Hyperosmolar Therapy in Severe Traumatic Brain Injury: A Survey of Emergency Physicians from a Large Canadian Province

<div><p>Introduction</p><p>Worldwide, severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality. Mannitol and hypertonic saline are therapeutic options for intracranial hypertension occurring in the acute phase of care. However, current practices of emergency physicians are unknown.</p><p>Methods</p><p>We conducted a self-administered survey of emergency physicians in the province of Québec, Canada, to understand their attitudes surrounding the use of hyperosmolar solutions in patients with severe traumatic brain injury. Using information from a systematic review of hypertonic saline solutions and experts' opinion, we developed a questionnaire following a systematic approach (items generation and reduction). We tested the questionnaire for face and content validity, and test-retest reliability. Physicians were identified through the department head of each eligible level I and II trauma centers. We administered the survey using a web-based interface and planned email reminders.</p><p>Results</p><p>We received 210 questionnaires out of 429 potentials respondents (response rate 49%). Most respondents worked in level II trauma centers (69%). Fifty-three percent (53%) of emergency physicians stated using hypertonic saline to treat severe traumatic brain injury. Most reported using hyperosmolar therapy in the presence of severe traumatic brain injury and unilateral reactive mydriasis, midline shift or cistern compression on brain computed tomography.</p><p>Conclusion</p><p>Hyperosmolar therapy is believed being broadly used by emergency physicians in Quebec following severe traumatic brain injury. Despite the absence of clinical practice guidelines promoting the use of hypertonic saline, a majority of them said to use these solutions in specific clinical situations.</p></div

Perceived facilitators and barriers to the use of hyperosmolar solutions.

<p>Perceived facilitators and barriers to the use of hyperosmolar solutions.</p

Respondents' demographic characteristics.

<p>Respondents' demographic characteristics.</p

Perceived utilization of hyperosmolar solutions.

<p>Perceived utilization of hyperosmolar solutions.</p

Factors influencing the intention of use of hyperosmolar solutions.

<p>Factors influencing the intention of use of hyperosmolar solutions.</p

Flow diagram of participants.

<p>Flow diagram of participants.</p

Vasopressor use following traumatic injury – A single center retrospective study

<div><p>Objectives</p><p>Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers.</p><p>Methods</p><p>We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management.</p><p>Results</p><p>Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5).</p><p>Conclusions</p><p>In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.</p></div

Care trajectories of hemodynamically unstable patients.

<p>Care trajectories of hemodynamically unstable patients.</p

Patient flow diagram.

<p>*One patient was transferred to another hospital after the initial phase of resuscitation and could not provide outcome data. ICU—Intensive care unit, SBP—Systolic blood pressure, MAP—Mean arterial pressure.</p

Fluid volumes (mL) administered during the initial phase of resuscitation^*.

<p>Fluid volumes (mL) administered during the initial phase of resuscitation^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0176587#t003fn002" target="_blank">*</a>}.</p