Outcome of patients with traumatic brain injury managed on a standardised head injury protocol

Abstract

A standardised protocol in the management of severe head injury in our hospital enables pre-determined critical care-paths and consistent treatment regimes to be instituted. In Singapore there has been no previously reported data on the outcome of severely head injured patients. Over a 6-month period, 48 consecutive patients who were enrolled in our severe head injury protocol were prospectively studied. In addition to demographic and outcome data, physiologic measurements obtained from a computerised patient information system (Carevue Hewlett-Packard 9000) were analysed to determine the mean cerebral perfusion pressure (CPP) and intracranial pressure (ICP) achieved throughout the protocol period. Median Glasgow Coma Score for all patients on admission to the protocol was 6 (range 4 to 8). The mean age was 34.46 +/- 15.03 years with a male to female ratio of 43:5. The average duration of treatment on the protocol was 110.73 hours. Initial ICP measured was 25.5 +/- 19.68 mmHg. Outcome was measured at 6 months post-injury using the Glasgow Outcome Score. Favourable outcome (GOS 4-5) was seen in 29 of 48 patients (60.4%) while 12 out of 48 (25%) had an unfavourable outcome. There was a mortality of 14.6% (7 of 48 patients). Patients who survived had a higher mean CPP (P = 0.00005), a lower initial ICP and a mean ICP (P = 0.007 and 0.0009). The use of a protocol with standardised treatment goals in the management of traumatic brain injury allows for the optimal use of limited resources and provides consistency in treatment. Good outcome is related to early aggressive resuscitation to prevent hypotension and hypoxia, prompt evacuation of surgical mass lesions and the maintenance of an adequate cerebral perfusion pressure. Our results are comparable with that reported in other established neurotrauma systems.