Establishing a Statewide Brain Injury ConsortiumNational Epidemiology Traumatic Brain Injury (TBI) is the leading cause of death and disability in children and adults from ages 1 to

Establishing a Establishing a

Statewide Brain Injury Statewide Brain Injury

ConsortiumConsortium

Daniel Hutton, D.O.Daniel Hutton, D.O.

DisclosuresDisclosures

NoneNone

A Primer on Traumatic A Primer on Traumatic

Brain InjuryBrain Injury

National EpidemiologyNational Epidemiology Traumatic Brain Injury (TBI) is the leading cause of death and disability in Traumatic Brain Injury (TBI) is the leading cause of death and disability in

children and adults from ages 1 to 44.children and adults from ages 1 to 44.

CDC estimates the annual incidence of 1.4 million people in the USCDC estimates the annual incidence of 1.4 million people in the US 50,000 will not survive the trauma50,000 will not survive the trauma

235,000 will be hospitalized235,000 will be hospitalized

1.1 million1.1 million will be treated and released from the ERwill be treated and released from the ER

Men 1.5X greater riskMen 1.5X greater risk

Most common in first three decades of lifeMost common in first three decades of life Although, those over 75 had a 4 fold increase incidence of death related to TBIAlthough, those over 75 had a 4 fold increase incidence of death related to TBI

5.3 million in US alone (2% of population) require assistance with ADLs 5.3 million in US alone (2% of population) require assistance with ADLs secondary to TBIsecondary to TBI 80,00080,000--90,000 added each year due to permanent neurological injury90,000 added each year due to permanent neurological injury

Moderate & severe head injury are associated with a 2.3 and 4.5 times Moderate & severe head injury are associated with a 2.3 and 4.5 times increased risk of Alzheimer’s disease, respectively.increased risk of Alzheimer’s disease, respectively.

Cost of TBICost of TBI $56 Billion$56 Billion per year in direct and indirect costsper year in direct and indirect costs

Alves OL, Bullock R (2001). Excitotoxic damage in traumatic brain injury. in Clark RSB, Kochanek P. Brain injury. Boston: Kluwer Academic Publishers. p. 1.

Crooks CY, Zumsteg JM, Bell KR. Traumatic Brain Injury: A review of practice management and recent advances. Phys Med Rehabil Clin N Am 18 (2007), 681-710.

Langlois, J. ScD, MPH; Rutland-Brown, W. MPH; Wald, M. MLS, MPH; The Epidemiology and Impact of Traumatic Brain Injury: A Brief Overview; Journal of Head

Trauma Rehabilitation, Vol. 21, No. 5, pp. 375378 2006.

MMWR Morb Mortal Wkly Rep. 2007; 56:167-170

National EpidemiologyNational Epidemiology

Falls 28%Falls 28%

Most prevalent 0Most prevalent 0--4 years and >754 years and >75

Motor vehicle 20%Motor vehicle 20%

Most common 15Most common 15--19 years19 years

Struck by object 19%Struck by object 19%

Assault 11%Assault 11%

Bicycle 3%Bicycle 3%

Unknown 9%Unknown 9%

Types and Treatment Types and Treatment

of Traumatic Brain of Traumatic Brain

InjuryInjury

HistoryHistory

Neurosurgical intervention is perhaps one of the Neurosurgical intervention is perhaps one of the

oldest specialtiesoldest specialties

Trepanation performed 5000 BC in EuropeTrepanation performed 5000 BC in Europe

Performed for a multitude of reasons Performed for a multitude of reasons

SpiritsSpirits

EpilepsyEpilepsy

HeadachesHeadaches

OsteomyelitisOsteomyelitis

TraumaTrauma

HistoryHistory

Intracranial PressureIntracranial Pressure

Lundberg 1960Lundberg 1960

Langfitt, Klatzo 1965Langfitt, Klatzo 1965--1967 1967

Cerebral autoregulation and edemaCerebral autoregulation and edema

Rosner and Becker 1984Rosner and Becker 1984

A wavesA waves

Obrist, Bouma, Muizelaar 1986Obrist, Bouma, Muizelaar 1986--19911991

Cerebral ischemia and bloodflow dynamicsCerebral ischemia and bloodflow dynamics

Led to cerebral perfusion pressureLed to cerebral perfusion pressure

HistoryHistory

ClinicalClinical

GCS 1974GCS 1974

Jennett and TeasdaleJennett and Teasdale

Secondary Insults 1977Secondary Insults 1977

Miller and BeckerMiller and Becker

Hypotension 1993Hypotension 1993

ChesnutChesnut

HistoryHistory

ImagingImaging CTCT

4 hour window 19814 hour window 1981

SeeligSeelig

Marshall’s Criteria 1991Marshall’s Criteria 1991

Data CollectionData Collection TCDB 1983TCDB 1983

Monitoring TechniquesMonitoring Techniques SJVOSJVO22 19911991

DeardenDearden

PbOPbO22 20042004

Hemedex 2005Hemedex 2005

JaegerJaeger

Grading the InjuryGrading the Injury

Mild TBIMild TBI

GCS 13GCS 13--1515

Difficult to get true numbers, due to the rarity of admission to Difficult to get true numbers, due to the rarity of admission to hospitalhospital

Recovery is rapidRecovery is rapid 15% will have symptoms for greater than 3 weeks 15% will have symptoms for greater than 3 weeks post concussive post concussive

syndromesyndrome

Spectrum of symptoms Spectrum of symptoms Blurred vision, headache, nausea, vomiting, dizziness, Blurred vision, headache, nausea, vomiting, dizziness, emotional emotional

lability/depression, cognitive dysfunctionlability/depression, cognitive dysfunction

3030--40% have depression or anxiety40% have depression or anxiety

Need for early neurorehabilitationNeed for early neurorehabilitation

Lost productivity from MTBI totaled an estimated $12 billion in Lost productivity from MTBI totaled an estimated $12 billion in the United States in 2000 the United States in 2000

Moderate TBIModerate TBI

GCS 9GCS 9--1212

General FeaturesGeneral Features

Similar pathology to severe head injurySimilar pathology to severe head injury

More common in younger age groupsMore common in younger age groups

“Gray Zone” of treatment“Gray Zone” of treatment

90% able to have functional independence90% able to have functional independence

Severe TBISevere TBI

GCS 3GCS 3--88

Multiple etiologies for hemorrhage typeMultiple etiologies for hemorrhage type

Overwhelming indications for ventriculostomyOverwhelming indications for ventriculostomy

40% mortality40% mortality

Less than 20% have functional independenceLess than 20% have functional independence

Biomechanics and Biochemistry of Biomechanics and Biochemistry of

Traumatic Brain InjuryTraumatic Brain Injury

Mechanism of InjuryMechanism of Injury

BiomechanicsBiomechanics Contact injuries cause focal injuriesContact injuries cause focal injuries

No inertial load No inertial load

“coup” injuries“coup” injuries ContusionsContusions

Skull fractures/EDHSkull fractures/EDH

Translational acceleration injuries Translational acceleration injuries Inertial load is highInertial load is high

“contracoup” injuries“contracoup” injuries

Contusions, ICH, SDHContusions, ICH, SDH

Angular acceleration is a combination of translational and Angular acceleration is a combination of translational and rotational accelerationrotational acceleration Most commonMost common

DAI, et al.DAI, et al.



CalciumCalcium

Trauma increase causes activation Trauma increase causes activation of phospholipases Aof phospholipases A2 2 and C, and C, resulting in release of free fatty resulting in release of free fatty acids and diacylglycerol.acids and diacylglycerol.

Free fatty acids may further Free fatty acids may further damage the blood brain barrier damage the blood brain barrier and increase cerebral edema.and increase cerebral edema.

May also affect electron transport May also affect electron transport at the inner membrane of the at the inner membrane of the mitochondria, inhibiting ATP mitochondria, inhibiting ATP production and worsening production and worsening anaerobic metabolism and anaerobic metabolism and increasing intracellular lactate. increasing intracellular lactate.

Dhillon HS, Carman HM, Zhang D, et al: Severity of experimental brain injury on lactate and free fatty acid accumulation and

Evans blue extravasation in the rat cortex and hippocampus. J Neurotrauma 16:455-469, 1999.


BiochemicalBiochemical

GlutamateGlutamate

Excitatory amino acid Excitatory amino acid (Glutamate and Aspartate)(Glutamate and Aspartate)

Binds NMDA (Binds NMDA (NN--methylmethyl--DD--Aspartate), which normally Aspartate), which normally regulates Naregulates Na++ and Caand Ca2+2+

Regulation is through Regulation is through Magnesium (MgMagnesium (Mg2+2+) binding to ) binding to the receptorthe receptor

Excessive levels of excitatory Excessive levels of excitatory amino acids cause cell death in amino acids cause cell death in two ways:two ways:

Acute increase in NaAcute increase in Na++ and Cland Cl--

cause intracellular edemacause intracellular edema

Increase in intracellular CaIncrease in intracellular Ca2+2+


Other chemicals implicatedOther chemicals implicated

P53P53 upup--regulationregulation

Free radical damageFree radical damage

Leukotrienes, thromboxane (Arachadonic Acid Leukotrienes, thromboxane (Arachadonic Acid

derivatives)derivatives)

PARPPARP

CalpainCalpain

Management of Traumatic Brain Management of Traumatic Brain

InjuryInjury

Guidelines for the Management Guidelines for the Management

of Severe Traumatic Brain Injuryof Severe Traumatic Brain Injury

33rdrd EditionEditionA Joint Project of theA Joint Project of the

Brai n Trauma Foundat i onBrai n Trauma Foundat i onImprovi ng t he Out come of Brai n Trauma Pat i ent s Worl dwi deImprovi ng t he Out come of Brai n Trauma Pat i ent s Worl dwi de

andand

American Association of Neurological Surgeons (AANS)American Association of Neurological Surgeons (AANS)

Congress of Neurological Surgeons (CNS)Congress of Neurological Surgeons (CNS)

AANS / CNS Joint Section on Neurotrauma and Critical CareAANS / CNS Joint Section on Neurotrauma and Critical Care

New Yor k, 2007New Yor k, 2007

Prehospital Management of TBIPrehospital Management of TBI

Multitude of caregivers Multitude of caregivers FirstFirst--responders, EMTs, RNsresponders, EMTs, RNs

ATLS protocolsATLS protocols ABCDABCD

A and B:A and B: Hypoxia should be avoided Hypoxia should be avoided

and is prognosticand is prognostic

Reliable airway should be Reliable airway should be secured as soon as possiblesecured as soon as possible

CC A single episode of SBP<90 A single episode of SBP<90

doubles mortalitydoubles mortality

Give isotonic fluidsGive isotonic fluids ??Hypertonic??Hypertonic

OO22 satsat MortalityMortality Severe Severe

DisabilityDisability

>90%>90% 14.3%14.3% 4.8%4.8%

6060--90%90% 27.3%27.3% 27.3%27.3%

<60&<60& 50%50% 50%50%

Prehospital Management of TBIPrehospital Management of TBI

ATLS protocol (continued)ATLS protocol (continued) DD

GCSGCS PostresuscitationPostresuscitation GCSGCS

Most widely utilized clinical measurement for TBIMost widely utilized clinical measurement for TBI

GCS of 3GCS of 3--5 has a 70% predictive value of poor outcome5 has a 70% predictive value of poor outcome

Motor component most predictiveMotor component most predictive

Great disparities between medical personnelGreat disparities between medical personnel

40% discrepancy40% discrepancy

PupilsPupils Pupillar asymmetry (Anisicoria) is >1mm difference in diameterPupillar asymmetry (Anisicoria) is >1mm difference in diameter

Examine for orbital trauma, postresuscitationExamine for orbital trauma, postresuscitation

Braakman, et al.Braakman, et al.

Bilateral fixed, dilated pupils has a 91% mortality Bilateral fixed, dilated pupils has a 91% mortality

Unlateral fixed pupil has good outcome in 54%Unlateral fixed pupil has good outcome in 54%

Preponderance of epidural hematomasPreponderance of epidural hematomas

E E (Exposure and other injuries)(Exposure and other injuries) Other injuries….how about the spine?Other injuries….how about the spine?

21% of patients with severe TBI have cervical spine injuries21% of patients with severe TBI have cervical spine injuries

Braakman R, Gelpke G, Hebemma J, et al.: Systemic Selection of Prognostic Features in Patients with Severe Head Injury.

Neurosurg 6: 362-70, 1980.

Neurointensive CareNeurointensive Care

Understanding Neurointensive CareUnderstanding Neurointensive Care

It’s all about oxygen delivery!!!!It’s all about oxygen delivery!!!!

Optimize arterial oxygenationOptimize arterial oxygenation

Optimize Oxygen carrying capabilitiesOptimize Oxygen carrying capabilities

Optimize blood pressureOptimize blood pressure

Understand the forces helping or hindering OUnderstand the forces helping or hindering O2 2

deliverydelivery

MAP/CBF (Hemedex)MAP/CBF (Hemedex)

ICPICP

Checking the end productChecking the end product

SjOSjO22

PbOPbO22

Intracranial PressureIntracranial Pressure

How high is too high?How high is too high?

Marmarou (1991) 1030 severe TBI patients found Marmarou (1991) 1030 severe TBI patients found

that an ICP of 20 greatest predictive threshold for that an ICP of 20 greatest predictive threshold for

outcome at 6 months.outcome at 6 months.

Retanalert (2004) evaluated outcome in patients with Retanalert (2004) evaluated outcome in patients with

ICP of 25 vs. 20 and found no differenceICP of 25 vs. 20 and found no difference

CPP>70, SjOCPP>70, SjO22>54%>54%

Only 27 patientsOnly 27 patients

Marmarou A, Anderson RL, Ward JD, et al: Impact of ICP instability and hypotension on outcome in patients with severe head

trauma.J Neurosurg 1991;75:S159-S166.

Ratanalert SN, Phuepathom N, Saeheng S, et al: ICP threshold in CPP management of severe head injury patients. Surg Neurol

2004;61:429-435.

Cerebral Perfusion PressureCerebral Perfusion Pressure

What is it?What is it?

CPP=MAPCPP=MAP--ICPICP

More emphasized than ICPMore emphasized than ICP--guided treatmentguided treatment

Ties into hypotension as poor outcomeTies into hypotension as poor outcome

Rosner and Daughton (1990)Rosner and Daughton (1990)

CPP>70 had superior outcomesCPP>70 had superior outcomes

Serious complications, including ARDSSerious complications, including ARDS

Rosner MJ, Daughton S. Cerebral perfusion pressure management in head injury. J Trauma 1990;10:151-165.

Cerebral Perfusion PressureCerebral Perfusion Pressure

CPP <50CPP <50--60 associated with worse outcomes60 associated with worse outcomes

Usually confounded by severely elevated ICPUsually confounded by severely elevated ICP

Which is more predictive?Which is more predictive?

CPP (Andrews, 2002)CPP (Andrews, 2002)

Therefore, goal CPP is 60Therefore, goal CPP is 60--9090

Newest monitoringNewest monitoring

Licox (Brain tissue pOLicox (Brain tissue pO22))

Hemedex (Cerebral Blood Flow)Hemedex (Cerebral Blood Flow)

Andrews PJ, Sleeman DH, Statham PF, et al: Predicting recovery in patients suffering from traumatic injury by using admission

variables and physiological data: a comparison between decision tree analysis and logistic regresiion. J Neurosug 2002;97:326-336.

Osmotic TherapyOsmotic Therapy

MannitolMannitol

How does it work?How does it work?

Decreases blood viscosityDecreases blood viscosity

Immediate plasma expansion/reduces hematocritImmediate plasma expansion/reduces hematocrit

Improved rheology (deformability of the RBC) and Improved rheology (deformability of the RBC) and

increases oxygen delivery to injured areasincreases oxygen delivery to injured areas

Osmotic EffectOsmotic Effect

Delayed 15Delayed 15--30 minutes after dose30 minutes after dose

Unpredictable duration of treatment (90minUnpredictable duration of treatment (90min--6hrs)6hrs)

Use with caution in patients with hypotension, sepsis, Use with caution in patients with hypotension, sepsis,

nephrotoxic drugs or those with impaired kidney functionnephrotoxic drugs or those with impaired kidney function

Osmotic TherapyOsmotic Therapy

Mannitol (continued)Mannitol (continued)

How to give it?How to give it? No reliable answerNo reliable answer

Marshall, et al. report a faster infusion has a safer and more Marshall, et al. report a faster infusion has a safer and more reliable effect, and possibly longerreliable effect, and possibly longer 1g/kg1g/kg

Effects become less after multiple (3Effects become less after multiple (3--4) doses4) doses

Does it work every time?Does it work every time? NO!NO!

AutoregulationAutoregulation Muizelaar, et al. found Mannitol is effective in those with intact Muizelaar, et al. found Mannitol is effective in those with intact

autoregulation.autoregulation. Rheological effect possibly more important than osmotic effect.Rheological effect possibly more important than osmotic effect.

Marshall LF, Smith RW, Rauscher LA. Mannitol dose requirements in brain injured patients. J Neurosurg. 1978; 48: 169-172.

Muizelaar JP, Lutz HA, Becker DP. Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head

injured patiens. J Neurosurg. 1984; 61:700-706.

Osmotic TherapyOsmotic TherapyHypertonic SalineHypertonic Saline

How does it work?How does it work? Direct increase of solute load in vasculatureDirect increase of solute load in vasculature

How to give it?How to give it? Multiple formulationsMultiple formulations

3%, 5%, 7.5%, 23.4%3%, 5%, 7.5%, 23.4%

For increased ICPFor increased ICP Bolus over 10Bolus over 10--20 min20 min

Caution with CHFCaution with CHF

Contraindicated as bolus in hyponatremiaContraindicated as bolus in hyponatremia

Battison, et al. evaluated ICP control in severe TBI in a Battison, et al. evaluated ICP control in severe TBI in a randomized controlled trial of Hypertonic Saline vs. Mannitol vs. randomized controlled trial of Hypertonic Saline vs. Mannitol vs. DextranDextran HS at least as effective as Mannitol for controlling ICPHS at least as effective as Mannitol for controlling ICP

Small sample sizeSmall sample size

Battison C, Andrews PJ, Graham C, et al. Randomized, controlled trial of the effect of 20% mannitol solution and a 7.5% saline/6%

dextran solution on increased intracranial pressure after brain injury. Crit Care Med. 2005;33:196-202.

Secondary InjuriesSecondary Injuries


HypoxiaHypoxia

What is it?What is it?

How often does it occur?How often does it occur?

Survey of firstSurvey of first--responders to patients with severe head responders to patients with severe head

injury found preinjury found pre--intubation hypoxia (SaOintubation hypoxia (SaO22<85) occurred <85) occurred

55% of the time55% of the time

Over 50% of the time, hypotension was also present. Over 50% of the time, hypotension was also present.

In those with SaOIn those with SaO22<60% pre<60% pre--intubation, mortality rate intubation, mortality rate

was 50% and all survivors had severe disability. was 50% and all survivors had severe disability.

Stochetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in severe head injury. J Trauma

1996; 40:764-767.


HypotensionHypotension

Defined as SBP < 90Defined as SBP < 90

Most powerful predictor of poor outcomeMost powerful predictor of poor outcome

Single episode of hypotension doubles the mortality rate.Single episode of hypotension doubles the mortality rate.

Increased frequency and duration of hypotension has also Increased frequency and duration of hypotension has also

been shown to be an independent predictor of poor been shown to be an independent predictor of poor

outcomeoutcome

More focus should be paid to MAP/CPP, CBF, More focus should be paid to MAP/CPP, CBF,

PbOPbO22 to determine adequate perfusionto determine adequate perfusion

Chestnut RF, Marshall LM, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head

injury. J Trauma 1993; 34:216-222.

Pediatric Head InjuryPediatric Head Injury

General ConceptsGeneral Concepts

Hypotension should, in kind, be avoidedHypotension should, in kind, be avoided

Defined as systolic blood pressure less than the fifth Defined as systolic blood pressure less than the fifth

percentile for age group or signs of shockpercentile for age group or signs of shock

Quick formula: Hypotension= 70 mm Hg + 2(age in years)Quick formula: Hypotension= 70 mm Hg + 2(age in years)

Hypoxia with worsened outcome (PaOHypoxia with worsened outcome (PaO22<65)<65)

Hypotension + Hypoxia is only slightly worse than Hypotension + Hypoxia is only slightly worse than

hypotension alone.hypotension alone.

Mortality as high as 85% in some reportsMortality as high as 85% in some reports

PrognosisPrognosis

GCS scoreGCS score MortalityMortality

33 65%65%

44 45%45%

55 35%35%

66 24%24%

77--1313 1010--15%15%

TBI Mortality

0%

10%

20%

30%

40%

50%

60%

70%

GCS 3 GCS 4 GCS 5 GCS 6 GCS 7-13

GCS

Mo

rtali

ty

Newer NeuromonitoringNewer Neuromonitoring

How do we know if the therapy is effective at How do we know if the therapy is effective at delivering oxygen to the brain?delivering oxygen to the brain? Jugular Venous Saturation Monitoring (SjOJugular Venous Saturation Monitoring (SjO22))

Late 1980s and early 1990s Late 1980s and early 1990s

Gives global cerebral informationGives global cerebral information

Labor intensiveLabor intensive

Brain Tissue Oxygen Monitor (Licox)Brain Tissue Oxygen Monitor (Licox) 20002000--presentpresent

Gives partial pressure of Oxygen in brain parenchymaGives partial pressure of Oxygen in brain parenchyma

Observed levels of ischemiaObserved levels of ischemia

Currently, more of a prognostic tool. However, promising guidelines Currently, more of a prognostic tool. However, promising guidelines are emergingare emerging

Capable of microdialysisCapable of microdialysis

Discernable levels of PBODiscernable levels of PBO22 for ischemia and for ischemia and poorpoor outcomeoutcome

LicoxLicox

HemedexHemedex

Trauma Care in Trauma Care in

OregonOregon

Oregon Trauma SystemOregon Trauma System

1982 1982 –– Dr. Daniel Lowe evaluated 762 trauma cases from 26 Dr. Daniel Lowe evaluated 762 trauma cases from 26 PortlandPortland--area hospitalsarea hospitals He found 25% of the fatalities and 16% of all outcomes were He found 25% of the fatalities and 16% of all outcomes were

“inappropriate” for the severity of the injury“inappropriate” for the severity of the injury

Average response time for trauma surgeon was more than an hourAverage response time for trauma surgeon was more than an hour

1983 1983 –– State Senators Steve Starkovich and John Kitzhaber State Senators Steve Starkovich and John Kitzhaber M.D., introduced Senate Joint Resolution 23, which authorized M.D., introduced Senate Joint Resolution 23, which authorized Oregon Health Services (OHS) to develop a plan for a statewide Oregon Health Services (OHS) to develop a plan for a statewide trauma system. trauma system.

1985 1985 –– Senate bill 147 provided the authority to establish a Senate bill 147 provided the authority to establish a statewide trauma systemstatewide trauma system

1988 1988 –– Oregon Trauma System begins Oregon Trauma System begins


It was the first state to develop a system that included It was the first state to develop a system that included

small rural hospitals as well as large urban facilities and small rural hospitals as well as large urban facilities and

that was voluntarily entered into by the hospitals. that was voluntarily entered into by the hospitals.

Oraganized and centralized trauma careOraganized and centralized trauma care

Under the direction of the State Trauma Advisory Under the direction of the State Trauma Advisory

Board (STAB)Board (STAB)

The state is divided by geography and population into The state is divided by geography and population into

nine Area Trauma Advisory Board (ATAB)nine Area Trauma Advisory Board (ATAB)

Report to STABReport to STAB



Facts about the Oregon Trauma SystemFacts about the Oregon Trauma System

• Since its inception, 133,859 trauma patients have been treated • Since its inception, 133,859 trauma patients have been treated within the Oregon Trauma System, and 21,474 patients have within the Oregon Trauma System, and 21,474 patients have been transferred within the system to a higher level of care. been transferred within the system to a higher level of care.

• Forty• Forty--four hospitals throughout Oregon participate in the four hospitals throughout Oregon participate in the trauma system. trauma system.

• The trauma system includes six hospitals outside of Oregon • The trauma system includes six hospitals outside of Oregon ----four in Washington, one in Idaho and one in California. four in Washington, one in Idaho and one in California.

• Trauma patients are transported by 169 EMS agencies within • Trauma patients are transported by 169 EMS agencies within the trauma system. the trauma system.

Oregon Trauma SystemsOregon Trauma Systems

A few facts about injury prevention A few facts about injury prevention

The unintentional death rate for Oregon children ages The unintentional death rate for Oregon children ages 00--14 has dropped 54 percent since 1996. 14 has dropped 54 percent since 1996.

An Allstate Insurance study ranked the Portland An Allstate Insurance study ranked the Portland metropolitan area as one of the top 10 safest places for metropolitan area as one of the top 10 safest places for teenage drivers. teenage drivers.

Oregon is a leader in the nation for passing safety Oregon is a leader in the nation for passing safety legislation, including primary safety belt use; motorcycle legislation, including primary safety belt use; motorcycle helmet use; bike, skateboard, roller blade and scooter helmet use; bike, skateboard, roller blade and scooter helmet use for children under 16; graduated licensing helmet use for children under 16; graduated licensing laws for teens; and child safety seats and booster seat laws for teens; and child safety seats and booster seat use. use.

Oregon Trauma RegistryOregon Trauma Registry

Data PointsData Points Mechanism of injuryMechanism of injury

fall heightfall height

MVA speedMVA speed

composite description of what happened to the patientcomposite description of what happened to the patient

Response timeResponse time 911 call and scene times911 call and scene times

EMS agency was the first responder/ transporter EMS agency was the first responder/ transporter

Mode of transportMode of transport whether pt. arrived by ground or airwhether pt. arrived by ground or air

Field vitalsField vitals at multiple time pointsat multiple time points

GCS GCS

Airway status Airway status number of intubation attempts (ETCO2 values) number of intubation attempts (ETCO2 values)

other field interventions such as IV, IOother field interventions such as IV, IO and Cand C--Collar.Collar.

Intracranial pressure monitor insertion and tracheostomiesIntracranial pressure monitor insertion and tracheostomies

ICUICU length of staylength of stay

Total length of stayTotal length of stay

Outcome Outcome

DispositionDisposition

Sounds great, but how Sounds great, but how

are we doing?are we doing?

American College of Emergency Physicians American College of Emergency Physicians

2008 Report Card2008 Report Card

American College of Emergency American College of Emergency

Physicians 2008 Report CardPhysicians 2008 Report Card

Traumatic Brain Injury Traumatic Brain Injury

in Oregonin Oregon

Oregon TBI EpidemiologyOregon TBI Epidemiology

There were over 681 deaths in Oregon associated with There were over 681 deaths in Oregon associated with TBI in 2007.TBI in 2007.

Over 3,000 hospitalizations associated with TBI in Over 3,000 hospitalizations associated with TBI in 2007.2007. Males have higher rates of TBI associated death and Males have higher rates of TBI associated death and

hospitalization.hospitalization.

Firearms are the most frequent cause of TBI death.Firearms are the most frequent cause of TBI death.

Falls are the most frequent cause of TBI Falls are the most frequent cause of TBI hospitalization.hospitalization.

TBI was associated with over TBI was associated with over $145 million$145 million in in hospitalization charges in 2007.hospitalization charges in 2007.

Oregon TBI StatisticsOregon TBI Statistics

MortalityMortality The ageThe age--adjusted mortality rate due to TBI declined adjusted mortality rate due to TBI declined

between 1999 and 2006, yet increased in 2007 from between 1999 and 2006, yet increased in 2007 from 20062006 Increased public awarenessIncreased public awareness

Improved access to careImproved access to care

?? Helmet Law?? Helmet Law

The rate in 1999 was 20.0 per 100,000, while the 2007 The rate in 1999 was 20.0 per 100,000, while the 2007 rate was 17.5 per 100,000. rate was 17.5 per 100,000.

In total, there were In total, there were 4,506 deaths4,506 deaths in Oregon associated in Oregon associated with TBI between 1999 and 2007.with TBI between 1999 and 2007.



The rate of TBI is higher The rate of TBI is higher

in males than females, in males than females,

typically three times the typically three times the

female rate from year to female rate from year to

year. year.

In 2007, the male rate In 2007, the male rate

was 28.7 per 100,000 was 28.7 per 100,000

compared to the female compared to the female

rate of 7.2 per 100,000rate of 7.2 per 100,000


Age and Sex Age and Sex Age distribution of TBI rates shows Age distribution of TBI rates shows

that rates generally increase with age, that rates generally increase with age, and that the highest rates are among and that the highest rates are among males 85 and oldermales 85 and older

The rate for males in this age group is The rate for males in this age group is 137.4 per 100,000 population, while the 137.4 per 100,000 population, while the rate for females in the same age group rate for females in the same age group is 71.0 per 100,000.is 71.0 per 100,000.

The high rate among older men The high rate among older men generally reflects the higher risk and generally reflects the higher risk and mortality due to falls, motor vehicle mortality due to falls, motor vehicle traffic deaths, and firearmstraffic deaths, and firearms

PrePre--existing medical conditions were existing medical conditions were reported for 81.7% of geriatric patientsreported for 81.7% of geriatric patients



The leading causes of TBIThe leading causes of TBI--

related death indicate that related death indicate that

firearms were involved in 43% firearms were involved in 43%

29% were the result of MVT 29% were the result of MVT

injuryinjury

17% were due to falls17% were due to falls

10% were due to a variety of 10% were due to a variety of

other causes.other causes.


Mechanism of Injury in the ElderlyMechanism of Injury in the Elderly

The most common mechanism wasThe most common mechanism was

ground level fall (31.4%)ground level fall (31.4%)

falls from steps or stairs (19.5%)falls from steps or stairs (19.5%)

increases as the patients’ age increases. increases as the patients’ age increases.

third most common mechanism of injury was a fall from a third most common mechanism of injury was a fall from a

ladder (17.3%), which decreases in frequency as age ladder (17.3%), which decreases in frequency as age

increases. increases.

These three types of falls accounted for 68.2% of the These three types of falls accounted for 68.2% of the

known fall injuries known fall injuries


HospitalizationHospitalization

TBITBI--associated associated

hospitalization rates have hospitalization rates have

increased since 1997increased since 1997



Establishing a Establishing a

Statewide Brain Injury Statewide Brain Injury

ConsortiumConsortium

What is a brain injury consortium?What is a brain injury consortium?

Multiple centers, centralized reportingMultiple centers, centralized reporting

Routine review of trauma statistics and patternsRoutine review of trauma statistics and patterns

Trauma designation/Tertiary referralsTrauma designation/Tertiary referrals

Centralize the careCentralize the care

Directed at extending efficient care to local and rural areasDirected at extending efficient care to local and rural areas

Neurotrauma specialistsNeurotrauma specialists

FullFull--spectrum carespectrum care

PrePre--hospital/transporthospital/transport

Acute careAcute care

RehabilitationRehabilitation

Who is involved?Who is involved?

…..Everyone…..Everyone First RespondersFirst Responders

Emergency DepartmentEmergency Department

Trauma ServiceTrauma Service

NeurosurgeonsNeurosurgeons

IntensivistsIntensivists

NeurologistsNeurologists

PM&RPM&R

PT/OT/STPT/OT/ST

NeuropsychologyNeuropsychology

ICU and floor RNsICU and floor RNs

Many, many moreMany, many more

What are the goals of a brain injury What are the goals of a brain injury

consortium?consortium?

Organized, consistent careOrganized, consistent care

Clear guidelines (algorithms) for decisionClear guidelines (algorithms) for decision--makingmaking

“right patient, right facility, right treatment.”“right patient, right facility, right treatment.”

Timely access to specialty careTimely access to specialty care

Public servicePublic service

Public educationPublic education

Potential for researchPotential for research

What are the resources needed?What are the resources needed?

Multiple sites for care implementationMultiple sites for care implementation

SHRBSHRB

OHSUOHSU

Legacy EmanuelLegacy Emanuel

?Based on ATABs?Based on ATABs

Trauma CoordinatorsTrauma Coordinators

Neurotrauma director & liasonNeurotrauma director & liason

Expansion of data collection points Expansion of data collection points

Cooperation of rehab/longterm care facilitiesCooperation of rehab/longterm care facilities

Funding??Funding??

Are there models in place?Are there models in place?

Current Head injury consortiumsCurrent Head injury consortiums

MassachusettsMassachusetts

Not directed at the acute managementNot directed at the acute management

Focused on Rehab/Long term care Focused on Rehab/Long term care

StateState--based resources for the injuredbased resources for the injured

“No head injury was too “No head injury was too

trivial that it should be trivial that it should be

ignored or too severe that it ignored or too severe that it

be despaired of.”be despaired of.”

Hippocrates, 400 BCHippocrates, 400 BC

Thank youThank you

Documents

Establishing a Statewide Brain Injury ConsortiumNational Epidemiology Traumatic Brain Injury (TBI) is the leading cause of death and disability in children and adults from ages 1 to