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474 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Case study, Continued
Sam required. Sam’s mother relocated with Sam to support him a car, due to his cognitive impairment. His speech and language is
through his rehabilitation. impaired and requires both visual and auditory formats for him
to make judgements on more complex information formats. He
One year later appears to have acquired dyslexia. Sam has reduced higher level
Upon leaving hospital, Sam was discharged home into the care of physical coordination required for dynamic tasks but this should
his mother who is now his principal carer. He remains interstate continue to improve with therapy. Sam is confident that he can
with his mother to continue on as an outpatient at the Brain Injury overcome his disabilities and has commenced studying through
Rehabilitation Community and Home Centre. Sam is a young man TAFE. He will only be able to do this with maximum support from
and prior to his accident was studying. He is no longer able to drive his immediate and extended family.

Research vignette

Myburgh, John A. PhD, FJFICM; Cooper, D James MD, FJFICM; strategies and interventions to minimise secondary brain injuries
Finfer, Simon R. FJFICM; Venkatesh, Balasubramanian MD, FJFICM; in the prehospital period.
Jones, Daryl MBBS; Higgins, Alisa MPH; Bishop, Nicole MSc; Higlett,
Tracey MPH; the Australasian Traumatic Brain Injury Study (ATBIS) Critique
Investigators for the Australian; New Zealand Intensive Care This is a remarkable study in terms of the Australian and New
Society Clinical Trials Group. Epidemiology and 12-month out- Zealand intensive care unit multicentre collaborative effort that
comes from traumatic brain injury in Australia and New Zealand. was largely unfunded and achieved prospective epidemiological
Journal of Trauma-Injury Infection & Critical Care 2008; 64(4): research that benchmarked a detailed profile of prevalence, injury
854–62. patterns, management strategies and outcomes of patients with
brain injuries admitted to intensive care units (ICUs) in Australia
Abstract and New Zealand. Sixteen units participated in this study, repre-
Background senting 76% (16 of 21) of eligible trauma centres in both countries
An epidemiologic profile of traumatic brain injury (TBI) in Australia at the time of the study. It included not only prospective admission
and New Zealand was obtained following the publication of inter- and ICU management daily data but also prehospital and pre ICU
national evidence-based guidelines.
data. Also there was extensive follow-up at 6 and 12 months using
Methods: Adult patients with TBI admitted to the intensive care the Glasgow Outcome Score to assess not only mortality but mor-
units (ICU) of major trauma centres were studied in a 6-month bidity in terms of outcome. The findings of this study represented
prospective inception cohort study. Data including mechanisms of those of a well-resourced society that possessed an integrated
injury, prehospital interventions, secondary insults, operative and national health care system, sophisticated prehospital and emer-
intensive care management, and outcome assessments 12-months gency systems, and highly developed, standardised training and
postinjury were collected. certification of the relevant health professionals. The study results
should also be interpreted in the context of a high degree of public
Results: There were 635 patients recruited from 16 centres. The health awareness about vehicular trauma, increased legislation
mean (±SD) age was 41.6 years ± 19.6 years; 74.2% were men; regarding violations for speeding, restraining devices, helmets and
61.4% were due to vehicular trauma, 24.9% were falls in elderly drink-driving, improvements in roads, technological advances in
patients, and 57.2% had severe TBI (Glasgow Coma Scale score ≤8). motor vehicle design, and low levels of interpersonal violence and
Secondary brain insults were recorded in 28.5% and 34.8% under- firearm ownership.
went neurosurgical procedures before ICU admission. There was
concordance with TBI and ICU practice guidelines, although intra- Interestingly, this study did not suggest a substantial improve-
cranial pressure monitoring was used in 44.5% patients with severe ment in outcomes following dissemination of evidence-based
TBI. Twelve-month mortality was 26.9% in all patients and 35.1% guidelines for the management of TBI in comparison to historical
in patients with severe TBI. Favourable outcomes at 12 months controls in America, Europe and Australia, despite during the ICU
were recorded in 58.8% of all patients and in 48.5% of patients with admission, there was concordance with evidence-based guide-
severe TBI. lines concerning systemic monitoring and supportive measures
such as nutrition, thromboprophylaxis and gastric ulcer prophy-
Conclusions: In Australia and New Zealand, mortality and favour- laxis. Similarly, there were consistent practices in the participat-
able neurologic outcomes after TBI were similar to published data ing ICUs concordant with management guidelines for TBI. This
before the advent of evidence-based guidelines. A high incidence was typified by the low incidence of the use of ‘brain-specific
of prehospital secondary brain insults and an ageing population therapies’ such as osmotherapy, barbiturates, hypothermia,
may have contributed to these outcomes. Strategies to improve hyperventilation and corticosteroids. However ICP monitoring
outcomes from TBI should be directed at preventive public health was employed in less than half of patients admitted with severe