G Baluh, MD, E Mann-Salinas, PhD, A Staudt, PhD, J Gurney, MD, S Shackelford, MD, J Nielsen, MD, T Becker, MD. SAMMC
Objectives: Military surgeons deployed to locations with limited resources, i.e. Role 2 medical treatment facilities (MTF), are often required to care for patients sustaining severe traumatic brain injuries (sTBI). It is paramount in sTBI to prevent secondary brain injury with aggressive measures to maintain adequate brain perfusion and oxygenation. One of the few interventions available at the Role 2 for consideration in sTBI is hyperosmolar therapy to reduce intracranial hypertension and maintain adequate brain perfusion. Previous research demonstrates that many deployed surgeons have limited experience and comfort with performing emergent neurosurgical interventions. We hypothesize that this group of surgeons is also inexperienced with emergent medical management of sTBI and therefore sought to investigate Role 2 surgeon adherence to the JTS Neurosurgery and Severe Head Injury CPG recommendations regarding the use of hyperosmolar therapy with mannitol and hypertonic saline (HTS).
Methods: We conducted a secondary data analysis of the JTS Role 2 Database from March 2011 to August 2014. The study population included patients who were treated at Role 2 MTFs, sustained a head injury, and had an arrival Glasgow Coma Scale of 3-8. Head injuries were identified using patient diagnoses and procedure data. Medical interventions included use of mannitol and HTS. Neurosurgical procedures included burr hole, craniectomy, and craniotomy. To identify differences in patient characteristics and measured interventions, we used descriptive statistics and stratified patients by affiliation.
Results: A total of 39 “US Military” and 228 “Other” than US military casualties were identified. Overall, 40/267 (15.0%) received hyperosmolar therapy with mannitol and/or HTS. Of the US Military, no causalities received mannitol and 4/39 (10.3%) received HTS. Of the Other category, 1/228 (0.4%) received mannitol only, 26/228 (11.4%) received HTS only, and 9/228 (3.9%) received mannitol and HTS. No US Military underwent neurosurgical procedures and four in the Other category underwent craniotomy at the Role 2 MTFs.
Conclusion: Surgeons deployed to Role 2 MTFs and other forward environments must be prepared to manage casualties with sTBI. While resources are limited at Role 2 MTFs, HTS and mannitol should be available and considered early in the management of sTBI. This study demonstrated underutilization of these interventions. Pre-deployment training in surgical and medical management of sTBI should be performed, validated, and tracked for adherence. Additionally, neurosurgical teleconsultation should be readily available 24/7 and this resource should be utilized to help facilitate provision of optimal neurosurgical care at Role 2 MTFs.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86724
Program Number: MSS10
Presentation Session: Full-Day Military Surgical Symposium – Trauma/Critical Care Presentations
Presentation Type: MSSPodium