Early Indicators of Prognosis in Severe TBI
View the complete Guidelines, including methods and detailed evidence review here
The index of Guideline recommendations can be found below
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CONCLUSIONS
A. Which feature of the parameter is supported by Class I evidence and has at least a 70% positive predictive value? There is an increasing probability of poor outcome with a decreasing Glasgow Coma Scale (GCS) score in a continuous, stepwise manner.
B. Parameter measurements:
How should it be measured?
• It should be measured in a standardized way.
• It must be obtained through interaction with the patient (e.g., application of a painful stimulus for patients unable to follow commands).
When should it be measured for prognostic purposes?
• Only after pulmonary and hemodynamic resuscitation.
• After pharmacologic sedation or paralytic agents are metabolized.
Who should measure it?
• The GCS can be fairly reliably measured by trained medical personal.
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CONCLUSIONS
A. Which feature of the parameter is supported by Class I evidence and has at least a 70% positive predictive value? There is an increasing probability of poor outcome with increasing age, in a stepwise manner.
B. Parameter measurement for prognosis:
Age is not subject to observer measurement variability. Age should be obtained on admonition, preferably with documentation.
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Conclusions
A. Which feature of the parameter is supported by Class I evidence and has at least a 70% positive predictive value? Bilaterally absent pupillary light reflex.
B. Recommendations for parameter measurement for prognosis:
How should it be measured?
• A measurement difference of 1mm or more is defined as asymmetry
• A fixed pupil shows no response (< 1mm) to bright light.
• A pupillary size of > 4mm is recommended as the measure for a dilated pupil.
• The duration of pupillary dilation and fixation should be recorded.
The following pupillary exam should be noted with L (left) or R (right) distinction and duration:
• Evidence of direct orbital trauma
• Asymmetrical response to light
• Asymmetry at rest
• Fixed pupil (one or both)
• Dilated pupil (one or both)
• Fixed and dilated pupils (one or both)
When should it be measured?
After pulmonary and hemodynamic resuscitation
Who should measure it?
Trained medical personnel
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CONCLUSIONS
A. Which feature of the parameter is supported by Class I evidence and has at least a 70% positive predictive value (PPV)? A systolic blood pressure less than 90 mm Hg was found to have a 67% PPV for poor outcome and, when combined with hypoxia, a 79% PPV.
B. Parameter measurement:
How should it be measured?
Systolic and diastolic blood pressure should be measured using the most accurate system available under the circumstances. Monitoring by arterial line, when free of signal artifact, provides data that is both accurate and continuous and is the method of choice. Methods that do not determine the mean arterial pressure are less valuable.
When should it be measured?
Blood pressures should be measured as frequently as possible. The incidence and duration of hypotension (systolic blood pressure < 90 mm Hg) should be documented by direct blood pressure values.
Who should measure it?
Blood pressure should be measured by trained medical personnel.
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CONCLUSIONS
A. Which feature of the parameter is supported by Class I and strong Class II evidence and has at least 70% positive predictive value (PPV) in severe head injury?
• Presence of abnormalities on initial computed tomography (CT) examination
• CT classification
• Compressed or absent basal cisterns
• Traumatic subarachnoid hemorrhage (tSAH):
◦ Blood in the basal cisterns
◦ Extension tSAH
B. Parameter measurement:
How should it be measured?
• Compressed or absent basal cisterns measured at the midbrain level.
• tSAH should be noted in the basal cisterns or over the convexity.
• Midline shift should be measured at the level of the septum pellucidum.
When should it be measured?
• Within 12 hours of injury.
• The full extent of intracranial pathology, however, may not be disclosed on early CT scan examination.
Who should measure it?
A neuroradiologist or other qualified physician, experienced in reading CT-scans of the brain.