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There’ll be no recap of Dr. Bobrow’s excellent Grand Rounds lecture — you’ve already got the papers, the abstracts, and now you’ve got the lecture itself. We’re grateful for Dr. Bobrow’s generosity in not only coming to speak to us, but letting us post the audio from his talk online.

As for the resident and fellow presentations on central DI and general pediatric endocrine emergencies (thank Marisa and Karen, respectively), well, there’s not too much I can add, other than to check EMPeds.com for dosing information and sources like UpToDate, and online free text Pediatric Endocrinology for more background on presentation, diagnosis and treatment.

But for Dr. Jagoda’s provocative lecture on TBI and the upcoming ACEP clinical policy, see below.

First, some obligatory and quite deserved praise — when he discussed the nonsensical and contradictory AAN recommendations for management of concussion in sports, well, I was grateful we had someone as practice-driven and evidence-based as Dr. Jagoda helming the ACEP clinical policies committee (an overview of the AAN and NCAA guidelines, as well as others, is available free online).

Dr. Jagoda’s and Dr. Bobrow’s perspective on the prehospital TBI management debate, specifically the worse outcomes associated with field intubation (Bochiccho  2003, and Dunford 2003, plus some of Davis’ San Diego studies) was fascinating. I particularly enjoyed learning how this data led to BTF guidelines that tactfully handle the politically charged question of whether EMS should intubate, by focusing on ensuring O2 sats > 90%, ETCO2 monitoring, and limiting the interpretation of “likely to deteriorate.”

The commentary about how most of what we see in the ED is mild TBI, and how current methods for scoring injury and guiding therapy are inadequate, was much appreciated. As was noted, less than 10% of patients with GCS of 14 or 15 have intracranial lesions (and less than 1% are clinically significant — but we’ll leave it up to other services to decide what’s what), but up to 30% of GCS 13 patients have lesions on CT.  Hence, the whole GCS scale, which was never intended to be used for mTBI prognosis in the ED, is clearly too imprecise for our decisionmaking. The New Orleans Criteria (geared toward detecting any traumatic brain lesion) and Canadian rules (sensitive for neurosurgical lesions — both were compared in JAMA 2005) were based on large validated dabtabases and incorporated into our ACEP’s policy in 2002, which has been:

A head CT scan is not indicated in those patients with MTBI who do not have headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, or seizure.

The new clinical policy will go a little farther: Noncontrast head CT is indicated in patients with LOC or amnesia if one or more of the following is present: headache, vomiting, age over 60, intoxication, memory deficits, signs of trauma above the clavicle, seizure, GCS less than 15, coagulopathy, or focal neuro deficit. There will be no recommendations about MRI as there’s no studies of mTBI patients within 24 hours of injury, and no correlation has been shown between MRI findings and outcomes.

I was floored by the data on biomarkers for mild traumatic brain injury — I thought everything was still very theoretical, but now I’m looking forward to ordering expensive assays in the next few years. The crux is, based on Biberthaler’s prospective multicenter trial (in Shock 2006), a normal S-100B level within four hours of TBI would mean no CT scan is necessary. He estimates this could cut down on 30% of CT scans.

That, and the evidence-based exhortations to discharge these mTBI patients to a responsible third party who can explain the likelihood of post-concussive syndrome, made for a spirited lecture. More guidelines and the data behind them can be found at Brain Trauma Foundation, FERNE, and the government’s clearinghouse.

Posted on Wednesday, July 9th, 2008 at 10:31 pm by Nick. Filed under Post-Conference Letter, Blog.
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