Emergency department predictors of tracheostomy in patients with isolated traumatic brain injury requiring emergency cranial decompression

Clinical article

Muhammad Shahzad Shamim M.B.B.S., M.C.P.S., M.R.C.S.(Glasg), F.C.P.S., Mohsin Qadeer M.B.B.S., Ghulam Murtaza M.B.B.S., M.R.C.S.(Eng), S. Ather Enam M.D., Ph.D., F.R.C.S.I., F.R.C.S.C., and Najiha B. Farooqi M.B.B.S.
View More View Less
  • Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Patients with severe traumatic brain injury (TBI) frequently require a tracheostomy for prolonged mechanical ventilation and/or pulmonary toilet. It is now proven that the earlier the procedure is done, the more beneficial it is to the patient. The present study was carried out to determine if the requirement of a tracheostomy can be predicted on arrival of a patient to the emergency department. The prediction can potentially aid in combining the procedure with cranial decompression. In this study, the authors' aim was to determine the emergency department predictors of tracheostomy in patients with isolated TBI requiring emergency cranial decompression.

Methods

The authors performed a retrospective chart review of all patients who underwent surgery for isolated TBI and required more than 4 days of mechanical ventilation. Multivariate logistic regression analysis was used for predictive indicators.

Results

In patients with isolated severe TBI, a patient age of 31–50 years, the presence of preexisting medical comorbid conditions, a delay in emergency department arrival exceeding 1.5 hours, an abnormal pupil response on arrival, and a preoperative neurological worsening during hospital stay were independent predictors of the requirement for tracheostomy. These findings were validated in a small cohort of patients and were found to be significant.

Conclusions

Requirement of a tracheostomy can be predicted in patients with severe TBI on arrival to the emergency department. These results were validated in a small cohort of patients, and it was found that the positive predictive value of requirement of tracheostomy was directly proportional to the number of predictors present. Larger prospective studies with appropriate control groups are further recommended to validate the authors' findings.

Abbreviations used in this paper:

DSO = decompressive surgery only; DST = decompressive surgery and tracheostomy; GCS = Glasgow Coma Scale; TBI = traumatic brain injury.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: M. Shahzad Shamim, M.B.B.S., Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, PO Box 3500, Stadium Road, Karachi 74800, Pakistan. email: shahzad.shamim@aku.edu.

Please include this information when citing this paper: published online August 5, 2011; DOI: 10.3171/2011.7.JNS101829.

  • 1

    Agrawal A, , Joharapurkar SR, , Golhar KB, & Shahapurkar VV: Early tracheostomy in severe head injuries at a rural center. J Emerg Trauma Shock 2:56, 2009

    • Search Google Scholar
    • Export Citation
  • 2

    Arabi Y, , Haddad S, , Shirawi N, & Al Shimemeri A: Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care 8:R347R352, 2004

    • Search Google Scholar
    • Export Citation
  • 3

    Blot F, , Similowski T, , Trouillet JL, , Chardon P, , Korach JM, & Costa MA, et al. : Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 34:17791787, 2008

    • Search Google Scholar
    • Export Citation
  • 4

    Bouderka MA, , Fakhir B, , Bouaggad A, , Hmamouchi B, , Hamoudi D, & Harti A: Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 57:251254, 2004

    • Search Google Scholar
    • Export Citation
  • 5

    Branco BC, , Plurad D, , Green DJ, , Inaba K, , Lam L, & Cestero R, et al. : Incidence and clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review. J Trauma 70:111115, 2011

    • Search Google Scholar
    • Export Citation
  • 6

    Chintamani KJ, , Khanna J, , Singh JP, , Kulshreshtha P, , Kalra P, & Priyambada B, et al. : Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country—a prospective study. BMC Emerg Med 5:8, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Goettler CE, , Fugo JR, , Bard MR, , Newell MA, , Sagraves SG, & Toschlog EA, et al. : Predicting the need for early tracheostomy: a multifactorial analysis of 992 intubated trauma patients. J Trauma 60:991996, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Grände PO: The “Lund Concept” for the treatment of severe head trauma—physiological principles and clinical application. Intensive Care Med 32:14751484, 2006

    • Search Google Scholar
    • Export Citation
  • 9

    Gurkin SA, , Parikshak M, , Kralovich KA, , Horst HM, , Agarwal V, & Payne N: Indicators for tracheostomy in patients with traumatic brain injury. Am Surg 68:324329, 2002

    • Search Google Scholar
    • Export Citation
  • 10

    Holevar M, , Dunham JC, , Brautigan R, , Clancy TV, , Como JJ, & Ebert JB, et al. : Practice management guidelines for timing of tracheostomy: the EAST Practice Management Guidelines Work Group. J Trauma 67:870874, 2009

    • Search Google Scholar
    • Export Citation
  • 11

    Holmgren EP, , Bagheri S, , Bell RB, , Bobek S, & Dierks EJ: Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center. J Oral Maxillofac Surg 65:20052010, 2007

    • Search Google Scholar
    • Export Citation
  • 12

    Honeybul S, , Ho KM, , Lind CR, & Gillett GR: Decompressive craniectomy for neurotrauma: the limitations of applying an outcome prediction model. Acta Neurochir (Wien) 152:959964, 2010

    • Search Google Scholar
    • Export Citation
  • 13

    Honeybul S, , Ho KM, , Lind CR, & Gillett GR: Observed versus predicted outcome for decompressive craniectomy: a population-based study. J Neurotrauma 27:12251232, 2010

    • Search Google Scholar
    • Export Citation
  • 14

    Kane TD, , Rodriguez JL, & Luchette FA: Early versus late tracheostomy in the trauma patient. Respir Care Clin N Am 3:120, 1997

  • 15

    Kollef MH, , Ahrens TS, & Shannon W: Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 27:17141720, 1999

    • Search Google Scholar
    • Export Citation
  • 16

    Kollef MH, , Shorr A, , Tabak YP, , Gupta V, , Liu LZ, & Johannes RS: Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 128:38543862, 2005

    • Search Google Scholar
    • Export Citation
  • 17

    Major KM, , Hui T, , Wilson MT, , Gaon MD, , Shabot MM, & Margulies DR: Objective indications for early tracheostomy after blunt head trauma. Am J Surg 186:615619, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Nordström CH: The “Lund concept”: what it is and what it isn't. Intensive Care Med 33:558559, 2007

  • 19

    Rello J, , Ollendorf DA, , Oster G, , Vera-Llonch M, , Bellm L, & Redman R, et al. : Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 122:21152121, 2002

    • Search Google Scholar
    • Export Citation
  • 20

    Richard I, , Hamon MA, , Ferrapie AL, , Rome J, , Brunel P, & Mathé JF: [Tracheotomy in brain injured patients: which patients? Why? When? How?]. Ann Fr Anesth Reanim 24:659662, 2005. (Fr)

    • Search Google Scholar
    • Export Citation
  • 21

    Ross BJ, , Barker DE, , Russell WL, & Burns RP: Prediction of long-term ventilatory support in trauma patients. Am Surg 62:1925, 1996

  • 22

    Sugerman HJ, , Wolfe L, , Pasquale MD, , Rogers FB, , O'Malley KF, & Knudson M, et al. : Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 43:741747, 1997

    • Search Google Scholar
    • Export Citation
  • 23

    Vincent JL, , Lobo S, & Struelens M: Ventilator associated pneumonia: risk factors and preventive measures. J Chemother 13:Spec1 211217, 2001

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 498 120 14
Full Text Views 134 1 0
PDF Downloads 110 1 0
EPUB Downloads 0 0 0