Stuart Duffin is an intensive care doctor & anaesthetist working in Stockholm, Sweden. In this talk from #SWEETS17 he looks at the difficulties front line clinicians face when predicting prognisis in severe traumatic brain injury. How can we possibly be able to look reliably into the future to allow us to make the right decisions? How can we avoid falling into the fallacy of the self fullfilling prophecy and not even knowing it? Full talk: http://scanfoam.org/prognosis-in-tbi-a-hard-nut-to-crack/

1. Prognosis in brain injury
A hard nut to crack
Stuart Duffin
Intensive Care Department
Karolinska University Hospital, Solna
@stuart_duffin

2. Disclosures

3. Sara

4. Sara

5. What we really want to know is...
…how’s it going to go?

6. Extended
Glasgow
Outcome
Scale
(GOS-E)

7. Extended
Glasgow
Outcome
Scale
(GOS-E)

8. Extended
Glasgow
Outcome
Scale
(GOS-E)

9. It’s hard to make predictions,
especially about the future
-Yogi Berra

11. Glasgow
Coma
Scale

12. Pupils

13. Age
Nelson DW et al, J Neurotrauma
2010

14. CT features

15. Compressed
basal cisterns
Midline shift

16. Secondary injury
Hypoxia
Hypotension
Hypo/hyperglycemia
Anemia
……………….etc

17. Biomarkers
S100b

18. Thelin EP et al, Acta Neurochir (Wien).
2017 Feb;159(2):209-225

19. Beware the self fulfilling
prophecy…

20. Sara
A 22-year-old woman was the unrestrained driver in a roll-
over motor vehicle accident during which she was
ejected, and the car rolled on top of her. Her initial GCS
was 3 with non-reactive pupils bilaterally. In the field she
was hypotensive (BP 84/52, HR 74), with no O2 saturation
documented. She was intubated and transported to a
Level I Trauma Center. Here, her GCS was 3T with non-
reactive pupils bilaterally.
The initial trauma workup revealed an acute L parietal
subdural hematoma with 12 mm midline shift and uncal
herniation, diffuse axonal injury in the L thalamus and
bilateral atlanto-occipital dislocation, with associated
prevertebral swelling extending to C4. In addition, she had
multiple facial fractures, bilateral rib fractures with a left
hemo-pneumothorax, bilateral pulmonary contusions,
shock bowel and several extremity fractures. Toxicology
screen was positive for alcohol and marijuana.
Neurocrit Care (2013) 19:347–363

21. Sara
18% of doctors recommended
withdrawal of care
50% of neurosurgeons
recommended withdrawal of
care
Neurocrit Care (2013) 19:347–363
Death
66% or 80%?
GOS-E ≤ 3
79% or 90%?

22. Sara
6 months later
Communicating
Walking
Outpatient physio
Still improving…
Neurocrit Care (2013) 19:347–363

23. Take homes…
Early prognostication in TBI is a REALLY hard nut to crack
Age, motor score, pupils, compression/midline shift most useful
Beware the self fulfilling prophecy
Get the basics right, always
- It’s not rocket science, it’s only neurosurgery