

Type
Original Articles
Copyright
Copyright © The Canadian Journal of Neurological 2007

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