A
new study involving more than 21,000 patients who were transported to
the hospital by ambulance after sustaining a severe head injury found
that adherence to 3 simple interventions helped to increase chances of
survival.
CT scan of a brain of a patient with interhemispheric hemorrhage from trauamatic brain injury (TBI).
Getty
Focusing on adherence to these 3 simple interventions (by paramedics)
demonstrated clear efficacy by doubling the survival rate of severe
victims of traumatic brain injury (TBI) and tripling the survival rate
in those who required a breathing tube to secure their airway
(intubation).
The results of the
Excellence in Prehospital Injury Care (EPIC) study were published last week in
JAMA Surgery.
“The beauty of EPIC was that the "Three H-Bombs" (hypoxia, hypotension and hyperventilation) were managed by
simple interventions--this wasn’t a million-dollar ‘un-obtainium’ drug being tested, explained
Daniel Spaite, M.D., FACEP,
Professor and Virginia Piper Distinguished Chair of Emergency
Medicine, Co-Director of EMS Research, Associate Director-Arizona
Emergency Medicine Research Center, University of Arizona.
For the study, over 11,000 paramedics from 130 locations in Arizona
took a 2-hour training session on prehospital TBI treatment guidelines,
which focus on adherence to the 3 interventions: prevention and
treatment of hypoxia, prevention and avoidance of hyperventilation, and
addressing and treatment of hypotension.
The study, evaluating over 21,000 patients with moderate, severe, or
critical TBI, found that adherence to the prehospital TBI guidelines did
not affect overall survival, but did significantly improve survival in
patients with a severe TBI.
This is also the first major prehospital study to evaluate the impact
of national prehospital TBI treatment guidelines, which were developed
after years of research, replacing decades of management based on
outdated protocols.
While there was no significant impact on overall survival in those
with moderate TBI, the take-home is that simple interventions—addressing
hypoxia, hypotension, and avoiding hyperventilation—in those most
critically injured had a clear impact on their survival.
In the past, paramedics were taught to hyperventilate patients (who
required intubation) to blow off carbon dioxide. While this maneuver may
lower intracranial pressure, it also deprives the brain of critical
blood flow and oxygen. After nearly 4-5 minutes of diminished blood
flow, brain cells (neurons) begin to die.
EPIC reversed course by correcting old practices and reinforcing the
importance of avoiding hyperventilation (by measuring end tidal carbon
dioxide levels which are reflective of hyperventilation), allowing
paramedics to monitor this important parameter which has a lasting
impact on neurologic outcome.
In fact, the classic "golden hour" of trauma resuscitation, Spaite
explains, is not an hour at all when looking at outcomes for TBI. More
importantly, "given the time sensitive nature of neuronal survival, [4-5
min] no matter how good the neurosurgical and critical care is."
“The EMS providers already know how to put oxygen on a patient, how to initiate IVs, and how to intubate and ventilate. --it’s just those three simple interventions done right!,” emphasized Spaite.
“And this means that these life-saving best-practices can be done in
essentially any EMS system because they don’t require expensive and
sophisticated alterations in equipment or training,” added Spaite.
But training and re-training are essential to maximizing performance
when attempting to adhere to any specific guideline or protocol,
according to
Peter Antevy, M.D.,
a pediatric emergency physician at Joe Dimaggio Children’s Hospital,
and EMS medical director for Coral Springs Fire Department.
“These interventions, while seemingly basic, require training and
re-training, for EMS professionals to remain consistent in their
practice. This is similar to any other ‘protocol’ rollout which is the
way of the world in EMS,” stressed Antevy.
When we rolled out the RACE (Rapid Arterial Occlusion Evaluation)
scale for stroke [to evaluate for large vessel occlusion], we learned
that unless we continuously trained on it, the usage degraded over
time,” he added.
Similar to improving survival in TBI, improving survival in CPR using
“high-performance CPR”, allows us to see the effects of guidelines or
protocols on improving outcomes, according to Antevy.
“But having a guideline, and actually implementing the strategy are
two different animals--similar to having CPR guidelines and using the
High-Performance CPR process. Less than half of EMS agencies use the
“HP-CPR” model which is the only way to operationalize the guidelines to
enhance outcomes,” added Antevy.
EPIC further reinforces the concept that that prehospital
interventions are part of the spectrum of overall patient care that
begins at the scene and continues when a patient arrives in the
emergency department (ED) and is subsequently admitted to the hospital.
“ ”
Jason A. Ellis, M.D.,
Assistant Professor of Neurosurgery, Zucker School of Medicine at
Hofstra/Northwell, Department of Neurosurgery, Lenox Hill Hospital in
New York City.
“ : the data confirms what we already know in the trenches that ,” added Ellis.
Simply put, what we do in the early stages after acute injury is an
extension of principles of critical care that continue in the hospital.
By focusing and adhering to principles that maximize oxygenation, reduce
hypotension, and avoid hyperventilation, we can make a difference in
who survives.
Implementing simple interventions by EMS providers—administering high
flow oxygen, (intubating and ventilating when necessary), administering
intravenous fluids, and avoiding hyperventilation (by focusing on end
tidal carbon dioxide measurements)—can make a clear difference in
outcome in those with severe neurological impairment after TBI.
The big take-away of the study is that adherence and implementation
of these 3 simple resuscitative principles led to improved survival in
the subgroup with severe injury. It's these simple interventions that
ultimately improved survival and neurological outcome in this at-risk
group.
“In the last 40 years, essentially all of the treatments that have
been studied in the emergency care of TBI have been negative: there’s a
graveyard full of promising drugs and treatments that when finally
tested led to no improvement (e.g., steroids, progesterone, cooling,
etc).” explained Spaite.
“EPIC’s implementation of the Guidelines has broken a really long
losing streak-- it’s a major breakthrough after nearly half a century of
attempting to find ways to improve TBI outcome,” he added.
