Page 51 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
mortality rate of 65% for all patients and 98.5% for patients with admission GCS 3-5.48
After surgery, mortality rates dropped to 92.5%, but all survivors were in persistent
vegetative state.48 In contrast to these dramatic results, one study showed 2-year 2 functional outcome (GOS 4-5) in 66% of all patients and in 32% of patients with
admission GCS 3-5.59
PBI occurs both in military and civilian setting (Table VI). In the context of civilian population, PBI is mainly caused by gunshot wounds, either self-inflicted or caused by (mass) violence. In combat situations, TBI is most commonly caused by improvised explosive devices (IEDs), but also by artillery, rocket and mortar shells, mines or booby traps, aerial bombs and rocket-propelled grenades.60
Emergency management in patients with PBI should include aggressive resuscitation like described in the ATLS guidelines, since it appears to be associated with significant improvement of survival.61, 62 Initial mortality after gunshot wounds is high, with one study reporting a prehospital mortality rate of 76% in a civilian PBI population.63 If patients reach the hospital and survive initial resuscitation and stabilization, a head CT scan provides information on bullet trajectory, missile fragments, bony destruction and brain damage, including (hemorrhagic) mass lesions. Hemorrhagic contusion and intraventricular bleeding are the most common CT finding.63, 64
The surgical management for PBI differs in many aspects from that of closed TBI. PBI represents an open and contaminated type of brain injury, for which prophylactic broad spectrum antibiotics is common practice.65 Surgical management in PBI consequently should include the prevention of infection 66 and treatment of CSF fistulas.67-69 Principles of wound debridement have evolved under influence of experience in military settings from extensive debridement with repeated removal of retained fragments to more limited procedures. During the Second World War and Vietnam war, it was disproven that retained bone fragments were linked to the development of brain abcesses.67, 70-73 Moreover, studies have revealed significant morbidity and mortality associated with repeated and aggressive surgery to remove retained fragments.74-77 During the Israeli-Lebanese and Croatian conflicts, rapid evacuation and improved medical care, including use of CT-scanning, was broadly available, which led to a less aggressive surgical approach to preserve brain tissue.78, 79
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