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Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury.
- Source :
-
Emergency medicine journal : EMJ [Emerg Med J] 2021 Jan; Vol. 38 (1), pp. 21-26. Date of Electronic Publication: 2020 Sep 18. - Publication Year :
- 2021
-
Abstract
- Background: For the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing's triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.<br />Methods: We performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.<br />Results: Outcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, >160 mm Hg,<60 bpm and >5 mm. Cushing criteria (SBP >160 mm Hg and HR <60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing's response had a specificity of 93.2 (88.2-96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9-10.2), whereas sensitivity and LR- were only 36.8 (26.7-47.8)% and 0.7 (0.6-0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57-0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.<br />Conclusion: Traditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.<br />Competing Interests: Competing interests: None declared.<br /> (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
- Subjects :
- Bradycardia diagnosis
Early Diagnosis
England
Female
Glasgow Coma Scale
Humans
Hypertension diagnosis
Male
Middle Aged
Pupil Disorders diagnosis
Respiratory Insufficiency diagnosis
Retrospective Studies
Brain Injuries, Traumatic complications
Emergency Medical Services
Intracranial Hypertension diagnosis
Intracranial Hypertension etiology
Subjects
Details
- Language :
- English
- ISSN :
- 1472-0213
- Volume :
- 38
- Issue :
- 1
- Database :
- MEDLINE
- Journal :
- Emergency medicine journal : EMJ
- Publication Type :
- Academic Journal
- Accession number :
- 32948620
- Full Text :
- https://doi.org/10.1136/emermed-2020-209635