How Can Apps Help People with Brain Injury?

How Can Apps Help People with Brain Injury?


Apps are really important for individuals
with traumatic brain injury and PTSD and other kinds of brain conditions. What I found is that they really allow individuals
to apply cognitive skills in a very practical functional way in a way other than often they
get in more traditional kids of therapies. When an individual has a brain injury they
have difficulty with organization and time management and memory and decision making. And one of the interesting things about apps
is that apps allow them to apply strategies to deal with some of those issues that they
might be facing on an everyday life. But the apps give them immediate feedback
that they can then use in order to sort of determine whether or not they’re on the
right track. Whereas if you’re using something like paper
and pencil it’s not so easy to see the results. The other thing about apps is that they’re
with them every day, all day long. And so they’re able to actually use the
applications throughout the day to ben them and to help them with some of the cognitive
struggles that they have.

Traumatic Brain Injury (TBI): Insights from the National Institute of Nursing Research


MUSIC NARRATOR: The National Institute of Nursing Research,
or NINR, supports the science that improves health and wellness for people at every stage
of life. Research supported by NINR also develops the
science that can lead to better patient care. And the Institute supports tomorrow’s discoveries
by training the next generation of nurse scientists. Dr. Jessica Gill is among those who have benefited
from NINR’s training programs. Her research aims to identify those who are
at risk for ongoing complications from traumatic brain injury. DR JESSICA GILL: The focus of my lab is traumatic brain injuries, or TBIs. These are extremely common in the lives of
Americans. About one-fourth of individuals in America
will have at least one of these injuries during their lifetime. The focus of our work is to understand this
individual variability through looking at biomarkers that we can look at in the blood
to understand how genes and proteins relate to this risk with the idea that if we can
identify these individuals and we can find ways to treat them better, we can prevent the
onset of these symptoms. A big focus of my lab is looking at a protein
called tau which is a microtubule associated protein that is secreted from the brain when
there’s damage following a traumatic brain injury or a concussion. We’ve found that tau elevations relate to
recovery from TBIs. They’ve also been linked to greater risks
for neuro degeneration both from Alzheimer’s disease as well as something called chronic
traumatic encephalopathy or CTE, in which some athletes with multiple sub-concussive
hits and concussions can go on to have Alzheimer’s-like disease risk factors as well as symptoms and
deficits. One of the major limitations in looking at
tau is that it’s in very low concentrations following brain injury. So it’s something like looking for grains
of sand in an Olympic sized swimming pool but what we found is having five grains of
sand versus 50 grains of sand is really important to measure and to link to disability following
TBI’s. So what we’ve done is use an ultra sensitive
technology that’s been developed commercially and we’ve been able to look at tau in very
small quantities in these individuals with more mild related injuries and to be able
to look at it in their blood as well as their sweat and their saliva. One of the big findings from our lab is that
following a sports-related concussion we can see elevations in total tau in the blood relate
to a prolonged return to play. Such that those athletes that need a prolonged
return to play will have elevations in tau within their blood within six hours of the
concussion. What’s really important about this finding
is that if an athlete goes back to play prior to full recovery from that brain injury and
then has another concussion or brain injury they’re at the highest risk to have lasting symptoms
and deficits. So by having a biomarker that helps us make
those very difficult decisions, it helps improve the safety of the athletes. As a nursing scientist I approach research
as a way to address a question, and for me my question came from being an emergency room
nurse. I would see patients coming in acutely with
traumatic brain injuries and concussions. And we’d send them off but many of them would
not get better and we didn’t know why. So I came to the NIH to be able to do additional
training to better understand the reasons why these patients weren’t recovering with
a focus being if we can identify the reason, then we can find an intervention to help those
individuals.

Division of Vocational Rehabilitation Services for Traumatic Brain Injury (TBI)

Division of Vocational Rehabilitation Services for Traumatic Brain Injury (TBI)


[ Music ]>>Interviewer: The Brain Injury
Guide and Resources is a tool for professionals,
community members and family to understand Traumatic
Brain Injury as well as how to promote better living for
those who live with a TBI. In this interview we will
talk with John Harper, assistant director of
mental health services in the Missouri Division of
Vocational Rehabilitation Office of Adult Learning
and Rehabilitation. We’ll be discussing Division of Vocational Rehabilitation
services for TBI survivors. And John, thank you very
much for being with us. We appreciate it.>>John Harper: I’m
glad to be here.>>Interviewer: First of
all, what is the Division of Vocational Rehabilitation
and what are its primary goals?>>John Harper: The Vocational
Rehabilitation is the state agency in Missouri administering
the federal program under the Rehabilitation Act. The Rehabilitation Act is those
services that are provided under the federal law to assist
persons with disabilities with going back to work.>>Interviewer: And what are
the types of services provided by your division
related to education and then also employment?>>John Harper: Certainly. Well, really the focus,
the goal, is going to work from our services, and
if you can imagine any of the related services
that could support going to work, including education. We help people with retraining,
if need be, to go to work, attending college,
junior college courses, certificate training
programs and so forth. We also have some very
specialized services called supported employment. So let’s say an individual
is just interested in going back to work. We help them find a job, and we provide something called
job coaching services to assist that individual with
learning the job again, or having somebody to talk about
the relationships while working, all of those activities that
a lot of us take for granted.>>Interviewer: And does your
agency work with other agencies that might help people
with a TBI?>>John Harper: Certainly. Certainly. That’s one of the keys to the Vocational
Rehabilitation program. Really, administratively as
an agency, a federal agency, we’ve been around oh, I
guess about 85 to 90 years. So we started doing this
just after World War I as an agency federally,and
really had set the routine of collaborating
and coordinating with various agencies
across the country. VR initially was working with
Veterans returning to work, and started reaching out really
into the educational field. And that’s where we’re
located at the federal program.>>Interviewer: And how does a
person with a TBI get involved with your organization?>>John Harper: If an individual
is interested in our services, they merely need to contact
one of our 25 district offices across the state and request
to have an appointment with counselor, and that
counselor will walk them through the eligibility
process and describe to them the services that they
might have available to them to support them to
return to work.>>Interviewer: How successful
is your program, John? Are you able to get
people back to work?>>John Harper: Oh,
we’re highly successful. I’m very proud of
the Missouri program. Typically out of
the 85 VR agencies, the State of Missouri general
program is usually one, number one or number
two, in the country. Our success rate typically
is around 65 percent of the individuals that
we’ve provided services to go back to work. Very oftentimes those that
maybe don’t have a job, they usually return back to us because something is
going on in their lives. They just can’t move forward
yet, so they come back and then we’re successful
with them at a later date.>>Interviewer: So is it
typically maybe some other organization that
refers people to you? Is that how they get to you?>>John Harper: Well, yes. Certainly,it’s not unusual
for individuals that are, especially with Traumatic Brain
Injury, their treatment team to contact a VR counselor
and bring them in to the process
very early just to start creating some
relationship with the survivor and the family to have that
discussion about employment. One of the things that
we very often like to do in the VR agency is try to
help that person go back to the job they had
previously and retain that job. We can do many things working
with the individual as well as the employer to make
that transition back to work more effective.>>Interviewer: What if
the individual is not sure if they can go back
to work, John? Should they still
contact your agency?>>John Harper: Yes, certainly., hey should contact our agency. One of the primary services
we provide is Vocational Rehabilitation Guides
and counseling. Very oftentimes it
becomes a matter of timing for an individual, a survivor
of Traumatic Brain Injury, to make that determination,of
what’s the appropriate point that I need to go back to work, hen should I start
exploring that? Because there are many
factors regarding that, especially fatigue, and
it’s a primary factor.>>Interviewer: All right. John Harper, thanks so
much for being with us. We appreciate it.>>John Harper: Thank
you very much.>>Interviewer: And thank you
for watching this interview on Vocational Rehabilitation
Services After TBI, a service of the Brain
Injury Guide and Resources. [ Music ]

The Brain Injury Rehabilitation Program at Craig Hospital

The Brain Injury Rehabilitation Program at Craig Hospital


– There’s a reason why
thousands of patients like me have walked through the
doors of Craig Hospital every year since 1955. It’s not just because of
Craig’s world class outcomes, or expertise in brain injury, or the remarkable longevity of staff, leading research, peer mentoring, and family housing. It’s not because of the
patient centered treatment, or state-of-the-art facility. When you come to Craig, you’re not just getting
the best care out there. When you come to Craig, you join a family. (light upbeat music) – Craig is more than just a place for brain injury rehabilitation. It’s a place that changes you forever, and helps you return to an independent and meaningful life. – Why we chose Craig was, from the second that
I walked in the doors, in knew it was the right place. Everywhere that I went on the tour, I thought, oh my God, this is amazing, there’s people out and
about doing therapy, everyone looks so happy, felt like there was a camaraderie. – Following a catastrophic brain injury it’s important to understand that you, or your loved one may
need a very specialized, focused brain injury system of care. – This is where you wanna go for a complex traumatic brain injury because of the experience that we have as a collective group of physicians, and therapy, and nursing specialists. So, our specialized approach, and our years of experience and expertise, give us a real unique ability to address needs for the patients. – Knowing that they were
nationally renowned. That they had this
multi-disciplinary care team. They had exceptional patient outcomes, and as evidence that
where I was sending Mike was gonna be amazing. – After our initial assessment, we set up goals, we work everyday, every week, towards those goals. We align with the patient and their family in terms of where they
wanna be when they go home. – When we got there, they set us up, introduced us to our care team. – And the teams consist of the physician, a rehabilitation nurse, a neuropsychologist, a physical therapist, occupational therapist, and speech therapist, but we also have a therapeutic
recreation specialist, a music therapist. – The entire rehabilitation
team needs to understand those interactive dynamics. Personalized, individualized care, taking into account the individual, personal traits with
the injury’s severity, and then as an individual gets better with their injury, you as a team, have to have the experience and wherewithal to keep up
with their changing needs, and keep up with families
changing expectations, and be prepared for community integration, and the next phase of their life. – The other part is
critical of our component, in terms of team planning is, who is this patient? And recognizing this person before injury and where we have to get
them to after injury. – One thing that Craig always said is that we’re not just here for only you, we’re here for your whole family, which is something that made me feel super comfortable while being there because when a brain injury happens, it doesn’t just happen to an individual, it does happen to the entire family. – Craig houses families on the campus. So, right next to us is family housing. Families can be involved in
their loved one’s whole day, from getting up in the morning, to going to bed at night, and I think that’s a
comfort for families, too. – It’s not just a recommendation that families are involved. It’s actually, pretty much, an expectation that families are involved in all of our therapy sessions, in order to learn the skills, to be able to take their
loved one home with them. – I think, as a nurse, I was able to see that the
employees where super happy, and I think that that actually
makes a big difference in the care that you get, and in terms of their outcomes, you can see that. – Our discharge to home rate is very high. So, we’re not only able to
take folks through inpatient, but we’re also able to follow them through our community
reintegration program, and our driving program, and our outpatient program, back out into the community, and help support them to be successful. – The speech therapy, that was the main focus
point being an engineer and getting back at that cognitive level the demands of kinda high
paced work environment. – Speech pathologists and
occupational therapists work together for
augmentative communication. So, helping of patient’s
ability to communicate and then, assistive technology, which also may be, them being able to access technology, or use technology to, again, communicate with kinda the outside world. – What’s really impactful
about therapy here at Craig is maximizing somebody’s independence, bathing, dressing, feeding, homemaking, we have all the adaptive equipment, or adaptive techniques for somebody with limited mobility to be able to participate
in those activities. – When patients come to
Craig this is all new and what we really wanna
provide for them is hope, is opportunity, is really opening the
doors of what’s possible. – Years later, as I look back and we all look in the mirror, how am I in one piece? And I can’t fathom the recovery process going any better on any level, and I get a little smile to my face when I’m going through
the hallways at Craig because I know what I was like, and what Craig did for me. – It’s important to be confident that you’ve chosen the best quality care for yourself, or your loved one. Our patients live healthier, happier, and more independent lives than their peers at other facilities. At Craig, we don’t just provide
the best care out there. We empower lives. So, come to Craig and join our family. Visit craighospital.org to
start your admissions process.

CRASH-3 trial: The world’s first drug for traumatic brain injury

CRASH-3 trial: The world’s first drug for traumatic brain injury


An artist without imagination, is not an artist. I was out on my bicycle, I just came to, on the pavement and with people around me. What I eventually got diagnosed is
with a traumatic brain injury. After the accident, I had what would be
the equivalent of writer’s block I just couldn’t make any, I couldn’t,
I didn’t have the imagination. That was heartbreaking, actually. Head injury is a really awful problem, if it doesn’t kill you outright, it kills the person you were. Each year, worldwide, something like 60 million
people experience traumatic brain injury and many millions of them will die. The CRASH-3 trial shows that tranexamic acid, a simple, widely available drug, inexpensive could save tens of thousands of lives –
it’s a very important result and it’s really good news for public health. Traumatic brain injury is an injury to the
brain that comes from a mechanical force. You may get a torn vessel that continues to bleed and because the skull cannot expand if you have a clot that clot is going to press on the brain
and that causes further damage. Often, unfortunately, what we see is people then starting of with what seems to be a relatively innocuous injury and then deteriorates over a period of hours or days. The tragedy behind all of this – we don’t
have a treatment for any of these effects. I was asked, would I like to be part of this CRASH-3 study. I’m aware that I could have had the placebo but I like to think that I had the drug and that’s helped me to think more positively about my recovery. It’s the first drug that’s ever been shown to
improve outcome after traumatic brain injury. Tranexamic acid is safe in patients with head injury and reduces head injury deaths. It needs to be given as soon as
possible after head injury but if it is it will save tens of thousands of lives, worldwide. What we think the TXA (tranexamic acid) does to the brain is to stop any haemorrhage from getting
larger and causing more damage. And this is hugely exciting, after decades of research. Funded by the British public, it’s the largest clinical trial in head injury ever conducted. It was a global collaboration, involving doctors
and nurses from all around the world. High, middle and low income countries – working together – to try and find better treatments for traumatic brain injury. And it worked. It’s important to bear in mind that TXA (tranexamic acid)
is already a recommended drug for injury. What we didn’t know before, is whether TBI (traumatic brain injury) patients should be
included in that group of injuries, in general. I think now the practice would be, you’ve
been in a road traffic accident there’s a good chance you will benefit from this drug. So, in a way, the question is, why wouldn’t you give it? The return of imagination took several years. My life is different now. I just feel so lucky.

Living With A Stranger: My Husband’s Brain Injury

Living With A Stranger: My Husband’s Brain Injury


2 years ago, a stranger came to live in my house. The stranger looked a lot like my husband. But while my husband was warm, funny, and caring… The stranger was cold… humorless… and distant. My husband had always worked hard, taken care of the bills, and fixed the things around the house that needed fixing. But the stranger left that all up to me. He didn’t want to work. He didn’t care how we would pay the rent. Some days he didn’t even get out of bed. I no longer had a partner. And everything fell on MY shoulders. My husband and I were blessed with a beautiful daughter. And it might sound cliché but… she was his world. The stranger simply ignored her. Acted like she didn’t even exist. It seemed like he only cared about himself. And worst of all, the stranger had a terrible temper. He would get angry at the smallest things. Yell at me for hours because I simply asked him how he was feeling. His behavior, frightened and embarrassed our daughter. There were even times I was scared he might hurt me physically. But fortunately, it never came to that. My husband had always been very responsible and social. We enjoyed spending time with each other, and with our friends and family. But the stranger wanted me all to himself. He didn’t want anyone to visit. And he wouldn’t let me go out. I became more and more isolated. It seemed my whole life revolved around trying to hold our lives together. Taking care of our family, and taking care of this… lookalike. It felt like I was a nurse and a parent to a grown man. On the rare occasions I did get to see my friends I’d be desperate for them to ask me how I was feeling, how I was coping. For a shoulder to cry on. But they didn’t see my pain. They only asked me about the stranger. How HE was feeling. How HE was coping. It felt like I was living in a bubble. I wanted to scream. To cry out ‘WHAT ABOUT ME!’ I wanted to run away from it all. But I didn’t. I couldn’t. I kept it all locked up inside and carried on. I hid everything behind a smile and tried to make things as normal as possible for our family. Because the truth is… my husband never left. The man who came to stay is not a stranger. He’s the same man I met and fell in love with. The man I married and the father of our little girl. But 2 years ago, his life… our lives… changed forever. (CRASHING SOUND) My husband is one of the 5.3 million Americans who live with the devastating consequences of traumatic brain injury. And I am one of the millions of Americans who live with a spouse or loved one who has experienced a traumatic brain injury. Overnight I became my husband’s caretaker. His brain injury affected his memory. He forgot how to do simple tasks, making him feel confused and helpless. And for the longest time his feelings were trapped inside. But then one day he finally opened up to me about how he felt. How it seemed like he had an invisible rain cloud that followed him everywhere. And how the rain cloud made everything seem cold and gray. We became involved in the Brain Injury Association. He found support groups, and he got help. I also found a support group where I met others who were going through similar situations in their lives. It really helped to be able to talk to other people who understood what I was going through. We still have ups and downs. And there are still days that I worry about the future. But with patience, love and support, we are learning to adapt to our new lives together. Thank you for listening to my story.

Reducing Severe Traumatic Brain Injury in the U.S.


>>>GOOD AFTERNOON AND WELCOME TO THE CDC PUBLIC HEALTH
GRAND ROUNDS. THERE WILL BE A SIGNUP SHEET. SO THOSE FROM THE CENTER WHO ARE
NOT HERE IN PERSON, WE’LL HAVE A DISCUSSION ABOUT THAT LATER. BUT THOSE OF YOU WHO ARE HERE,
VERY GOOD TO SEE YOU. I ALSO WOULD LIKE TO WELCOME
MANY OF THOSE WHO ARE JOINING US BY INTERNET AND HERE ARE THE WEB
PAGE WHERE PEOPLE CAN WATCH US BASICALLY THROUGH YOUTUBE. TODAY’S TOPIC IS DRAMATIC BRAIN
INJURY. BEFORE WE LAUNCH INTO THE
SESSION, I WOULD LIKE TO TAKE A COUPLE OF MINUTES AND HAVE A
PERSONAL STORY OF A YOUNG GIRL WHO HAS EXPERIENCED TRAUMATIC
BRAIN INJURY BEING SHARED WITH YOU.>>IT WAS JANUARY 10th, 2005. I WAS 17 YEARS OLD AND MY HIGH
SCHOOL BASKETBALL TEAM WAS PLAYING A VARSITY GAME. AND IT WAS AROUND THE SECOND
QUARTER AND I WAS GOING UP FOR A REBOUND AND AS I CAME DOWN, THE
BACK OF MY HEAD COLLIDED WITH THE TOP OF ANOTHER GIRL’S HEAD. THE NEXT DAY, AFTER THE DAY I
GOT HIT, I WENT TO SCHOOL AND I WAS REALLY SICK. I KNOW I HAD A CONCUSSION
BECAUSE I SUFFERED THROUGH A CONCUSSION ANY SEVENTH GRADE
YEAR. I HAD ALL THE SYMPTOMS, DIZZY,
NAUSEOUS, I COULDN’T FOCUS IN SCHOOL. I CONTINUED TO PLAY A SECOND
GAME AFTER THAT AND I HAD PASSED OUT AFTER THE SECOND GAME IN THE
LOCKER ROOM. BASICALLY, I WAS BED RIDDEN IN
MY HOUSE FOR ABOUT SIX MONTHS STRAIGHT. I SLEPT ON THE COUCH BECAUSE OF
THE LIGHT. WE HAD TO PUT DARK SHEETS OVER
THE WINDOWS. MY MOM AND MY SISTER HAD TO HELP
ME WALK AROUND. I LOST MY BALANCE. I COULDN’T REALLY GET THAT BACK
FOR QUITE A WHILE. I DIDN’T KNOW IT COULD GET THIS
BAD. ALL ATHLETES HAVE A STRONG WILL
AND SINCE WE’RE YOUNG, WE KNOW THAT WE HAVE TO SUCK IT UP, SUCK
THINGS UP, WHETHER, YOU KNOW, YOU SPRAIN YOUR ANKLE OR YOU
HURT YOUR FINGER, YOU JUST GO IN THE GAME AND YOU SHAKE IT OFF
AND YOU DON’T COMPLAIN, YOU DON’T CRY. BUT THIS IS THE BRAIN AND HEAD
WE’RE TALKING ABOUT AND YOU CAN’T SUCK IT UP. SO UNFORTUNATELY INSTEAD OF
MISSING A GAME, I MISSED THE SEASON, I MISSED SPORTS FOR THE
REST OF MY LIFE AND I MISS OUT ON A GREAT LIFE THAT I COULD
HAVE HAD. ATHLETES NEED TO KNOW, IF YOU
THINK YOU HAVE A CONCUSSION, DON’T HIDE IT, REPORT IT. IT’S BETTER TO MISS ONE GAME
THAN THE ENTIRE SEASON.>>SPEAKERS, WE ACTUALLY HAVE
ONLY THREE SPEAKERS TODAY, BUT THEY CERTAINLY MAKE UP IN
QUALITY FOR THE FIVE OR FOUR THAT WE NORMALLY HAVE. OUR OWN DR. LISA McGUIRE, DR. DAVID WRIGHT FROM THE EMORY UNIVERSITY AND DR. ART KELLERMANN FROM RAND CORPORATION. EACH ONE OF THEM WILL TALK ABOUT
DIFFERENT ASPECTS OF HOW WE ARE DEALING WITH TRAUMATIC BRAIN
INJURY. THIS IS A COURSE THAT QUALIFIES
FOR THE CONTINUING EDUCATION CREDIT AND FOR THE FIRST TIME
NOW, WE ARE GOING TO BE HAVING Q&A SESSIONS AFTER YOU LISTEN TO
THE SESSION. YOU SHOULD GO TO THE WEB PAGE,
ANSWER FOUR OF THE FIVE QUESTIONS TO BE ABLE TO GET THE
CREDIT FOR THIS SESSION. SO JUST SITTING AND LISTENING IS
NOT ENOUGH ANY MORE. I WOULD ALSO LIKE TO POINT OUT
THAT, AS ALWAYS, WE ARE COORDINATING SLIDE CLIPS WITH
THE TOPIC OF OUR GRAND ROUNDS AND I WOULD LIKE TO THANK OUR
COLLEAGUES FROM THE INJURY CENTER WHO HAVE MADE THE
SELECTION FOR THIS WEEK. FINALLY, THIS IS A GROUP OF
PEOPLE THAT, AS ALWAYS, HAD TO DO SOME TEAM WORK. SO IN THIS TERM, DAVID CALL A
CALL AT THE EMORY AND WE ALL DEALT TO SEE HOW THE PATIENTS
DEAL WITH THESE REALLY SERIOUS AND LIFE THREATENING ISSUES AND
NURSE TONYA OR NURSE JACKIE WAS WATCHING ASIDE AND HAD TO GIVE
AN ENORMOUS AMOUNT OF CREDIT FOR THESE UNBELIEVABLY PROFESSIONALS
WHO HAVE WORKED WITH ME AND TOLERATED A LOT OF LITTLE DO
THIS, DON’T DO THIS TO MAKE THIS WHAT I HOPE IS GOING TO BE,
AGAIN, AN OUTSTANDING SESSION. I’D LIKE TO BRAG ABOUT THE
NUMBER OF PEOPLE THAT COME AND VIEW THIS SESSION BECAUSE IT’S
REALLY NOT JUST THE NUMBER OF PEOPLE IN THE AUDITORIUM. IT’S THOUSANDS OF PEOPLE, AS YOU
CAN SEE FROM THIS CHART, WHO HAVE BEEN WATCHING US LIVE. AND TO BE VERY SPECIFIC IN THE
PAST COUPLE OF YEARS THAT WE HAVE BEEN DOING THIS, WE HAVE
HAD 329,751 PEOPLE WHO HAVE WATCHED US ELECTRONICALLY. IN SOME WAY, WHETHER IT’S LIVE
OR DOWNLOADED OUR SESSIONS. THAT’S A HUGE NUMBER OF PEOPLE
FOR A PUBLIC HEALTH TOPIC. TO ASSURE THAT WE ACTUALLY
CONTINUE WITH THE QUALITY AND WITH THE INTEREST THAT WE HAVE
GOTTEN SO FAR, WE ARE GOING TO BE TAKING A BREAK. AND AFTER TWO YEARS OF DOING
THIS MONTH AFTER MONTH, WHAT WE WOULD LIKE TO DO IS WE WOULD
LIKE TO DO A LITTLE BIT OF REASSESSMENT, WHAT IS IT THAT
WORKS VERY WELL, WHAT IS IT THAT NEEDS TO BE IMPROVED? WE WOULD LIKE TO CONTINUE MAKING
THIS ABOUT SCIENCE AS THE FOUNDATION OF WHAT WE DO, AS THE
FOUNDATION OF DECISIONS THAT ARE BEING MADE AND RECOMMENDATIONS
THAT STEM FROM A LOT OF THESE DECISIONS. WE ALSO WOULD LIKE TO KEEP
EVERYTHING ABOUT PRACTICE AND THE EXCITEMENT OF PUTTING SOME
OF THESE INTERVENTIONS IN PRACTICE, BUT IN THE END, IT
REALLY IS ALL ABOUT YOU, THOSE OF YOU WHO ARE EITHER COMING
HERE IN PERPENDICULAR OR WHO ARE WATCHING US THROUGHOUT THE
COUNTRY AND WORLDWIDE AS THIS POINT, WHAT IS IT THAT MOTIVATES
YOU TO COME HERE, TO LISTEN TO THESE SESSIONS AND WHAT IS IT
THAT YOU TAKE BACK FROM THEM THAT IS USEFUL FOR YOU IN YOUR
WORK? SO WITH THAT, JUST TO GIVE YOU A
SENSE OF WHAT IS COMING IN THE NEXT NINE TO TEN MONTHS — LIKE
I SAID, WE WILL BE TAKING A BREAK IN OCTOBER AND NOVEMBER. THEN WE HAVE ROUND UP ANOTHER
SERIES OF WHAT I THINK YOU WILL FIND EXTREMELY INTERESTING
TOPICS AS I HAVE LISTED HERE. AS IT HAPPENS, WE TRIED TO
COORDINATE A LOT OF EVENTS AND TRIED TO POINT OUT EVENTS THAT
HAPPENED AT THE SAME TIME AS OUR GRAND ROUNDS. SO JUST TODAY, IN OUR NEW
SECTION, WE HAVE A YEAR OF ASSESSMENT OF WHAT IS IT THAT
HAS BEEN DONE IN A BATTLE SESSION, AS YOU KNOW, MOTOR
VEHICLE CRASHES ARE ONE OF CDC’S WINNABLE BATTLES. I’M GOING TO READ TO YOU ONE
SENTENCE FROM THAT ARTICLE THAT CAME TODAY. IN 2009, ABOUT 12,000 MORE
INJURIES WOULD HAVE BEEN PREVENTED AND ABOUT 450 MORE
LIVES SAVED IF ALL STATES HAD PRIMARY ENFORCEMENT SEAT BELT
LAWS. AND YOU WILL SEE THAT SEAT BELT
LAWS, MOTOR VEHICLE CRASHES AND TRAUMATIC BRAIN INJURIES ARE
VERY MUCH INTERTWINED. BEFORE WE MOVE TO OUR
SPECTACULAR SPEAKERS, WE ARE GOING TO MOVE TO OUR SPECTACULAR
CDC DIRECTOR, WHO IS NOT HERE TODAY, BUT IS GOING TO PROVIDE
HIS COMMENTS THAT HE HAS VIDEOTAPED.>>ABOUT 1.7 MILLION AMERICANS
HAVE A TRAUMATIC BRAIN INJURY EACH YEAR. TBIs ARE CAUSED BY FALLS, MOTOR
VEHICLE CRASHES, FIREARMS AND BLAST INJURIES. THE RESULTS CAN RANGE FROM MILD
TO SEVERE. SOME CAN RESULT IN LIFELONG
COGNITIVE IMPAIRMENT OR EVEN DEATH. SEVERE TBIs AFFECT FAMILIES AND
COMMUNITIES AND THEY’RE PREVENTABLE WITH PRIMARY
PREVENTION STRATEGIES, INCLUDING HELMETS AND SEAT BELT USE LAWS. WHEN TBIs OCCUR, EARLY
IDENTIFICATION AND MANAGEMENT ARE KEY TO MINIMIZING SECONDARY
BRAIN INJURY WHILE REHABILITATION IS KEY TO REGAIN
FUNCTION AND MINIMIZE PERMANENT DISABILITY. IMPLEMENTING PREVENTION
STRATEGIES AND RESPONDING TO TBIs IS COMPLICATED BY THE
COMPLEX NATURE OF TBI. NO ONE STRATEGY WILL ADDRESS ALL
RISKS OR CONSEQUENCES OF TBI. WE NEED STRONGER INJURY
SURVEILLANCE, MORE USE OF EXISTING PRIMARY PREVENTION
STRATEGIES AND RESEARCH TO EXPAND OUR EVIDENCE BASE FOR
PREVENTION. THE RULE OF PUBLIC HEALTH AND
REDUCING TBIs INCLUDES KEY ACTIVITIES SUCH AS SUPPORTING
SURVEILLANCE, IDENTIFYING BEST PRACTICES, IMPLEMENTING AND
DISSEMINATING RESPECTIVE INTERVENTION AND RIGOROUSLY
EVALUATING INTERACTION TO SEE IF WE HAVE THE INTENDED IMPACT. THIS SESSION WILL DISCUSS TBIs,
PROMSING TO PREVENT AND TREATMENT THEM AND MANY OF THE
CHALLENGES WE FACE MOVING FORWARD. THANK YOU.>>>GOOD AFTERNOON I’M LISA McGUIRE FROM CDC’S
NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL. I’M GOING TO TALK TO YOU THIS
AFTERNOON ABOUT THE THE PUBLIC HEALTH ROLE IN SEVERE TRAUMATIC
BRAIN INJURY OR TBI. THE CDC DEFINES A TBI AS A BRAIN
INJURY THAT DISRUPTS THE NORMAL FUNCTIONING OF THE BRAIN. IT CAN BE CAUSED BY A BUMP, A
BLOW OR A JOLT TO THE HEAD OR ALSO A PENETRATING HEAD INJURY. THERE ARE AT LEAST 1 MILLION
TBIs SUSTAINED IN THE UNITED STATES EVERY YEAR. THESE NUMBERS UNDERESTIMATE THE
TRUE BURDEN OF TBIs. THEY DO NOT INCLUDE TBIs TREATED
IN NONHOSPITAL BASED BEDDING, SUCH AS A DOCTOR’S OFFICE OR
OUTPATIENT CLINIC. THEY ALSO DO NOT INCLUDE TBIs
THAT WERE SUSTAINED BY MILITARY PERSONNEL THAT HAVE BEEN TREATED
IN EITHER A MILITARY OR VETERAN’S ADMINISTRATION MEDICAL
SETTING. TO ILLUSTRATE THE MAGNITUDE OF
TBI IN THE MILITARY, THE DEPARTMENT OF DEFENSE REPORTED
THAT MORE THAN 31,000 U.S. MILITARY PERSONNEL WERE
DIAGNOSED WITH A TBI IN 2010. FINALLY, TBIs OFTEN GO
UNDIAGNOSED IN THE PRESENCE OF OTHER LIFE THREATENING
CONDITIONS. AT LEAST ONE PERSON SUSTAINS A
TBI EVERY THREE MINUTES IN THE UNITED STATES. MALES ARE MORE LIKELY TO SUSTAIN
A TBI THAN FEMALES AND WHEN MALES DO SUSTAIN A TBI, THEY’RE
THREE TIMES MORE LIKELY TO DIE FROM THAT TBI THAN FEMALES ARE. CDC HAS ESTIMATED THAT 5.3
MILLION PEOPLE LIVE WITH A LONG-TERM COGNITIVE AND
PSYCHOLOGICAL IMPAIRMENT OR OTHER LONG-TERM CONSEQUENCES
ASSOCIATED WITH A TBI. USING LIFETIME ESTIMATES OF COST
OF TBI IN THE U.S. FOR THE YEAR 2000 AND AJUSTING FOR INFLATION,
WE ESTIMATE THAT THE 2010 COST FOR TBIs WERE $76.3 BILLION. OF THAT, $11.5 BILLION WERE DUE
TO DIRECT MEDICAL COSTS AND $64.8 BILLION ARE DUE TO
INDIRECT COSTS SUCH AS LOST WAGES, PRODUCTIVITY LOSS AND
NONMEDICAL RELATED EXPENDITURE. NOW LET’S DISCUSS THE CAUSES OF
TBI. FALLS ARE THE OVERALL LEADING
CAUSE OF TBI AMONG CIVILIAN POPULATIONS. FOR EXAMPLE, ACTRESS NATASHA
RICHARDSON FELL WHILE SKIING. THIS RESULTED IN AN EPIDURAL
HEMATOMA THAT CAUSED HER DEATH. MOTOR VEHICLE CRASHES ARE THE
SECOND LEADING CAUSE OF TBI AND THEY’RE THE LEADING CAUSE OF TBI
RELATED DEATHS. TBIs ACCOUNT FOR NEARLY
ONE-THIRD OF ALL INJURY RELATED DEATHS IN THE U.S. IT’S ALSO IMPORTANT TO KNOW THAT
TBIs DO NOT OCCUR IN ISOLATION. THEY MAY OCCUR IN COMBINATION
WITH OTHER INJURIES WHICH MAY BE SERIOUS OR LIFE THREATENING. WE WILL NOW LOOK AT THE RATES OF
TBI BY AGE AND CAUSE. FALLS ARE THE LEADING CAUSE OF
TBIs. THE RATES ARE HIGHEST IN
CHILDREN AND OLDER ADULTS. FALLS COST APPROXIMATELY 50% OF
THE TBIs IN CHILDREN AGE ZERO TO 14 YEARS AND A LITTLE MORE THAN
60% OF THE TBIs IN ADULTS AGE 65 YEARS OLD AND OLDER. MOTOR VEHICLE CRASHES ARE THE
SECOND LEADING CAUSE OF TBIs. HOWEVER, MOTOR VEHICLE CRASHES
ARE THE LEADING CAUSE OF TBI FOR TEENS AND ADULTS 15 TO 34 YEARS
OLD. MALES AGE 5 TO 24 YEARS OLD AND
ANYBODY WHO IS AGE 85 YEARS OLD AND OLDER HAVE THE HIGHEST RATES
OF TBI DEATH FROM MOTOR VEHICLE CRASHES. TBI SEVERITY IS CLASSIFIED AS
MILD, MODERATE OR SEVERE. FOLLOWING AN INJURY,
CLASSIFICATION MAY BE BASED ON THE LENGTH AND DEPTH OF COMA OR
ALTERED CONSCIOUSNESS. IT ALSO CAN BE BASED ON THE
ANATOMICAL DESCRIPTION OF THE INJURY OR THE FUNCTIONAL
OUTCOME. DR. WRIGHT WILL TELL US A LITTLE
BIT MORE ABOUT THIS IN HIS PRESENTATION. WHY FOCUS ON THIS IN SEVERE TBI? MANY TBI SURVIVORS, PRIMARILY
THOSE WITH SEVERE TBI CAN FACE LONG-TERM DISABILITY. ONE STUDY ESTIMATED THAT
NATIONWIDE 43% OF TBI SURVIVORS WHO HAD BEEN HOSPITALIZED HAD
TBI RELATED DISABILITIES REMAINING ONE YEAR AFTER THEIR
INJURY. ADDITIONALLY, THE COST OF FATAL
TBIs AND TBIs REQUIRING HOSPITALIZATION, MANY OF WHICH
ARE SEVERE, ACCOUNT FOR APPROXIMATELY 90% OF THE TOTAL
TBI MEDICAL COSTS. I WILL NOW DISCUSS NONFATAL TBIs
AND HOW TO REDUCE THE CONSEQUENCES. HERE ARE SOME POTENTIAL
CONSEQUENCES, LET ME HIGHLIGHT JUST ONE, COGNITIVE IMPAIRMENT. COGNITIVE IMPAIRMENT OR DEFICIT
CAN INCLUDE MEMORY LOT LOSS AND DIFFICULTIES AND PLANNING OR
PROBLEM SOLVING. THIS CAN AFFECT THE PERSON’S
ABILITY TO PERFORM EVEN VERY SIMPLE TASKS, SUCH AS
REMEMBERING WHERE THEIR KEYS ARE OR FINDING THEIR WAY HOME AT THE
END OF THE DAY. TBIs AFFECT THE FAMILIES, THE
COMMUNITY AND THE SOCIETY AS A WHOLE. FOR EXAMPLE, FAMILY MEMBERS MAY
NEED TO ADJUST THEIR ROLE WITHIN THE FAMILY IN ORDER TO PROVIDE
CARE. A PRIMARY BREAD WINNER MAY NO
LONGER BE ABLE TO WORK AT THE SAME JOB WITH THE SAME INTENSITY
OR EVEN WORK TODD. AT ALL. SOCIETAL FACTORS MAY INCLUDE
ECONOMIC STRESS, PRODUCTIVITY LOSS, INCREASED DEPEND YANTANCE
ON SOCIAL PROGRAMS OR SUPPORT. THERE ARE THREE WAYS TO REDUCE
THE SEVERE TBI AND ITS CONSEQUENCES. PRIMARY PREVENTION, EARLY
MANAGEMENT AND THE COMPREHENSIVE APPROACH TO REHABILITATION AND
REINTEGRATION. I WILL START WITH HIRING
PREVENTION. THE OPTIMAL WAY TO REDUCE
MORBIDITY, MORTALITY, AND ECONOMIC CONSEQUENCES OF
INJURIES IS TO PREVENT THEIR OCCURRENCE. THERE ARE SEVERAL AVENUES FOR
PREVENTION, INTERVENTION PRESENTED HERE. FALLS ARE THE NUMBER ONE CAUSE
OF TBI. TO REDUCE FALLS, EXERCISE AND
BALANCE TRAINING HAVE BEEN SHOWN TO BE EFFECTIVE. ONE OF THE CHALLENGES WITH
PRIMARY PREVENTION IS ENSURING STRATEGIES ARE BROADLY ADOPTED. MANY ARE BEST IMPLEMENTED
THROUGH POLICY. AND, DOCTOR KELLERMANN WILL
ADDRESS THESE. WHEN TBIs DO OCCUR, RAPID
TRANSPORTATION TO APPROPRIATE TRAUMA CARE IS NECESSARY. CDC SUPPORTED RESEARCH
DEMONSTRATED THAT THE RISK FOR DEATH FOR SEVERELY INJURED
PATIENTS WAS 25% LOWER WHEN THE PATIENT RECEIVED CARE AT A LEVEL
ONE TRAUMA CENTER. THE GUIDELINES FOR FIELD TRIAGE
OF INJURED PATIENTS PROVIDES EMERGENCY MEDICAL SERVICE
PROVIDERS OR EMS WITH THE ABILITY TO IDENTIFY SEVERELY
INJURED PATIENTS. THEN TO RAPIDLY TRANSPORT THEM
TO THE HIGHEST LEVELS OF CARE WITHIN THE TRAUMA SYSTEM. UNFORTUNATELY, NEARLY 45 MILLION
AMERICANS DO NOT HAVE ACCESS TO A LEVEL ONE OR A LEVEL TWO
TRAUMA CENTER WITHIN ONE HOUR EITHER BY GROUND OR AIR
TRANSPORT. THESE FACILITIES HAVE THE
RESOURCES TO TREAT PATIENTS WITH THE MOST LIFE THREATENING
INJURIES. THE BRAIN TRAUMA FOUNDATION
GUIDELINES PROIT PROVIDE HEALTH CARE PROFESSIONALS WITH EVIDENCE
BASED PATIENT CARE TREATMENT RECOMMENDATIONS. SOME EXAMPLES ARE LISTED HERE. CDC RECOMMENDS THE WIDESPREAD
ADOPTION OF THESE GUIDELINES. DR. WRIGHT WILL DISCUSS THIS, AS
WELL. EACH PATIENT NEEDS AN
INDIVIDUALIZED COMPREHENSIVE APPROACH TO REHABILITATION AND
REINTEGRATION. THIS WILL HELP TO ENSURE THE
PATIENT REACHES THEIR MAXIMUM FUNCTIONAL POTENTIAL AND LEARNS
TO ADAPT TO THEIR DISABILITY. U.S. CONGRESSWOMAN GABRIEL
GIFFORDS, AS YOU KNOW, WAS SHOT IN THE HEAD EARLIER THIS YEAR. SHE SUSTAINED A SEVERE TBI. HER ABILITY TO OBTAIN
COMPREHENSIVE REHABILITATION SERVICES IS ONE FACTOR THAT’S
LED TO HER RECOVERY. REHABILITATION REQUIRES A
COMPLEX MIX OF SERVICES. UNFORTUNATELY, NOT EVERY PERSON
IS ABLE TO OBTAIN THESE NEEDED SERVICES. FOR EXAMPLE, SOME SERVICES ARE
NOT PROVIDED IN EVERY GEOGRAPHICAL AREA. AND EVEN WHEN THOSE SERVICES ARE
AVAILABLE, HEALTH INSURANCE CAN LIMIT THE AMOUNT OF TYPE OF
SERVICES THAT A PERSON MIGHT RECEIVE. FINALLY, THE DEVELOPMENT AND
VAEBLGZ OF NEW REHABILITATION INTERVENTION, INCLUDING THE
LENGTH OF TIME FOR RECOVERY MUST INCORPORATE THE GROWING EVIDENCE
OF NEURAL PALACE ADVERTISE TYUR NEURAL PLASTICITY. OUR GOAL IS TO IMPROVEMENT THE
MANAGEMENT OF TBI WHEN IT HAPPENS. KEY ACTIVITIES IN THIS EFFORT
ARE SURVEILLANCE, IDENTIFICATION OF EVIDENCE BASED STRATEGIES AND
DISSEMINATION AND IMPLEMENTATION OF THOSE STRATEGIES. SURVEILLANCE IS IMPORTANT TO ALL
STAGES OF THE PREVENTION RESPONSE. WE AT PUBLIC HEALTH DO HAVE A
ROLE. MANY CURRENT DATA SOURCES DO NOT
PROVIDE THE LEVEL OF DETAIL NEEDED TO FULLY UNDERSTAND THE
EPIDEMIOLOGY AND LONG-TERM CONSEQUENCES AND OUTCOMES OF
TBI. THE DEVELOPMENT OF A STANDARD
DEFINITION FOR TBI, IN ADDITION TO A TRUE NATIONAL INJURY
SURVEILLANCE SYSTEM WILL INFORM PREVENTION EFFORTS. LONGITUDINAL OR FOLLOW-UP
STUDIES WILL HELP US EVALUATE INTERVENTION FOR THEIR
EFFECTIVENESS. WE HAVE A ROLE IN DEVELOPING,
IDENTIFYING, AND DISSEMINATING EVIDENCE-BASED PRIMARY
PREVENTION STRATEGIES. MANY OF THESE STRATEGIES
RECOMMENDED BY CDC’S GUIDE TO COMMUNITY PREVENTIVE SERVICES
ARE BEING IMPLEMENTED ACROSS THE U.S. WE KNOW THAT NOT ONE SIZE FITS
ALL. THE MULTIPLE POTENTIAL CAUSES OF
TBI REQUIRE MULTIPLE INTERVENTION WITH ACTION ON ALL
LEVELS. MOVING FORWARD, WE NEED TO
TAILOR INTERVENTION FOR HIGH RISK POPULATIONS AND TO EVALUATE
PROGRAMS AND POLICIES IN ORDER TO IMPROVE IMPLEMENTATION. THROUGH RESEARCH, PUBLIC HEALTH
CAN ADDRESS GAPS IN EXISTING POLICIES AND WITH STATE ASK
LOCAL COMMUNITIES CAN FULLY IMPLEMENT EFFECTIVE
INTERVENTION. WE HAVE A ROLE IN THE
IDENTIFICATION DISSEMINATION OF EARLY MANAGEMENT STRATEGIES FOR
TBI. ESPECIALLY THROUGH THE
IMPROVEMENT OF GUIDELINES OF FIELD TRIAGE AND TRAUMA SYSTEMS
DEVELOPMENT. ACCESS TO TRAUMA CARE IS CRUCIAL
TO MINIMIZING LONG-TERM CONSEQUENCES OF TBI. HOWEVER, THIS ACCESS IS NOT
AVAILABLE IN ALL AREAS. WE CAN ALSO SUPPORT THE
DEVELOPMENT OF TRAUMA SYSTEMS INTEGRATED WITHIN PUBLIC HEALTH
ACROSS THE UNITED STATES. WE HAVE A ROLE IN SUPPORTING THE
REHABILITATION AND REINTEGRATION OF INDIVIDUALS BACK INTO THEIR
COMMUNITY. THE CURRENT EVIDENCE SHOWS THAT
A COMPREHENSIVE PROGRAM OF REHABILITATION IS THE MOST
EFFECTIVE WAY OF MINIMIZING NEGATIVE CONSEQUENCES. IN ORDER TO SUPPORT THIS, WE
NEED TO WORK WITH PARTNERS TO IDENTIFY MECHANISMS FOR
REIMBURSEMENT THAT ALLOW FOR INCREASED ACCESS TO
COMPREHENSIVE CARE. FURTHER, WE NEED TO COLLABORATE
WITH THE CLINICAL COMMUNITY TO BUILD THE EVIDENCE BASED FOR
COMPREHENSIVE REHABILITATION, INCLUDING LINKAGES TO PUBLIC
HEALTH PREVENTION, INCIDENT HER VENGZ TO SUPPORT LIFELONG
HEALTH. PARTNERSHIPS ARE THE ENGINE THAT
DRIVES PROGRESS TO PREVENT AND TREATMENT TRAUMATIC BRAIN
INJURY. FOR EXAMPLE, ONE COMMON
DEFINITION OF TBI CAN OHM BE REACHED IF ALL PARTNERS AGREE TO
IMPLEMENT IT WITHIN THEIR SURVEILLANCE SYSTEM. ADDITIONALLY, SHARING THE
FINDINGS BETWEEN THE MILITARY AND CIVILIAN MEDICAL COMMUNITIES
CAN ENCOURAGE REHABILITATION ACTIVITY. FEDERAL AGENCIES, STATE AND
LOCAL HEALTH DEPARTMENTS AND NATIONAL AND COMMUNITY
ORGANIZATIONS CAN COOPERATE TO IDENTIFY AND IMPLEMENT EFFECTIVE
PREVENTION STRATEGIES. PUBLIC HEALTH DOES HAVE A ROLE. OUR NEXT SPEAKER THIS AFTERNOON
IS DR. DAVID WRIGHT.>>GOOD AFTERNOON. THANK YOU, LISA. MY NAME IS DAVID WRIGHT. I AM THE DIRECTOR OF EMERGENCY
NEUROSCIENCES AT EMORY UNIVERSITY AT THE DEPARTMENT OF
MEDICINE AND I’M A PRACTICING PHYSICIAN AT GRADY MEMORIAL
HOSPITAL, ARGUABLY, ONE OF THE BUSIEST TRAUMA CENTERS IN THE
NATION. SO TODAY WE ARE GOING TO TALK
ABOUT OR DISCUSS, RATHER, THE IMPORTANCE OF THE FOUNDATION
GUIDELINES AND ALSO KIND OF REVIEW THE EXISTING RESEARCH
GAPS FOR HOPES OF OPPORTUNITIES IN CHANGE AND IMPROVEMENT AND
INTRODUCE WHAT I’M EXCITED ABOUT, A NOVEL AND POTENTIAL
TREATMENT FOR TRAUMATIC BRAIN INJURY. FIRST, I WANT TO COVER A LITTLE
BIT ABOUT WHAT GOES ON AFTER A BRAIN INJURY OCCURS. THE INITIAL TRAUMA IS REALLY
ONLY THE FIRST PHASE OF INJURY. IT’S THE SECONDARY PHASE THAT’S
CHARACTERIZED BY ACTIVATION OVER A WHOLE HOST OF NEUROTOXIC
EVENTS AND ACTIVATION OF PATHWAYS THAT CAUSE PROBABLY
MOST OF THE MORBIDITY AND MORTALITY AFTER SURVIVABLE
INJURIES. THIS SECONDARY INJURY BEGINS
IMMEDIATELY AT THE TIME OF THE ACCIDENT AND THEN CONTINUES TO
OCCUR FOR MONTHS, EVEN UP TO A YEAR AFTER THE INJURY. NOW, THE EARLIEST MECHANISMS
DISCOVERED WERE THE RELEASE OF NEUROTRANSMITTERS, THE INFLUX OF
HUGE AMOUNTS OF CALCIUM INTO THE CELL AND OTHER IONS WHICH
OVERWHELM THE CELL AND CAUSED EVENTUAL NECROSIS AND CELL
DEATH. HOWEVER, I THINK THIS SLIDE IS
PRETTY OBVIOUS TO EVERYONE, RIGHT? WE KNOW IT TO BE MUCH MORE
COMPLICATED THAN THAT. IN FACT, THERE ARE MULTIPLE
PATHWAYS THAT ARE ACTIVATED. IN THIS SLIDE, YOU CAN BEGIN TO
SEE MANY OF THOSE PATHWAYS THAT ARE ACTIVATED, INCLUDING THE
RELEASE OF INFLAMMATORY CYTOKINES, EDEMA AND EVEN
SELF-SUICIDE, SOMETHING CALLED APOTOSIS. SO IT’S IMPORTANT TO RECOGNIZE
THE COMPLEXITY OF BRAIN INJURY AND WHAT’S GOING ON AFTERWARDS
SO THAT WE CAN BETTER INFORM DRUG DISCOVERY AND ALSO DEVELOP
SUCCESSFUL TREATMENT STRATEGIES. HOWEVER, EVEN WITH A CLEARER
UNDERSTANDING OF THE PATH OF PHYSIOLOGY AT TBI AND OVER 150
DIFFERENT TARGETS AVAILABLE FOR US, WE HAVE YET TO FIND A
TREATMENT THAT CAN IMPROVE THE FUNCTIONAL OUTCOME. WHERE ARE WE CURRENTLY TODAY? THERE ARE FLEEMTS AVAILABLE THAT
TARGET THE SECONDARY CASCADE AND IMPROVE FUNCTIONAL OUTCOME. THIS HAS LED EXPERTS AROUND THE
COUNTRY TO EXAMINE WHY IS THIS? WHAT ARE THE RESEARCH GAPS? WHAT ARE THE REASONS FOR
CLINICAL FAILURES? WELL, THE MOST OBVIOUS RESEARCH
GAP IS THE VERY DEFINITION AND CLASSIFICATION OF TRAUMATIC
BRAIN INJURY. WE CURRENTLY — OR OUR CURRENT
APPROACH IS BASED SOLELY ON AN INDIVIDUAL’S RESPONSE TO THE
ENVIRONMENT. HOW AWAKE ARE THEY? THIS CATEGORIZATION OR SCALE
DIVIDES PATIENTS INTO MILD, MODERATE AND SEVERE. THIS IS CRUDE, OKAY? OVEN CONTAMINATED BY ALCOHOL,
OTHER DRUGS, SUCH AS A DRUG THAT WE GIVE THEM, AND IT LACKS, MOST
IMPORTANTLY, ANY PATHOLOGICAL LINK. IT TELLS YOU NOTHING ABOUT
WHAT’S GOING ON IN THE BRAIN AT THE TIME OF THE INJURY. THIS DOES A DECIDES SERVICE TO
THE INJURY AND OUR ABILITY TO ASSESS THE PATIENTS. THIS IS AN EXAMPLE. THIS IS SIX DIFFERENT PATIENTS. EACH OF THESE PATIENTS HAVE A
SCALE OF SIX. NONE OF THEM HAVE THE SAME TYPE
OF INJURY. NONE OF THEM WILL HAVE THE SAME
PROGNOSIS. SO THE LACK OF A GOOD
CLASSIFICATION SYSTEM HAS REALLY IMPACTED BOTH OUR ABILITY TO
ASSESS AND MANAGE PATIENTS, BUT ALSO HAMMERED OUR CLINICAL
TRAUMAS. WE NEED A BETTER CLASSIFICATION
SYSTEM. ANOTHER GAP IS OUR MECHANICISTIC
APPROACH TO DRAMATIC BRAIN INJURY, THAT MAGIC BULLET. SINGLE ION CHANNEL BLOCKERS SUCH
AS CALCIUM CHANNEL BLOCKERS AND OTHER THINGS HAVE BEEN TRIED AND
THEY ACTUALLY WORK IN ANIMALS. WHEN THEY TAKE THEM TO THE
CLINICAL TRIAL, THEY DON’T WORK ANY MORE. SO THESE SINGLE, SINGLE PATHWAY
APPROACHES ARE NOT LIKELY TO BE ROBUST ENOUGH TO WORK IN A HUMAN
MODEL. WHAT WE REALLY NEED IS A MULTI
DIMENSIONAL APPROACH, EITHER DRUGS THAT ARE PLEOTROPIC OR
MULTIPLE DRUGS AT ONE TIME. FORTUNATELY THE NIH IS NOW
EXPLORING MULTIPLE DRUG THERAPIES IN THEIR GRANT
PROGRAM. HOWEVER, TO ME, THE ELEPHANT IN
THE ROOM IS OUR CURRENT THERAPY. AND THE VERY ABILITY CAUSED BY
IT. THE DIFFERENCES IN MORTALITY IN
TRAUMATIC BRAIN INJURY PATIENTS ACROSS THIS COUNTRY IS HUGE,
SOMEWHERE AROUND 20% TO 65% MORTALITY DEPENDING ON WHAT
HOSPITAL YOU GO TO. IT REALLY DOES MATTER WHERE YOU
GO FOR CARE IN THE UNITED STATES. THIS BACKGROUND VARIABILITY IS
UNACCEPTABLE, OKAY? IT IS LIKELY RESPONSIBLE FOR
DROWNING OUT MULTIPLE OR RATHER DROWNING OUT ANY TREATMENT
EFFECT OF OUR PREVIOUSLY PROMISING THERAPIES IN CLINICAL
TRIALS. HERE WE GO. SO, INDEED, THE BETTER
IMPROVEMENT AND OUTCOME THAT 20% IS LINKED ACTUALLY TO FOLLOWING
A SET OF SIMPLE BRAIN TRAUMA FOUNDATION GUIDELINES. NOW, THERE’S CLEAR EVIDENCE THAT
THESE GUIDELINES IMPROVE CARE AND SAVE LIVES. YET THE ADOPTION RATE OF THESE
ARE UNBELIEVABLY ONLY ABOUT 65% IN THE U.S. SO CONSEQUENTLY, THERE’S STILL A
LOT OF VARIABILITY IN A MORTALITY AND MORBIDITY OF
TRAUMATIC BRAIN INJURY PATIENTS. IT’S ESTIMATED THAT IF WE
ADOPTED THESE WIDELY OR UNIVERSALLY, THAT WE WOULD SAVE
SOMEWHERE AROUND $262 MILLION IN MEDICAL CARE COSTS, 43 MILLION
IN REHABILITATION COSTS AND ALMOST 4 BILLION IN LIFETIME
SOCIETAL COSTS EVERY YEAR. SO, AFTER DECADES OF FAILURE IN
THE SEARCH FOR AN EFFECTIVE DRUG TREATMENT, THERE IS HOPE. IN 1991, DR. DONALD STEIN, ONE
OF THE WORLD’S TOP NEUROSCIENTISTS AND A COLLEAGUE
OF MINE HERE AT EMORY SUSPECTED THAT PROGESTERONE MIGHT HAVE
POTENT NERVE PROTECTIVE PROPERTIES. AT THE TIME, THIS RESEARCH WAS
THOUGHT TO BE CRAZY. EVERYBODY THOUGHT DON WAS CRAZY. AFTER ALL, EVERYBODY KNOWS THAT
PROGESTERONE IS JUST A FEMALE HORMONE, RIGHT? HOW COULD IT HELP VICTIMS OF
TRAUMATIC BRAIN INJURY? FORTUNATELY, THE CDC PLAYED A
PIVOTAL ROLE IN THIS EARLY RESEARCH. DON PUT IT THIS WAY, AND I
QUOTE, THE CDC WAS THE FIRST FEDERAL AGENCY WILLING TO TAKE A
GAMBLE ON WHAT MANY AT THE TIME THOUGHT WAS PIE IN THE SKY. THEIR INITIAL TWO-YEAR GRANT TO
MY TEAM KICK STARTED IT ALL. WITH A BOOST FROM THE CBC, DON’S
TEAM INITIATED A WHOLE SERIES OF ELEGANT EXPERIMENTS THAT
PROVIDED THE DATA NECESSARY FOR THE NIH. AND TO GET THE NIH’S ATTENTION. THIS STORY ACTUALLY DEMONSTRATES
AN IMPORTANT LINK BETWEEN CLINICAL MEDICINE AND PUBLIC
HEALTH. BOTH DISCIPLINES WANT TO REDUCE
DISEASE AND INJURY BURDEN. CLINICAL MEDICINE CONSIDERS THE
INDIVIDUAL, WHERE PUBLIC HEALTH, OBVIOUSLY, HAS A BROADER VIEW. IN THIS CASE, THE CDC RELATIONED
THAT THIS UNORTHODOX IDEA HAD THE POTENTIAL TO SAVE HUNDREDS
OF THOUSANDS OF LIVES IN THE U.S. AND ACROSS THE WORLD. WHAT DON DISCOVERED WAS THAT HIS
FEMALE RATS WERE PERFORMING BETTER AFTER A HEAD INJURY. INDEED, WHEN THE RATS WERE
EXCEEDINGLY HIGH IN PROGESTERONE LEVELS, SUCH AS IN PREGNANCY,
THEY HAD MUCH BETTER OUTCOMES THAN THEIR MALE COUNTERPARTS AND
THEIR NONPREGNANT COUNTERPARTS. AND EVEN MORE IMPORTANTLY, BY
GETTING PROGESTERONE TO THESE ANIMALS AFTER THE INJURY, IT
IMPROVED OUTCOME IN BOTH MALE AND FEMALE ANIMALS. MORE RECENTLY, THE MECHANISMS
FOR HOW PROGESTERONE WORKS HAVE BEEN FURTHER DELINEATED. AS IT TURNS OUT, PROGESTERONE IS
PLEO TROPIC, LIKE THE DRUG COCKTAIL THAT I WAS SPEAKING
ABOUT BEFORE, WORKING AT MANY DIFFERENT SITES AND PROVIDING
SOME ROBUST NEUROPROTECTION. SO TODAY, THERE’S OVER 180
SUPPORTED PUBLICATIONS FROM MULTIPLE LABORATORIES THAT
CONFIRM DON’S FINDINGS. IT SEEMS DON WASN’T SO CRAZY
AFTER ALL. BUT THE REAL QUESTION IS, WILL
IT WORK IN HUMANS? SO ON THE STRENGTH OF DON’S LAB
SCIENCE AND OTHERS, ART KELLERMANN AND I SECURED AN NIH
GRANT TO RUN A SMALL POLLUP STUDY OF 100 GRANGER PATIENTS. THIS WORK WAS DONE RIGHT HERE. WE WERE ACTUALLY STUNNED AT THE
RESULTS. OUR STUDIES SHOW THAT
PROGESTERONE WAS NOT ONLY SAFE, IT REDUCED MORTALITY ALMOST 50%. IT’S IMPORTANT TO NOTE THAT THIS
IS A SMALL STUDY, OKAY? SO THE FINDINGS HAVE TO BE
INTERPRETED WITH CAUTION. HOWEVER, THAT SAID, A YEAR
LATER, VERY SIMILAR FINDINGS IN 159 PATIENTS WERE DEMONSTRATED
AND SHOWED AN IMPROVEMENT IN THREE AND SIX-MONTH OUTCOMES. COMBINED, THESE FINDINGS WERE
COMPELLING AND THE NIH IS NOW SPONSORING A HUGE PHASE THREE
CLINICAL TRIAL CALLED PROTECT THREE. MY COLLEAGUES AND I HOPE TO
ENROLL 1140 SUBJECTS IN 31 DIFFERENT TRAUMA CENTERS ACROSS
THE COUNTRY IN WHAT’S KNOWN AS THE NEUROLOGIC EMERGENCY
TREATMENT CENTERS NETWORK. THIS TRIAL SHOULD PROVIDE THE
EVIDENCE WE NEED TO DETERMINE WHETHER PROGESTERONE REALLY IS
THAT LONG, SOUGHT AFTER DRUG FOR TRAUMATIC BRAIN INJURY. SO WHAT IS THE PATH FORWARD? WELL, WE NEED TO REALLY URGE
CLING CLINGISHANS ACROSS THE COUNTRY TO PROVIDE THE
FOUNDATIONS FOR CARE. THIS IS CRITICAL FOR NOT ONLY
PATIENTS’ LIVES, BUT FOR IMPROVING CLINICAL TRIALS AND
HAVING THE HOPE THAT WE CAN ACTUALLY SEE A DIFFERENCE WITH
THE DRUG AT THE CLINICAL STYLE STAGE. SECOND, WE NEED TO DEVELOP A
BETTER CLASSIFICATION SYSTEM FOR BRAIN INJURY. THE ONE WE HAVE CLEARLY DOESN’T
WORK. WHETHER THAT BE BIOMARKERS AND
OTHER STRATEGIES, WE NEED ONE. THIRD, WE NEED TO KEEP TRYING. YES, THERE HAVE BEEN A LOT OF
ALTERNATIVES AND THERE ARE OTHER THERAPIES BEING CONSIDERED AT
NIH AND OTHER PROGRAM WEBS DRUGS THAT PLEOTROPIC OR COMBINATION
THERAPIES ARE MORE LIKELY TO BE SUCCESSFUL. AND LASTLY, WE NEED TO
STRENGTHEN OUR PARTNERSHIPS BETWEEN CLINICAL MEDICINE AND
PUBLIC HEALTH TO IMPROVE PREVENTION, PUBLIC AWARENESS AND
OUTCOMES. IT’S VERY IMPORTANT, THIS LINK
BETWEEN CLINICAL MEDICINE AND PUBLIC HEALTH. IT PROVIDES NOT ONLY A
SURVEILLANCE SYSTEM TO KNOW WHETHER OUR INTERVENTIONS ARE
WORKING, BUT ALSO ALLOWS US TO DISSEMINATE AND ENSURE THAT THE
TRAUMA FOUNDATION GUIDELINES ARE WIDELY ACCEPTED AND USED ACROSS
THE COUNTRY. I’D LIKE TO THANK YOU AND NOW
OUR NEXT SPEAKER IS ARTHUR KELLERMANN.>>GOOD AFTERNOON. I’M ART KELLERMANN, DIRECTOR OF
RAND HEALTH. BEFORE I JOINED RAND, I
PRACTICED EMERGENCY MEDICINE. WHEN I STARTED MY CLINICAL
CAREER, MANY PEOPLE THOUGHT IT ODD THAT AN ER DOC WOULD HAVE A
PUBLIC HEALTH DEGREE. BUT IT MAKES SENSE BECAUSE
EMERGENCY PHYSICIANS SEE WHAT HAPPENS WHEN PUBLIC HEALTH
FAILS. RICHARD THINMAN, NOBEL PRIZE
WINNING PHYSICIST ONCE OBSERVED THAT IT TAKES VERY LITTLE ENERGY
TO SCRAMBLE AN EGG AND ALL OF OUR SCIENCE IS INCAPABLE OF
REVERSING THE TRANSACTION. IT TAKES VERY LITTLE INJURY TO
SCRAMBLE A BRAIN, TOO, WITH EQUALLY LASTING EFFECTS. THAT’S WHY IT’S IMPORTANT TO
PREVENT AS MANY BRAIN INJURIES AS POSSIBLE AND LIMIT THE
SEVERITY OF THOSE THAT OCCUR. ONE OF THE MOST POWERFUL WAYS TO
DO THIS IS THROUGH EFFECTIVE PUBLIC POLICIES. TO ILLUSTRATE MY POINT, CONSIDER
THE SPECTACULAR PROGRESS WE’VE MADE IN REDUCING DEATHS AND
INJURIES FROM MOTOR VEHICLE CRASHES. MOTOR VEHICLE CRASHES ARE ONE OF
THE CDC’S WINNABLE BATTLES. THE FOCUS IS JUSTIFIED. IN ADDITION TO BEING A LEADING
CAUSE OF INJURY-RELATED DEATH IN THE UNITED STATES, MOTOR VEHICLE
CRASHES ARE THE LEADING CAUSE OF TRAUMATIC BRAIN INJURY RELATED
DEATH TO AMERICANS LESS THAN 75 YEARS OF AGE. INJURY CONTROLLED EXPERTS SPEAK
OF THE FOUR Es OF INJURY PREVENTION. THEY ARE EDUCATION, ENFORCEMENT
OF SAFETY LAWS AND REGULATIONS, ENGINEERING AND ECONOMIC
INCENTIVES. ALL FOUR STRATEGIES HAVE A
PUBLIC POLICY DIMENSION. LET’S START WITH THE FIRST “E,”
EDUCATION. DRIVERS ED PROGRAMS ARE A
PERENNIAL FAVORITE WITH STATE LEGISLATORS AND MANY PARENTS. UNFORTUNATELY, THEY DON’T WORK. A REVIEW OF THREE WELL-DESIGNED
NATIONAL EVALUATIONS FOUND THAT DRIVERS ED PROGRAMS MAY
PARADOXICALLY INCREASE CRASHES BY LOWERING THE AGE AT WHICH
TEENAGERS BECOME LICENSE WITHOUT MATERIALLY AFFECTING THEIR CRASH
RATES ONCE THEY DO. THE STUDY MOST FAMILIAR IN THE
UNITED STATES TOOK PLACE RIGHT HERE IN DeKALB COUNTY IN THE
LATE 1970s. OVER 16,000 STUDENTS WERE RAB
COMELY ASSIGNED TO THREE GROUPS, STANDARD DRIVERS EDUCATION,
DRIVERS ED PLUS, AN 80-HOUR LONG COURSE INCLUDING CLASSROOM
SIMULATION, DRIVING RANGE AND ON THE ROAD COMPONENTS AND A
CONTROL GROUP THAT RECEIVED NO FORMAL DRIVER EDUCATION. SUBSEQUENT ANALYSIS FOUND NO
MEANINGFUL DIFFERENCES AMONG THE THREE GROUPS IN THEIR SUBSEQUENT
RATE OF CRASHES OR TRAFFIC VIOLATIONS. PUBLIC EDUCATION DOESN’T WORK SO
WELL, EITHER. EARLY PR CAMPAIGNS TO FIX THE
NUT BEHIND THE WHEEL WERE INEFFECTIVE. SO WERE SUBSEQUENT CAMPAIGNS
DESIGNED TO CONVINCE THE PUBLIC TO VOLUNTARILY BUCKLE UP. NEW PASSENGER CARS HAVE HAD SOME
FORM OF SAFETY BELTS SINCE 1964. BUT AS RECENTLY AS 1982,
VOLUNTARY RATES OF USE WERE DISMAL. THE FIRST WIDESPREAD SURVEY
CONDUCTED THAT YEAR FOUND AN OVERALL USE RATE OF 11% AMONG
DRIVERS AND FRONT CEASE PASSENGER SPASS ENG SEAT
PASSENGERS. THINGS BEGAN TO IMPROVE, BUT BY
THE EARLY 1990s, RATES OF BELT USE STAGNATED AT AROUND 66% TO
86%. LAW ENFORCEMENT AGENCIES
LAUNCHED A CAMPAIGN OF CLICK IT OR TICKET. IT BOOSTED SAFETY BELT USE RATES
ABOVE 80%. PUBLIC AWARENESS AND ATTITUDES
CHANGED, AS WELL. PROGRAMS LIKE CLICK IT OR TICKET
WORK BEST IN PRIMARY ENFORCEMENT STATES WHERE AN OFFICER CAN
ISSUE A CITATION UPON OBSERVING AN UNBELTED MOTORIST. IT’S HARDER TO MOTIVATE THE
PUBLIC IN SECONDARY ENFORCEMENT STATES WHERE AN OFFICER MUST
STOP THE VEHICLE FOR SOME OTHER VIOLATION BEFORE A SEAT BELT
CITATION CAN BE ISSUED. TODAY, IT’S WIDELY ACCEPTED THAT
THE BEST WAY TO BOOST SEAT BELT USE ABOVE 83% AND KEEP IT THERE
IS THROUGH HIGH VISIBILITY ENFORCEMENT, PLUS SPECIAL
PROGRAM TOES REACH HIGH RISK GROUPS SUCH AS OCCUPIANTS OF
PICKUP TRUCKS, RESIDENTS OF RURAL COMMUNITIES AND NIGHTTIME
DRIVERS. IN CONTRAST TO THE STEADY
PROGRESS WITH SAFETY BELT USE, ALCOHOL IMPAIRED DRIVING HAS
PROVEN TO BE A TOUGHER NUT TO CRACK. BETWEEN 1982 AND THE ’90s,
PROGRESS WAS MADE. GRASSROOTS ORGANIZATIONS LIKE
MOTHERS AGAINST DRUNK DRIVING PLAYED A ROLE. SO DID HIGH VISIBILITY DUI
ENFORCEMENT AND AGAINST PUBLICITY. PUBLIC POLICIES HELPED, AS WELL. EXAMPLES INCLUDE STATE LAWS
LOWERING THE LEGAL LIMIT OF BLOOD ALCOHOL CONCENTRATION TO
0.8, ADMINISTRATIVE LICENSE REVOCATION FOR DUI AND RAISING
THE MINIMUM DRINKING AGE FROM 18 TO 21. UNFORTUNATE, SINCE THE MID
1990s, RATES OF ALCOHOL IM IMPAIRED DRIVING HAVE PLATEAUED. AS A RESULT, IM BARED DRIVING
STILL CAUSES ONE-THIRD OF FATAL CRASHES AND AN ONGOING TOLL OF
TRAUMATIC BRAIN INJURIES. IN CONTRAST TO DRIVERS ED,
GRADUATED DRIVER’S LICENSING LAWS WORK. GDL IS A THREE-PHASE SYSTEM FOR
BEGINNING DRIVERS. THE LEARNER’S PERMIT ONLY ALLOWS
DRIVING UNDER THE SUPERVISION OF A FULLY LNSD ADULT, TYPICALLY A
PARENT. AN INTERMEDIATE LICENSE FOLLOWS. IT ALLOWS UNSERVICED DRIVING,
BUT WITH CERTAIN SIGNIFICANT RESTRICTIONS. TOGETHER, THESE TWO PHASES ALLOW
A YOUNG DRIVER TO LOG VITAL HOURS OF EXPERIENCE BEHIND THE
WHEEL BEFORE GRADUATING TO A FULL, UNRESTRICTED LANGUAGE. NOW, THE MOST STRINGENT GDL
PROGRAMS, THOSE WITH AT LEAST A SIX-MONTH HOLDING PERIOD DURING
THE LEARNER STAGE, NIGHTTIME RESTRICTIONS BEGINNING NO LATER
THAN 10:00 P.M. AND ONLY ONE TEEN PASSENGER IN THE CAR WERE
ASSOCIATED WITH A 38% REDUCTION IN FATAL CRASHES AND A 40%
REDUCTION IN INJURY CRASHES AMONG 16-YEAR-OLD DRIVERS. NOW, A NEWSPAPER PUBLISHED JUST
LAST WEEK SUGGESTED SOME OF THESE BENEFITS OF GDL MAY BE
OFFSET BY HIGHER RATES OF FATAL CRASHES INVOLVING 18-YEAR-OLD
DRIVERS. PERHAPS THE THINKING GOES THAT
MORE TEENS ARE PUTTING OFF GETTING THEIR DRIVER’S LICENSE
TO AVOID THE HASSLES OF GDL AND ARE, THEREFORE, GETTING ON THE
ROAD AT 18 WITHOUT THE BENEFIT OF THOSE EXTRA HOURS BEHIND THE
WHEEL. NOW, EVEN IF THIS IS TRUE, AND
MORE RESEARCH IS NEEDED, IT DOESN’T DIMINISH THE BENEFITS OF
GRADUATED DRIVERS LICENSING FOR YOUNGER DRIVERS. MOTORCYCLE HELMET LAWS ARE
EFFECTIVE, AS WELL. THE FIRST HELMET LAW WAS ENACTED
AS FAR BACK AS 1966, BUT BY 1975, UNIVERSAL HELMET LAWS ARE
IN PLACE IN 47 STATES IN THE DISTRICT OF COLUMBIA. BUT AFTER FEDERAL PENALTIES WERE
ELIMINATED IN 1975, ABOUT HALF THE STATES REPEALED THEIR
STATUTES. SINCE THEN, SEVERAL STATES HAVE
REENACTED OR REPEALED THEIR HELMET LAWS. BUT ONE THING IS CLEAR. MOTORCYCLE HELMETS PROTECT
BIKERS’ HEADS IN A CRASH. A REVIEW FOUND THAT HELMETS
DECREASED THE RISK OF DEATH IN A CRASH BY 42% AND DECREASED THE
RISK OF HEAD INJURY BY FULLY 69%. STATES THAT ADOPT HELMET LAWS
QUICKLY SEE USAGE RATES CLIMB TO 90% OR HIGHER. CONVERSE
CONVERSELY, STATES THAT REPEAL THEIR LAWS SEE HELMET USE RATES
PLUMMET TO 15%. AND RATES OF FATAL INJURY
CLOSELY TRACK CHANGING RATES OF HELMET USE. SOME OF OUR BIGGEST POLICIES
HAVEN’T COME FROM THE BEHAVIOR OF CHANGING DRIVERS. THEY COME FROM CHANGING THE
BEHAVIOR OF MANUFACTURERS THROUGH REGULATION. THEY HAVE COME FROM ENCOURAGEING
THAT THIRD “E,” ENGINEERING. TODAY, AUTOMOBILES ARE
ENGINEERED TO BE CRASHWORTHY. KEY FEATURES INCLUDE A STRONG
OCCUPANT COMPARTMENT, THE SAFETY CAGE, CRUMBLE ZONES THAT ENFORCE
A SERIOUS CRASH, SIDE ELEMENTS THAT RESIST INTRUSION AND A
STRNG ROOF THAT WON’T COLLAPSE IN A ROLLOVER. INITIALLY, OCCUPANT RESTRAINTS
WERE LIMITED TO SEAT BELTS AND FRONTAL LAYER BACKS. TODAY, SUPPLEMENTAL SIDE AND
CURRENT AIR BAGS PROTECT YOUR HEAD, YOUR CHEST AND OTHER VITAL
ORGANS FROM SIDE IMPACTS. A CAR WITH CURTAIN AIR BAGS, IN
FACT, SAVED MY SON’S LIFE AND HIS SUFFERING A TRAUMATIC BRAIN
INJURY IN A SIDE IMPACT CRASH. NOW, ONCE MANUFACTURERS FOUGHT
SAFETY REGULATIONS TOOTH AND NAIL. BUT AT SOME POINT, AUTO EXECS
REALIZED, WAIT A MINUTE, IF THE CAR SACRIFICES ITSELF TO SAVE
YOU, YOU’RE GOING TO NEED TO BUY ANOTHER CAR. MANDATORY CRASH TESTING IS
ANOTHER VALUABLE POLICY, BASED ON DYNAMIC TESTING NEW CARS
TODAY EARN A CRASHWORTHINESS RATING. TODAY, SAFETY SELLS. THANKS TO ORGANIZATIONS LIKE
NITSA, CONSUMER REPORTS AND THE INSURANCE INSTITUTE FOR HIGHWAY
SAFETY, CONSUMERS CAN QUICKLY GET OBJECTIVE INFORMATION ABOUT
A CAR’S SAFETY FEATURES AND CRASHWORTHINESS. NO MATTER HOW GOOD WE GET AT
PREVENTING CRASHES, SOME WILL STILL OCCUR. AND WHEN THEY DO, PROMPT AND
EFFECTIVE TREATMENT MAKES ALL THE DIFFERENCE. TRAUMA CENTERS SAVE LIVES. THAT’S WHY REGIONALIZED TRAUMA
CARE SYSTEMS STRIVE TO GET THE RIGHT PATIENT TO THE RIGHT
HOSPITAL AT THE RIGHT TIME. CDC’S NEW TRAUMA TRIAGE
GUIDELINES WILL HELP. PROPERLY IMPLEMENTED, THEY’LL
SAVE THOUSANDS OF LIVES AND TENS OF MILLIONS OF DOLLARS ANNUALLY. SURVIVING THE IMMEDIATE INJURY
IS ONE THING. FULL RECOVERY IS ANOTHER. REHABILITATION BENEFITS BRAIN
INJURY PATIENTS. NOTABLE POLICY GAPS REMAIN. THEY INCLUDE BETTER EVIDENCE ON
HOW TO EVALUATE SPORTS-RELATED CONCUSSIONS AND WHEN AN INJURY
PARTICIPATAN CAN BE ALLOWED TO RETURN TO PLAY. ACCESS TO CARE IS IMPORTANT, NOT
ONLY FOR DAILY EMERGENCIES, BUT IN DISASTERS. CURRENTLY, ACCESS TO TRAUMA CARE
AND REHABILITATION IS INADEQUATE IN MANY PARTS OF THE UNITED
STATES, PARTICULARLY RURAL AND FRONTIER COMMUNITIES. THE BIGGEST POLICY CHALLENGE IN
REHABILITATION IS THE CURRENT DISCONNECTION BETWEEN WHAT
SCIENCE SAYS IS GOOD CARE AND WHAT IS COVERED BY PUBLIC AND
PRIVATE INSURERS. INSURERS SAY THEY WANT TO FIND
EVIDENCE-BASED TREATMENT, BUT THE EVIDENCE BASE IS THIN ON
SEVERAL IMPORTANT QUESTIONS. PUBLIC POLICY IS NOT STATIC. CONCERNS ABOUT PERSONAL FREEDOM
CAN TRUMP EVEN ROBUST EVIDENCE OF THE BENEFIT OF HELMET AND
SEAT BELT LAWS, PRODUCT SAFETY REGULATIONS AND EVEN LAWS THAT
ENCOURAGE EMBARRASSED DRIVING. FUNDING IS ALSO A PROBLEM. AT A TIME WHEN HEALTH CARE IS
CONSIDERING A GROWING SHARE OF FEDERAL, STATE AND FAMILY
BUDGETS, IT WILL BE HARD TO KWON VINCE POLICYMAKERS TO ADEQUATELY
FUND EMS, TRAUMA CARE AND REHABILITATION. NEVERTHELESS, IT’S IMPORTANT TO
ACKNOWLEDGE HOW FAR WE’VE COME. A LITTLE MORE THAN TEN YEARS
AGO, THE CDC IDENTIFIED MOTOR VEHICLE SAFETY AS ONE OF THE TEN
GREATEST PUBLIC HEALTH ACHIEVEMENTS OF THE 20th
CENTURY. AND EARLIER THIS YEAR, THE CDC
RECOGNIZED MOTOR VEHICLE SAFETY AS ONE OF THE TEN SIGNIFICANT
PUBLIC HEALTH ACHIEVEMENTS OF THE LAST DECADE. THANKS SO SMART PUBLIC HEALTH
POLICIES, HUNDREDS OF THOUSANDS OF PEOPLE, INCLUDING MY SON, ARE
ALIVE AND WELL TODAY. MOTOR VEHICLE INJURIES ARE MORE
THAN A WINNABLE BATTLE. IT’S A BATTLE WE’RE WINNING. THANK YOU VERY MUCH. NOW, WE HAVE A FEW MINUTES FOR
QUESTIONS. AND WHILE I AM TODAY, NOW, OUT
OF TOWNER, I USED TO BE A NEAR NEIGHBOR, I HAVE THE PRIVILEGE
OF MODERATING THIS SESSION. SO AS YOU ARE STREAMING TO THE
MICROPHONES, SO THAT FOLKS AT HOME AND ON THEIR WEBSITE CAN
LISTEN TO YOU, I’M GOING TO MOVE BACK OVER TO THE MICROPHONES. I WOULD ENCOURAGE IF YOU HAVE A
QUESTION OR A BRIEF COMMENT, PLEASE SHARE THEM WITH THE
AUDIENCE. I WILL BE AGGRESSIVE IN
ENFORCING THE ONE QUESTION RULE SO THAT EVERYBODY WHO HAS A
QUESTION HAS A CHANCE TO ASK IT. NOW, I KNOW THAT CDC PEOPLE
AREN’T THAT SHY. BUT BECAUSE YOU ARE, I WILL
START WITH THE FIRST QUESTION. LISA, I WONDER IF YOU COULD JUST
ELABORATE A LITTLE BIT MORE ABOUT THE CDC’S HEADS UP
CAMPAIGN. YOU MENTIONED IT, BUT YOU HAD A
LOT OF CONTENT TO COVER AND I WONDER IF YOU COULD ELABORATE A
BIT, PARTICULARLY GIVEN THE OPENING VIDEO.>>THANK YOU. CDC HAS A HEADS UP CAMPAIGN AND
IT ORIGINALLY STARTED WITH OUR MATERIAL AND YOU SAW TRACY AT
THE BEGINNING IN OUR VIDEO. OUR MATERIALS FOR YOUTH SPORTS
ARE DESIGNED FOR STOOUNT STUDENT ATHLETESES, PARENTS, COACHES,
WE’RE EXPANDED TO TRAINER, SCHOOL PROFESSIONALS SO THE
SCHOOL NURSE OR SCHOOL GUIDANCE COUNSELOR WHO SEES THE STUDENT
ATHLETE GOING FROM ONE SPORT TO THE NEXT, THEY TEND TO BE THE
TBAL PERSON IN THAT STUDENT ATH LEETH’S LIFE. WE ALSO HAVE MATERIAL THROUGH
FALLS PREVENTION THAT WE WORK COLLABORATIVELY WITH OUR
COLLEAGUES AND DIVISION OF UNINTENTIONAL INJURY. WE ALSO HAVE MATERIALS ON SHAKEN
BABY SYNDROME, AS WELL.>>QUESTION AT THE MICROPHONE.>>THIS IS FOR DR. KELLERMANN.>>I’M SORRY, YOU NEED TO
IDENTIFY YOURSELF. THEY ALL KNOW WHO YOU ARE, BUT
FOR DAVID AND ME, IF YOU COULD, IDENTIFY YOURSELF AND FOR PEOPLE
WHO ARE LISTENING IN.>>ARLENE GREENSPAN FROM THE
INJURY CENTER. MY QUESTION IS ONE ABOUT POLICY. WE REALLY UNDERSTAND AND
APPRECIATE N INJURY CENTER THE IMPORTANCE THAT POLICY PLAYS IN
REDUCING MORBIDITY AND MORTALITY. HOWEVER, AS YOU MENTIONED, WE’RE
CURRENTLY IN A CLIMATE THAT IS ANTI-REGULATION,
ANTI-LEGISLATION AND OFTEN WE’RE ACCUSED OF BEING A NANCY STATE
WHEN WE SUGGEST POLICIES THAT ARE PUBLIC HEALTH ORIENTED. CAN YOU GIVE SOME INSIGHTS INTO
WHAT STRATEGIES WE CAN USE TO PROMOTE GOOD PUBLIC HEALTH
POLICY AND HOW WE GO ABOUT CONVINCING PEOPLE THAT THIS IS
NOT PART OF BEING A NANNY STATE, BUT MAKES SENSE FISCALLY AS WELL
AS PUBLIC HEALTHWISE?>>IT’S A GREAT QUESTION. AND IT IS VERY TIMELY, GIVEN THE
CURRENT CLIMATE THAT WE’RE IN. FOR 17 YEARS, I WORKED WITH A
HAND FULL OF COLLEAGUES IN GEORGIA TO DEFENSE GEORGIA’S
MOTORCYCLE HELMET LAW, WHICH WAS NOT POPULAR WITH EVERY SINGLE
CONSTITUENT IN THE STATE, BUT WILDLY POPULAR WITH THE MAJORITY
IN THE STATE. BUT THERE WAS A SMALL AND VOCAL
GROUP THAT FEELS THAT THEIR NEED TO FEEL THE FREEDOM OF WIND
BLOWING THROUGH THEIR HAIR IS MORE IMPORTANT THAN THE NEED TO
WEAR A MOTORCYCLE HELMET. THEY HAD A FOLLOWING AND HAVE A
FOLLOWING AT THE GEORGIA GENERAL ASSEMBLY. I HAD A VERY SIMPLE ANSWER TO
THAT, WHICH WAS I ABSOLUTELY BELIEVE IN PERSONAL FREEDOM AND
PERSONAL CHOICE AND PERSONAL RESPONSIBILITY. I ALSO LIKE TO KEEP MY MONEY IN
MY WALLET. AND WHEN PEOPLE HAVE A SEVERE
BRAIN INJURY AND DON’T DIE OR IF THEY HAVE A SEVERE BRAIN INJURY
AND END UP AT A PUBLIC FUNDED TRAUMA CENTER, THE RESOURCE
CONSUMPTION IS ENORMOUS. THE DISABILITY CHALLENGES ARE
PROFOUND. THEY’RE NOT THE ONLY ONE WHO
SUFFERS FOR THAT MISFORTUNE OR THAT INJURY. THEIR FAMILY SUFFERS, THEIR
EMPLOYER SUFFERS, THEIR CHILDREN SUFFERS, THE LOCAL ECONOMY
SUFFERS, THE STATE’S SYSTEM IS COMPROMISED. SO, IN FACT, WE ALL HAVE AN
INTEREST AS A SOCIETY AND BALANCED AGAINST THAT, THE MINOR
INCONVENIENCE OF HAVING A MUSHY HAIR DO WHEN YOU GET TO WHEREVER
YOU’RE GOING IS A SMALL PRICE TO PAY FOR THE PAYOFF. WE DON’T QUESTION, IN MOST
STATES IN THIS COUNTRY MORE THE NEED TO WEAR A SAFETY BELT. THAT IS A BRILLIANT BRAIN INJURY
STRATEGY FOR A MOTOR VEHICLE. WEARING THE HELMET IS THE SAME
EFFECTIVE STRATEGY ON A MOTORCYCLE. SO MY PERSONAL STRATEGY IS TO
APPEAL TO FISCAL CONSERVATIVEISM. THOSE WHO ARE PARTICULARLY THE
STRONGEST LIBERTARIANS ALSO TEND TO BE PHYSICAL CONSERVATIVES AND
CAN RELATE TO THAT ARGUMENT BETTER THAN SOME OTHERS AND IT
IS A POWERFUL, POWERFUL ARGUMENT.>>BRENDAN JACKSON. I’M REALLY GLAD — I WAS
WONDERING WHAT SITUATION IS LIKE FOR PEDESTRIAN BICYCLE INJURIES
AND IS FATALITIES AND WHAT STEPS ARE EFFECTIVE ONES THAT WE CAN
TAKE?>>I’LL GIVE A BRIEF ANSWER, BUT
I ALSO WANT TO LET ME PANELISTS JOIN IN. PEDESTRIAN INJURIES HAVE BEEN A
VERY, VERY CHALLENGING AREA. WE TYPICALLY, SOCIETY, THE FIRST
THING WE ALWAYS THINK ABOUT IS EDUCATION. AND LEFT RIGHT LEFT AND THOSE
SORTS OF THINGS TO TRAIN PEDESTRIANS OR TO TRAIN KIDS IS
IMPORTANT. BUT BY AND LARGE, THE MOST
EFFECTIVE STRATEGIES FOR PEDESTRIAN SAFETY HAVE COME FROM
BETTER LIGHTING IN POORLY LIT AREAS, RESIDENTIAL DESIGN,
THINGS THAT SEPARATE PEDESTRIANS FROM TRAFFIC FLOW, TRAFFIC
CALMING MEASURES THAT SIMPLY SLOW DOIN’ TRAFFICWN TRAFFIC. WHILE WE HAVE MANY PEOPLE
CALLING IN OR LISTENING IN FROM AROUND THE COUNTRY, THOSE OF YOU
IN THIS PART OF THE COUNTRY KNOW THAT BEAUFORT HIGHWAY IS A VERY
DIFFICULT PLACE FOR PEDESTRIANS. YOU HAVE RETAIL STORES AND
GROCERY STORES ON THE OTHER SIDE OF THE TREAT AND RESIDENTS ON
THE OTHER SIDE AND IT CAN BE A HALF MILE OR A MILE TO A
CROSSWALK. THOSE CHALLENGES ARE VERY
DIFFICULT. FOR BICYCLES, WE HAVE SEEN A
STEADY IMPROVEMENT, BUT A PLATEAUING OF THE USE OF BICYCLE
HELMETS, WHICH ARE MORE EFFECTIVE. WE DO MORE MARKING OF LANES IN
THE UNITED STATES, WHEREAS THE EUROPEANS PHYSICALLY SEPARATE
THEIR BIKE LINES FROM VEHICLES. THAT’S A VERY EFFECTIVE
STRATEGY, BUT A LOST COSTLY ONE ON THE FRONT END. WE KNOW STRATEGIES THAT WORK. WE HAVE TO USE THEM MORE
CONSISTENTLY. ANYONE WANT TO WEIGH IN ON THAT? BUT A GOOD QUESTION. THANK YOU.>>>
I HAVE A QUESTION FOR DR. WRIEFT. DAVID, EARLY ON WHEN WE WERE
DOING THIS WORK WITH PROGESTERONE AND EVERYONE THAT
YOU WILL THOUGHT DON WAS CRAZY, WHENEVER I WOULD TELL ANYONE
THAT WE WERE EXPLORING A THERAPY THAT HAD ALL THESE BENEFICIAL
EFFECTS, SEEMED TO WORK WELL IN EXPERIMENTAL ANIMALS AND WE HAVE
SOME PROVOCATIVE CLINICAL DATA IN HUMANS. THEY WOULD GET REALLY EXCITED
AND THEY WOULD GO, WHAT IS IT? WHAT IS IT? AND I WOULD SAY, IT’S
PROGESTERONE. AND THE NEXT REACTION INVARIABLY
WAS THEY WOULD LAUGH. HAS THAT CHANGED?>>WELL, I STILL FEEL LIKE WE’RE
SWIMMING UPSTREAM. AND YEAH, WE STILL GET GIGGLES,
WE GET LAUGHS, WE GET A LOT OF DISBELIEF. THAT IS WHAT OUR PHASE THREE
MULTI CENTER CLINICAL TRIAL IS HERE TO PROVE. IT’S INTERESTING, IF WE HAD
DISCOVERED PROGESTERONE IN THE BRAIN FIRST, IT IS PRODUCED IN
THE BRAIN, IN FACT, IT’S THE ONLY HORMONE/STEROID PRODUCED IN
THE BRAIN. IF WE DISCOVERED IT THERE FIRST,
WE MAY HAVE A COMPLETELY DIFFERENT PERCEPTION OF WHAT
PROGESTERONE DOES. IT’S MADE IN THE BRAIN BY THE
BRAIN FOR THE BRAIN. AND IT ONLY HAPPENED THAT WE
DISCOVERED IT IN THE OVARIES FIRST AND ITS ROLE IN THE
MENSTRUAL CYCLE. IN
INDIED, IT MAY BE THAT ITS EFFECT IN PREGNANCY IS TO COAT
THE BRAIN DURING FETAL DEVELOPMENT. THAT IS HYPOTHESIZES BY A NUMBER
OF GYN AND NEUROEXPERTS. IT’S IMPORTANT HOW THE BODY USES
DIFFERENT COMPOUNDS IN DIFFERENT PLACES FOR DIFFERENT PURPOSES. IT’S A BEAUTIFUL EXAMPLE OF THE
HUMAN BODY AND HOW IT DOES THAT.>>AS YOU ALL HEARD FROM LISA’S
OPENING REMARKS, INJURY IN JOURNAL IN BRAIN INJURY IN
PARTICULAR SEEMS TO BE LINKED TO THE Y CHROMOSOME. I THINK IT’S A CRUEL TRICK OF
FAITH THAT HAD ONLY TESTOSTERONE BEEN THE OF COURSEIVE TRAUMATIC
BRAIN INJURY, WE WOULD HAVE EVERY PHARMACY AROUND THE
COUNTRY STANDING IN LINE WAITING TO BUY IT. I THINK WE HAVE ONE MORE FOR ONE
QUESTION.>>YOU DISCUSS ALCOHOL AND
DRIVING AND THE EFFECT OF SOME OF THE PRESCRIPTION DRUG ABUSE
THAT IS — THAT IS PREVALENT AS WELL AS THE PRESCRIPTION
APPROXIMATED USED WHILE DRIVING, IS THERE ANY SURVEILLANCE ON THE
CDC?>>WELL, THANK YOU FOR THAT
QUESTION. OUR COLLEAGUES IN THE DIVISION
OF UNINTENTIONAL INJURY DO FOCUS ON MEDICATION USED AND MISUSED
IN THAT AND THEY DO LOOK AT THAT IN RELATIONSHIP TO MOTOR VEHICLE
INCIDENTS. AND I’M NOT SURE IF SOMEONE
WOULD LIKE TO COMMENT SPECIFICALLY ON THE SPECIFICS OF
THAT OR WOULD LIKE TO JUST GET WITH YOU AFTER THE SESSION.>>THANK YOU.>>THAT CONCLUDE THESE SESSION. I WOULD LIKE TO THANK ALL OF YOU
WHO ARE PRESENT IN THE AUDITORIUM AND I’D LIKE TO THANK
ALL WHO TUNED IN ON THE WEB AND OVER THE LINES. THANK YOU FOR PARTICIPATING. BRAIN INJURIES MATTER. THEY CAN BE PREVENTED. WE CAN MAKE A DIFFERENCE AND WE
ARE WINNING THIS BATTLE. THANK YOU.>>AND WE ARE GOING TO ASSESS
WHAT KIND OF CHANGES AND MODIFICATIONS WE ARE GOING TO
MAKE IN THE NEXT — IN THE THIRD YEAR OF THE GRAND ROUNDS, WE ARE
HIRING ARTHUR AS OUR PERMANENT MODERATOR. THANK YOU ALL VERY MUCH.

Recovering from Traumatic Brain Injury: Ryan’s Story

Recovering from Traumatic Brain Injury: Ryan’s Story


I remember looking around and just there
was not another soul there I knew we need to get the hospital right
now and it was very, very serious, but I didn’t realize exactly how serious it
was That morning had rained just a little
bit. Jess was out running errands. Our daughter Morgan, it was her first season
of soccer so I’d been wanting to get her out to the soccer field, just to practice. Our son Cameron was playing goalie, and Ryan was out there just kind of walking around, playing a little bit and
then just picking grass, here and there. Morgan kicked the ball and it went wide right of the soccer goal. I went to go
retrieve it and as I picked it up and I was turning around, there was
the full-sized, adult sized soccer goal was in mid-fall. I looked over to my
right and there was Ryan laying there, his eyes wide open, and the
dramatic, super pronounced swelling across his forehead. I picked him up and
I carried him maybe three or four steps calling out his name
not getting any response at all. That’s when I realized that he’s not breathing. Luckily my phone was in my pocket. I made the phone call real quick, let them know where we’re at, “Sent help now!” I had gotten CPR training
a couple years before and I just I tried to do my best.
The first responders got there immediately they’re like “hey we need to
get a life flight in here”, that’s when I I gave Jess a call. I knew the situation was bad because before we hung up the phone, Andy said he didn’t know
if Ryan was going to make it. They took him to CT and quickly
determined he needed to go into emergency surgery. The impact had caused
a portion of his skull to bone to be pushed in, so it’s putting a lot of
pressure on his brain and we removed those bone fragments and took the pressure off of his brain, and were able to repair his skull that way. Ryan was
semi-comatose and he could maybe follow some very simple commands, but he really
couldn’t talk or walk or speak or do anything that a typical three-year-old
should do. When you have a brain injury such as Ryan did a portion of the brain
is injured and that portion of the brain that’s injured does not recover. Other
parts of the brain that are not injured take over the functions that were lost,
and this is where it’s really important for patients to have good, high-quality
rehab, which we do fortunately have here at Arkansas Children’s Hospital. We evaluated him to come to the rehab floor where he stayed with us for about a month and he
was able to eat and drink some by the time he left but he still had the g-tube
in, he was also able to talk some by the time he left, he was also starting to
walk and to do some playful activities (SINGING) “Jingle Bells, Jingle Bells” Singing songs and not completing the
ending phrase to see if Ryan would pipe in, you could almost see his wheels turning when Andrew would play those songs for him, and I do think it helped, not only with his speech, but just with his
general cognitive progress. I’ve had the privilege of following him since he’s
been discharged. He is back to normal, he is able to walk and talk and play and do
everything now that a five-year-old should be able to do and he’s done
incredibly well after having this tragic accident.

“Guidelines for the Management of Pediatric Severe Traumatic Brain Injury” by Pat Kochanek

“Guidelines for the Management of Pediatric Severe Traumatic Brain Injury” by Pat Kochanek


Hi. I’m Pat Kochanek. I’m the Grenvik Professor of Critical Care
at the University of Pittsburgh and lead author of the guidelines for the management of severe
traumatic brain injury in children. In today’s presentation, we’ll talk about
the three exciting new guidelines documents, the full guidelines, the executive summary,
and the new algorithm articles that are published in the March issue of Pediatric Critical Care. Welcome. This is World Shared Practice Forum. My name’s Robert Tasker. I’m the Director of Neurocritical Care. And today, I have Dr. Pat Kochanek with me,
who is the Ake Grenvik Professor of Critical Care Medicine at the University of Pittsburgh. He’s also the Director of Research at the
Safar Institute. And most importantly, you’ll all know him
as the editor-in-chief of Pediatric Critical Care Medicine. And in 2017, he was the Thomson Reuters Science
Watch most prolific writer with most citations in the field of traumatic brain injury research. Today, Pat is here to talk to us about the
new third edition update for the Brain Trauma Foundation guidelines in traumatic brain injury
management in children. So Pat, I’d just like to ask you, how did
all of this come about? It’s a huge organizational achievement, but
how did it start, and how did you get here? It’s a great question. And thanks for the kind introduction. The guidelines have been a process that, as
you know now with the third edition, are one that brings together a really multidisciplinary
group of people. Not only intensivists and neurosurgeons, emergency
medicine, anesthesia, child neurology, et cetera, but also evidence-based medicine experts,
and obviously all the people required to do all the publishing. And it’s a process that many people may not
know that, a couple decades ago, this was tried and failed, initially, by other groups. And in large part, Nancy Carney and the Organ
Health Sciences Group, with the Brain Trauma Foundation, kind of assembled a group of people
with the first edition of the guidelines that were able to finally take it to the finish
line. And now, the third edition has really come
together. And although it’s a huge undertaking, it’s
so much easier than it was in the beginning. And beyond the actual people whose names you
see on the masthead of the documents, there are other people. Hector Wong, for instance, served as the guest
editor to, in essence, address any potential conflicts. And he brought on reviewers to review. And so there was a huge cast. But as I mentioned, I think it was a lot easier
this time than it was particularly the first time. Thank you. So why have we got three documents this time? Talk us through that. I think it’s really great, first of all–
that’s my initial reaction– the fact that we have three documents. In fact, if you look back at the greatest
critique of the last edition of the guidelines was that there wasn’t a bedside handbook,
an algorithm type of document. And I think that, if you look back at the
guidelines, we have three documents now. You can see that we have the full guidelines. And the full guidelines, of course, are essentially
the bible. But they have everything in them. But we then also, this time, have published
now, rather than as a supplement, in the regular pages of Pediatric Critical Care Medicine,
and dually published in the regular pages of the journal Neurosurgery, we have an executive
summary. And that executive summary is a thumbnail
of the essence of what has changed, that there are 22 recommendations and there are nine
new recommendations. And so that is really a distilled, easy-to-read
version. And if nothing else, I suggest you read the
tables of that document. And then, this time, we did something that
we did in a very spartan way in the first version of the guidelines. And that is tried to put together a bedside
caregivers document, an algorithm that isn’t just evidence-based, that is consensus and
evidence-based. And if you were to go back to the last guidelines,
the number one, if you want to call it, complaint of people was, where’s the algorithm? Where is my bedside document that I can look
at? Are there a couple of charts that can help
guide me through? You can argue why wasn’t there one in the
last document. And that’s an interesting point. And the reason there wasn’t one is that, in
that era, the Brain Trauma Foundation was in, if you want to call it, kind of a purist
era. They wanted to minimize consensus. They wanted evidence. And so an algorithm was, in essence, not sought
out. And I think hearing all of the feedback that
we really need something like this, because the evidence is better, but it’s still not
solid enough. And so this algorithm article, I think, is
a fantastic addition. We’ll talk a little bit more about it later,
but it’s a really special addition. So that’s why there are three documents. Really, from a logistics standpoint, if you
read the executive summary and use the algorithm and have the full document as kind of your
backup if you need to really go into the details, I think that’s the best way to navigate the
three. Can I just interrupt? Yes, yes. So all of the previous recommendations and
levels of evidence were relating to the outcome of death or mortality. Here, now, we’ve introduced a different outcome
level, which is ICP control. Perhaps you could just talk us through that. That’s a great point. And it’s a very interesting point in that,
really, there’s been no definitive positive study that has ever shown that an intervention
improves outcome in severe TBI in children. And you’ll see in minute we’ve certainly had
one that has at least a level three evidence, if I remember correctly, supporting against. And I guess we’ve got a couple of those. Outcome has been such a difficult parameter,
whether it’s mortality or whether it’s Glasgow Outcome Scale, to get a therapy to favorably
affect that, that the next best surrogate that we have, obviously, is intracranial pressure. And so we have two different types of targets
for our recommendations. One is, is it useful for outcome, for improving
overall outcome? And can we really make a recommendation in
that? And the other is, can we make a recommendation
to control ICP? As you know, the evidence to definitively
say that controlling ICP improves outcome is also just not solid enough. And so thus, the need for a dichotomy between
those two. Perfect. Thank you. So perhaps you could take us through the evidence
tables that are summarized in the executive summary, just to highlight various aspects
here. Yeah. As I mentioned, there are 22 recommendations. And there are also some other notes within
the tables. And they’re very useful. And there are nine new recommendations. And so if you look through the executive summary
tables, you see that, for instance, the recommendations for monitoring, probably the hottest topic
on the planet is ICP monitoring. And based on the available evidence, there
is a recommendation for the suggestion for ICP monitoring. It’s interesting that there is that recommendation,
given the fact that almost everything that you do is based on using ICP monitoring. And we’ll talk a little bit later, I’m sure,
about if you don’t use ICP monitoring, you’re still stuck with, in essence, ICP-based care
without the number. So there is at least a level three recommendation
for that. There’s also, once again, a recommendation
for advanced neuro monitoring for PbrO2, partial pressure of brain oxygen, and with a Licox
monitor. And it’s a parenchymal monitor, for those
who aren’t familiar with it. And if you do use one, that you target a level
of above 10 millimeters of mercury. And that’s a threshold. We’ll talk a little bit about thresholds in
general later. It wasn’t felt that there was enough evidence
to support a recommendation for use of the monitor. It’s used more commonly in research institutions,
et cetera. But if you do use it, that was the threshold
that was recommended. And then there are two recommendations on
neuroimaging. One, that a normal CT scan does not rule out
increased intracranial pressure. And I think that’s an important recommendation. And also, that routine repeat use of a CT
scan is not recommended, unless, of course, there’s some clinical deterioration. And all of these are level three recommendations. All of these are level three, as you can see. Yes. And I’ll try to point out the three level
twos with a little bit more clarity. Thank you. And then, with the thresholds, there are,
again, level three recommendations for an intracranial pressure threshold of 20, to
keep it less than 20. And that is interesting because the latest
adult guidelines had a 22 recommendation. It’s interesting also that, with this recommendation,
I think like cerebral perfusion pressure, there may be an age-dependent value. It might be that, in an infant, 20 is a little
high. But we just don’t have the evidence to say
more. And the same as with cerebral perfusion pressure. We had a recommendation, once again, for a
minimum of 40, but we also have a recommendation that 40 to 50 may be a more practical recommendation,
given that we don’t want to breach that threshold of 40. And we also mentioned there may be age-specific
thresholds specifically for CPP, given the well recognized age-dependence of blood pressure
and the importance of blood pressure in the CPP calculation. But once again, we can’t make specific recommendations. I think one of the papers from your center
back in Cambridge, when you were there, was one of the best that came as close to giving
us a shot at doing that, and maybe future studies will be able to pin that down a little
better. So for hypertonic saline now, we do have a
level two recommendation for bolus administration of 3%, and with specific doses, and I think
that that’s a nice advance in this guideline. I think the paper by Steve Shein, I think,
really helped contribute to this because it was the first time that an actual comparison
between therapies– first tier types of therapies, whether it was hypertonic saline, or fentanyl,
et cetera, provided evidence that the hypertonic saline not only improved ICP, but it also
was the only therapy that improved CPP, and that was kind of an exciting finding from
that. We also continue to have level three recommendations
for a hypertonic saline as a continuous infusion, and that was in the prior guidelines. But now, in other new 23.4% hypertonic saline
recommendation based on studies from down under, I guess you would say. Really exciting to see. You, I’m sure, and maybe the audience isn’t
as aware, but 23% is used much more commonly in the adult world. Interestingly, I think the pediatric field,
largely related to the work out of San Diego, brought hypertonic saline back into the armamentarium
with 3%, and in the adult world, brought the 23% in, and now we have a 23% paper in pediatrics. So having that in your armamentarium. Just to make clear, we couldn’t find any studies
in regard to mannitol. It’s a really great point. And despite the history of mannitol use, I’m
really hopeful that ADAPT will now be able to– the ADAPT trial, led by Mike Bell, which
just closed 1,000 patients– it’s a comparative effectiveness trial funded by the NINDS, and
I’m really hopeful that is going to give us some insight into the effect of mannitol. Part of the reason we don’t have evidence
for mannitol is that some of the really early studies supporting its use were, in essence,
accepted. And people didn’t feel the need to replicate
them, but the studies in that era just don’t hold up to the rigor of today’s type of reports. And so it’s a bit of a conundrum, and it’s
kind of a bummer, I guess you would say, but it doesn’t mean that we don’t recommend against
mannitol as an alternative to hypertonic saline. We just don’t have the evidence in the articles
to support its use. The other thing with regard to the hyperosmolar
therapy is that, once again, we have some safety recommendations showing that sustained
increases at high levels, and whether you pick 160 or 170, you start to see complications. And whether it’s evidence of an endotheliopathy
with thrombocytopenia, and pulmonary complications, or whether you have thrombotic complications,
it starts to come in. And so you get a trade for use at those higher
levels. Also we had some other new recommendations
this time. Again, very exciting. A category that, I think, pediatrics has also
led the way in initially. We were kind of the first people to put a
chapter in on sedation. We didn’t have much to say, but it has– I
think it really stimulated some studies. This study out of Wash U showing that midazolam
and fentanyl combined, in particular, was associated with not an improvement in ICP
when used as a bolus, but actually some deleterious effects. So that was somewhat of a complicated study,
but there were clearly some signals of a deleterious effect, allowing us to have a level three
recommendation against routine bolusing of those agents. I think it’s really important, though, to
recognize that in that recommendation, that we are assuring that the patient, the kid,
is already adequately sedated. So this is not to tie the hands of the caregiver
to not sedate or provide appropriate analgesia to kids with severe TBI, but rather if you
are already doing that, just coming in with additional boluses don’t seem to produce important
improvements in ICP. Although, if you were to compare the study
from Wash U, Jose Pineda’s group, they saw, really, predominantly negative effects. In Steve Shein’s study, we saw some benefit
on ICP, but no benefit on CPP. I think taken together, it really argued more
for give boluses of hypertonic saline or other therapies if you are adequately sedating. And then, of course, another very important
difference between the adult guidelines and pediatric guidelines– in the adult world,
propofol is, in a number of studies, been shown to be a very good way to provide sedation
in neurocritical care of adults, but obviously, with a black box warning. It’s just not on the table in pediatrics. And although we don’t have a study in TBI
saying we can’t use it, you could argue there’s something at a higher level preventing the
use of it as a continuous sedation approach in pediatric TBI. I also wanted to mention that we don’t have
a specific recommendation on neuromuscular blockade, but we do say that its use is up
to the treating physician, and we deal with that a little bit more in the algorithm. We also have a number of other level three
treatment recommendations– cerebral spinal fluid drainage if you’re using a ventricular
catheter. Seizure prophylaxis, level three also, although
we didn’t have evidence to say levetiracetam, or fenotin, or fosphenytoin were better. Either was better. And then we also had a level three recommendation
against prophylactic hyperventilation. However, if you have refractory intracranial
hypertension, now kind of as a second tier hyperventilation can be used, and there is
a level three recommendation for it. And once again, I think that becomes a little
clearer on the algorithm. It’s kind of like what you use upfront versus
hey, we’re not winning, now what are the choices I have, I guess would be the way I would put
it. I think one of the greatest improvements in
not necessarily as much related to the new data as much as related to the interpretation
of it, has come with the temperature control, and we now have a level two recommendation. And now this, as you are talking, this is
with overall outcome, as was the early hyperventilation. Not for ICP control, but for overall outcome–
a recommendation against prophylactic hypothermia. So if a patient comes in, you just immediately
cool them in kind of a neuro-protective fashion, and despite how wonderful that sounds, and
despite many animal studies suggesting that there was some potential for that, it’s just
never panned out. Although, we still don’t have, in essence,
perfect studies on that. There are some signals that during re-warming,
you might run into some difficulties, and I always say hypothermia is not a pill. It’s complicated. And so in those studies, if anything, there
were some trends in some of them for deleterious effects, and so we have a level two recommendation
against doing that. However, for ICP control, once again, if your
first line therapies are failing, moderate hypothermia to attenuate intracranial hypertension
is on the table. So it’s like a differentiation between what
you would do first tier, and then what you would do second tier. Exactly. A preventative strike with mild cooling is
not recommended. In fact, we recommend against it. Whereas if the conventional first line therapies
are failing, hey, this is something that is– there is evidence to say that it can control
ICP, and that’s a very different situation than upfront application. And similarly, for refractory intracranial
hypertension, we have level three recommendations, once again, for barbiturates, and for decompressing
craniotomy. And those are, basically, the same. There was a little bit more evidence supporting
them, but still, all at level three. I mean, perhaps, it’s also worth just mentioning
that we did have pediatric neurosurgeons review all of the evidence on the decompressing craniotomy
literature to go through that in really quite some detail as well. Oh, yes. That was something that, I think, in all three
guidelines, we have been very, very mindful to be inclusive on the team, and I think that
everyone felt comfortable with every recommendation. I think there really was a consensus on the
evidence portion. I think there was an excellent consensus even
on the algorithm, but there was strong agreement. And even recognizing that some centers use
decompressive craniotomy in a more prophylactic way. But I think the evidence that we can state
in the guidelines are the use of it for a refractory intracranial hypertension. Or in a neurologic deterioration, et cetera,
it could be that you would use it upfront if you had a terrible injury with a large
parenchymal lesion, et cetera, but it is in that context. And then the final two areas in the treatment,
one is in nutrition, and there is a level two recommendation that, once again, is in
the guidelines. It’s a really excellent study, but it’s a
study on a very specific immune modulating diet, and the study was well conducted, and
thus, enough to give it level two recommendation. But beyond that, if we’re not using that diet,
it doesn’t help us very much because it was so specific. It’s an excellent study, but it’s difficult
to generalize beyond it. In contrast, we now have another new recommendation
to start nutrition within 72 hours. That approach has even stronger evidence subsequent
to the guidelines. Again, and that’s for improving overall outcome. It’s a level three recommendation, but it
did not differentiate whether you– exactly what kind of rate of enteral nutrition or
exactly what the recipe was, but I think it’s still a first step forward on that. And then finally, interestingly, the recommendation
on corticosteroid use moved from a level two against to a level three against. And people may not realize this, that we’re
humans putting together these guidelines. And the backdrop upon which they are crafted
changes with time. This, to me, is a really interesting example
that earlier on when the CRASH trial came out, it was a study of steroids in adults
with thousands of patients– negative, deleterious. It influenced the field like a hammer, and
I think that that study probably was given too much weight by us in the past. And as we’ve looked more rigorously and said
to ourself, but where’s the pediatric evidence? We have said– and maybe part of it is well,
we’ve gotten some better pediatric evidence for other pieces of this. So that study, even though it’s, I think,
a level one in the adult guidelines, it’s not a pediatric study, and so we can’t just
simply extrapolate. And the pediatric evidence is really level
three against corticosteroids. And the other thing I think that we are trying
to be very mindful of is that we don’t want to tie the hands of our caregivers to not
be able to use steroids in the setting of adrenal suppression. And whether it’s etomidate, or whether it’s
prior steroid use, or other problems– HPA axis. Sure, HPA axis injury. Absolutely. So I think in that setting, we moved that
from a level two to a level three. That’s one of the more interesting nuances,
I think. If you weren’t really looking carefully at
the guidelines, you wouldn’t have thought that changed, but it’s an interesting thing. That’s a great summary, Pat. And you sort of alluded to it when you mentioned
that there have been other studies coming out since this was all written. And the question is do we have to wait another
five or six years before the next set of guidelines? Or is there going to be a completely different
strategy with dealing with new evidence as it comes out? It’s a great idea. Living guidelines is something that has been
discussed. I think that there is interest from the Brain
Trauma Foundation of doing that. It’s not easy, though. It takes a lot of work. And I think that it probably takes a certain
level of financial support too. And so exactly whether that will come together,
I don’t know. I really don’t. I think it’s a great idea. I think the other question is a living guideline
kind of is so logical now. Everyone just goes to their phone for what
happened last night. I think that is certainly where it’s going
to go. I think it’s interesting that we’re almost
in a scenario where the mechanics to make that happen in the transition need to be worked
out. And I hope it does happen, but I do think
that it’s not a trivial undertaking to do. That’s how I would describe it. I would think if we could update at least
every year or two years, that would be even a step that probably is going to be necessary,
because otherwise, these become outdated pretty quickly. Thank you, Pat. That was really clear. And now, it comes to the bedside document
or the algorithm. Perhaps, you could just sort of talk us through
the concept and the figures that appear there. Yeah, as I mentioned a little earlier, with
the first guidelines, there was an algorithm. At that point in time, we felt it was really
important. That initial algorithm in that first document,
though, was really a synthesis of the evidence into an algorithm with a little bit of consensus. It was still a very largely evidence driven
document. As I mentioned, the Brain Trauma Foundation
with a second edition really pushed for “We need pure evidence”, and kind of almost a religious
kind of approach. And this time around, I think it just became
so clear from the feedback that we received that people want more than that. And so we put together– and I’m really pleased
to say that the two of us together are the co-lead authors of this, and it’s a fantastic
thing. I think it’s one of the best things I’ve ever
been part of in my career. That tried to really build a much stronger
consensus layered upon the evidence, and address some issues that are really neglected, and
it was really fun– even discussing this at the guidelines committee, we had great people. Marc Wainwright, and Mike Bell, and–
Dave Adelson. Dave Adelson, and Monica Vavilala, Nate Selden. And everyone was weighing in on this, and
things like– TBI is this multifaceted disease, where you have ICP, CPP, brain tissue O2,
all these different readouts, simultaneously, and each of them is their own linear pathway,
but they influence each other, and there’s never any discussion of those in kind of a
sterile guidelines document. Or things like the tempo. I always chuckle because when we were talking,
Mike Bell had a great comment. He said you have a guidelines, and you have
a level one pathway, and you say well, in one patient they blow through this in 15 minutes. In another patient, it’s like they behave,
and they follow it, and their ICP raises over several days, and you can just nicely
implement the therapy. But you’re stuck with the same sterile guideline. You know, things like weaning. You can read through all the guidelines, and
no one ever says, well, is there anything about weaning? How do you take the therapies off? We all do it in our own way, and we all, generally,
take the most toxic and the last thing on as the first thing off, et cetera, but no
one ever discusses it. You just don’t find it in a document. And another point in the algorithm that I
think is really important– and this became– we discussed this– I think we were really excited when we started
discussing this in that thresholds that are generated in guidelines document are the minimum
threshold. And the classic, obviously, is a CPP of 40,
and we say, man, that’s low. And if you’re targeting 40, you’re going to
be in the 30s some time period. And we’re going, wow, but you’re stuck with
that. And so the algorithm article discusses, I
think, really nicely that these thresholds are minimum targets. And whether it’s a hemoglobin of seven, or
an ICP of 20, or a CPP of 40, or a brain tissue O2 of 10. Heck, you can find articles that say we should
use 25 or 30 as the target, but the strongest evidence, the most cautious, of course, is
10. And you might argue, well, why not just raise
those empirically? But more therapy might also get you into trouble. And so running something too rich– I mean,
look at with fluid overload now. It used to be– I always used to say, pour
it like you don’t own it. But now, we are all saying hey, there is a price to pay for these things that we do in the ICU. And so the concept of a minimum threshold
is one that we discuss in the algorithm. We would like, now, to turn to the audience
to ask a question. When you respond, please leave your city and
country. What did you find most helpful about the three
new guidelines documents? I think we’re really pleased that it’s nice,
visually, to look at. You see the linear pathways. You see the potential interaction. The first tier algorithm, which is, I think,
a really nice graphical display, builds on the baseline care. And these kind of things, if you look back
at the prior guidelines, in the introductory article, were kind of a brief discussion,
but they weren’t really laid out for the bedside caregiver. And I think this time, for the first time,
we’ve really laid them out and said, here’s a strawman to utilize. And going back to Mike Bell’s analogy, you
might have a patient that blows through this in a few hours, and then you might have another
patient that never progresses to second tier therapy. Some utilization of this allows you to do
all of your management. I think one of the other things about this
that I always personally felt we fell short in the prior guidelines is herniation is so
devastating. It’s just so important, and yet there are
no studies on it. Even in the adult side, there are only a few
studies on herniation. It’s really interesting if you look at those
adult studies. And you mean what would you would do in an
emergency? That’s right. And not only what you would do, but what are
the consequences? It’s not like well, we’re going to randomize
to A or B in herniation. That’s a little tricky. And not to say that it couldn’t be done to
try to improve what our best approach is on that, but I think one of the things– if you
look at some of the– I think there’s about three adult studies on herniation– the interesting
thing is that there is a pretty decent number of patients that herniation can be reversed. We think of it as it’s so devastating, and
rightfully so, but it’s not always. And the early signs and symptoms in some patients
can be reversed, and it may be 40% or 50%. And so that’s really important. All the more reason to have a recipe. And so we have what I called the herniation
pathway, and it has a nice backdrop on, well, what are the signs and symptoms because it
varies from patient to patient, obviously. And then how do you manage it? And that is the setting that hyperventilation,
titrating to pupillary, reversal of pupillary dilation is indicated. And on an FiO2 of 1.0, and then bolus mannitol
or hypertonic saline. It’s interesting, in the adult studies, it’s
usually 23.4% saline, but I think in pediatrics, people still– the guidelines committee felt
that in this setting, more people are comfortable with mannitol. And what we didn’t want to do was to try to
introduce something new in that crisis setting that people are trying to find something that
they’re not prepared for. Maybe that will ultimately evolve, but that
wasn’t the goal of this. And then, of course, if you have an EVD in
place, to open it, and make sure you’re maximally draining CSF. And then get to–
Imaging and surgery. Of course. And so having that kind of crystallized on
there, if it saved one or two kids, it was a great addition to these. And then as I mentioned, within this, we have
a nice discussion about an ICP pathway, and how do you progress down it. And the CPP pathway– what do you do to add
to this? And then the brain tissue O2 pathway. And one of the things that’s always brought
up, well, how does one influence another? And the classic example I think that is really
a nice one is that if you were in a unit, and you’re monitoring all three of these,
and you have a situation where the ICP is under control, and the CPP is under control,
and your ICP, say, is 16, and you’re on osmolar therapy, and it’s taken barbiturates to get
to that. But now you have a patient whose brain tissue
O2 levels are low. Say, they’re seven or eight. And you’re saying, well, our ICP is under
control, but our brain tissue O2 is inadequate. Should we just be satisfied with that? A classic example is to say, well, let’s let
the pCO2 rise a little bit. Or let’s raise our blood pressure a little
bit. Hemoglobin. Transfuse. Yes, do an intervention that will maybe improve
brain tissue O2. So now, all your targets are adequately addressed,
even recognizing we don’t know exactly what the best value is. But the range of targets for each of these,
and references to the individual protocols that people use, are all in the algorithm
papers as well. Yes, absolutely. And then, of course, once you get beyond this,
you, of course, have refractory intracranial hypertension, and another tier. And you could argue, well, is it artificial
to really consider this a tier, et cetera? I think maybe in the past, we might have thought
to some extent that’s the case, but now, I think you can see it from the new guidelines,
by having level two evidence for hyperosmolar therapy, it kind of opened the door to really
more definitively say yes, that’s level two evidence, and that’s a therapy that, in general,
until you get to high levels of sodium, is probably reasonably safe. And now you get to therapies that are much
more risky. And so if you’re not controlling ICP with
that first tier of therapies, you have choices. And as I mentioned, barbiturates, moderate
hypothermia, hyperventilation, and pushing osoms. I like the way this is presented, now, because
it’s not linear. We don’t know what order to do these things. Would you do barbiturates and then hypothermia? Or hypothermia, then barbiturates? Or the hyperventilation? Have you got a comment about that? Yeah, it’s a really great point. We not only don’t know what order that this
should be first, and this should be second, but we also don’t know because, commonly,
you need more than one of these. We all have tons of patients where, hey, we’ve
had to go to barbiturates and push a hyperosmolar therapy to 165, or whatever. Or push ventilation. Or, hey, we have to cool. So what combination? Not only what order, but is there a combination? And I think two things come to mind with me,
and that is that combinations are common, and we don’t know which one’s better. But also, it may be that either individual
use or combination use, the efficacy depends on the center because I think that these kind
of advanced therapies, they take skill. They really do. You start barbiturates, you better be ready
to support hemodynamics. I remember Brad Peterson from San Diego saying
I would never allow the blood pressure to be low if I started of a barbiturate infusion. With that kind of mindset that you don’t start
it and wait for trouble, you are all over it. You’ve got the presser, essentially, teed
up to the patient at the time you start it. And there may be some centers that are great
at decompression, and they want to go to decompression at that point. Obviously, the evidence, even on the adult
side, pretty equivocal on that also. So I do think this may vary, depending on
the center. And I think the other thing is that this whole
guidelines, the backdrop of it, is as if we are dealing with one disease. And we know now that it’s very likely that
the phenotypes of TBI are going to be important, and it may be that particularly for something
like second tier therapies, that one type of second tier therapy is way more effective,
say, if you have someone with diffuse axonal injury, and diffuse swelling, that may be
very different than someone who had a big subdural, and has a focal lesion, or a big
contusion. And so ultimately, this will evolve to something
much more elegant. We would like to turn again to our audience
to ask a question. When you respond, please leave your city and
country location. What do you think might be changed to improve
the value of future guidelines to caregivers? And the other component of this, if we’re
going to go to these advanced therapies in the second tier, we’ve also got a section
on advanced neuro-monitoring. And there wasn’t a great deal of evidence
in the main document to support these– like EEG, transcranial Doppler, so-called PRX,
et cetera. So have you got a comment about that component? If you look carefully at the algorithm document,
we do make some comments even on the first tier to say that, for instance, if you use
neuromuscular blockade, we strongly suggest using continuous EEG. And obviously, once you start to get into
these more second tier therapies, advanced monitoring, I think, can be very helpful. As you say, we don’t really have great evidence. I’m one of the people that believes that it’s
nice to have advanced monitoring as much as you can from the word go. Recognizing that you don’t overreact to any
one monitor. I really think that as with therapies, I’m
a believer in a little of a lot of therapies, rather than a lot of one therapy. That’s where I’ve seen people get into trouble
is almost being a zealot about one approach, and pushing it, really, and I think that we
see in all of these therapies that the toxicities are dose-dependent. And so if you can use a little of a lot of
therapies, almost like an artist, you can– and with many advanced monitors, I think that
that’s one of the ways that you can optimize outcome. I don’t think we’re there yet in a guideline
or an algorithm, and I’m just saying that kind of off the cuff. It’s a wish for the future. But I do think there is something to that. There’s, perhaps, one area that I just want
to pull you back on, and sort of garner your thoughts on, that’s the question of what if
we haven’t got invasive ICP monitoring? What do we do? I think that is, really, a burning hot question
right now. That was really set into motion by Randy Chestnut’s
best trip study published in the New England Journal a few years back. And then more recently, Tellen Bennett’s JAMA
Pediatrics paper, and questioning whether this is, really, the key target that we should
be aiming for. And I think it’s so interesting because we’re
really excited that we actually do have a section in the algorithm article about this
question. And the real gap, though, is that if you don’t
use ICP monitoring, that there is no pediatric, not only data, there isn’t even a consensus
or single center description of how you should manage it. And in Tellen’s paper, which wasn’t a study
of how to do it, it was just the way some people are managing what’s happening– what
are the consequences? Can we use statistics to try to sort this
out? And in that paper that questioned it, there
was no protocol. There were some percentages of what percentage
of people use barbiturates, and what percentage of people– so A, we don’t really even have
a document in pediatrics. But we do have Randy Chestnut in the supplement
to that article in the New England Journal if you go in there, and they, of course, titrated. And they recruited over 12-year-olds, I think,
in that study. Yes. Yes, that’s right. They titrated to clinical exam and imaging. I think that if you look at the results of
that paper, there’s some truly fascinating results. One is that in many cases, the amount of therapy
that was used was greater than if you used ICP monitoring. It kind of makes sense that if you just have
to guess at what kind of brain swelling there is, that you’re going to need to overshoot
because if you run it too thin, then you could get into trouble. And so, obviously, using those metrics– exactly
how often you were to scan, et cetera– is totally unclear. But if you were to use those kind of metric,
you would use the therapies that we have developed based on ICP monitoring, and then just have
to empirically implement them, and write your own protocol as to how you want to do it,
or try to use the Randy Chestnut protocol in a pediatric analog of it. But you would have no evidence other than
the evidence based on ICP. So you can’t get around the ICP influence
on it. I do think there’s one other take home point,
though, from those studies, and that is I really believe that it may get back to the
phenotyping. That we have underutilized imaging to help
us guide our treatment. Not so much we don’t get enough imaging, but
we, in general, have gotten imaging to say oh, they need to go to surgery, rather than
wow, there’s still a lot of swelling there. This brain looks tight. It’s almost like getting a compliance readout,
instead of just an ICP readout, and saying, hey, we’re going to need therapy for a longer
period of time. And I don’t think we’ve really– we haven’t,
in any way, skimmed the surface even of how we might use imaging. And if we could get bedside MR, for instance,
and perfusion MR, and things like that, I think it could really help influence our care. So I don’t have an answer for the no ICP other
than if that is the approach, you need to craft a protocol based on the Chestnut study,
and we really need the results of those kind of things, if that is what you’re doing, to
be published. And remarkably, it seems like the number of
centers that don’t use ICP monitoring– or use them in selected patients– is pretty
substantial. The other thing that I would say about that
is the ADAPT trial isn’t going to provide us any information about that because, obviously,
in that trial, ICP monitoring was an entry criteria. So that still will be a gap, even if adapt
gives us some clues as to how to better manage. I’m hoping that based on adapt and the other
studies, that we actually become better at utilizing and treating ICP, and that it will
lead to better outcomes, rather than trying to take a step back and fly blind, I guess
would be how I would put it. Thank you very much, Pat. It’s been a real pleasure to speak with you,
and talk about the guidelines documents. It’s a huge and massive achievement. Thank you. Thank you, and it’s in the March issue of
PCCM.