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Prognostication in Severe Traumatic Brain Injury in Adults #239

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Fast Facts and Concepts
Screening for Intensive Care Unit Delirium #160
Richard Altman, M.D., Eric Milbrandt, M.D., M.P.H., and Robert Arnold, M.D.
Background
Delirium is an acute, fluctuating change in mental status,
accompanied by sleep/wake cycle disruption, inatten-
tion, and altered perceptions (hallucinations/delusions; see
Fast Facts #1, 60). Delirium can be hypoactive or hyperactive.
Patients with hypoactive delirium are calm, but inattentive
and manifest decreased mobility. Patients with hyperactive
delirium are agitatedand combative, and also lack the ability to
maintain attention to complete tasks. Delirium can be consid-
ered a marker of acute brain dysfunction, much like shock is
evidence for dysfunction of the cardiovascular system.
1
ICU Delirium
Delirium occurring in the intensive care unit (ICU) is as-
sociated with an increased length of hospitalization, increased
need for institutionalization, and higher short- and long-term
mortality.
2
In the ICU, delirium occurs in as many as 80% of
patients, but is often overlooked or misdiagnosed because of
the difficulty of assessing mental states in intubated patients.
Three assessment tools have been described in the literature to
aid in delirium diagnosis.
1. The Confusion Assessment Method-Intensive Care
Unit (CAM-ICU) Assessment Tool is the best docu-
mented method of diagnosing delirium in the ICU.
3
This tool was specifically designed for use in nonverbal
(i.e., mechanically ventilated) patients. With the CAM-
ICU, delirium is diagnosed when patients demonstrate
(1) an acute change in mental status or fluctuating
changes in mental status, (2) inattention measured
using either an auditory or visual test, and either (3)
disorganized thinking, or (4) an altered level of con-
sciousness. Importantly, the CAM-ICU can only be
administered if the patient is arousable to voice with-
out the need for physical stimulation. The CAM-ICU
includes very specific assessment questions/tools,
found online at www.icudelirium.org/delirium/
CAM-ICUTraining.html
When administered by a nurse, the CAM-ICU takes only
1 to 2 minutes to conduct and has a minimum of 93%
sensitivity and 89% specificity for detecting delirium as
compared to full DSM-IV assessment by a geriatric
psychiatrist.
2–4
National guidelines recommend routine
use of the CAM-ICU for delirium assessment in all crit-
ically ill patients and treatment with haloperidol when
delirium is present.
5
However, these recommendations
are based on expert opinion and limited case series. It
remains unknown whether diagnosis and/or treatment
of delirium will lead to better patient outcomes. While
there are some early observational cohort data suggest-
ing that patients treated with haloperidol have lower
hospital mortality, this finding needs confirmation in a
randomized, controlled trial before being applied to
routine patient care.
2. The Intensive Care Delirium Screening Checklist
assesses eight features of delirium: altered level of
consciousness, inattention, disorientation, hallucina-
tions, psychomotor agitation/retardation, inappropri-
ate mood/speech, sleep/wake cycle disturbance, and
symptom fluctuation. The sensitivity and specificity of
this tool were 99% and 64%, respectively, in one report.
6
3. The Delirium Screening Checklist is another recent
tool that uses a checklist similar to the Intensive Care
Delirium Screening Checklist.
7
Recommendation
It is believed that prompt recognition and treatment of ICU
delirium is important for patient safety. Use of rapid tools
such as CAM-ICU can help identify ICU delirium and are
recommended when assessing mental status changes. The
benefit of routine use of these screening tools is yet to be
tested.
Fast Facts and Concepts are edited by Drew A. Rosielle M.D., Palliative Care Program, University of Minnesota Medical Center–Fairview
Health Services, and are published by the End of Life/Palliative Education Resource Center at the Medical College of Wisconsin. For more
information write to: drosiel1@fairview.org. More information, as well as the complete set of Fast Facts, are available at EPERC:
www.mcw.edu/eperc
Version History: This Fast Fact was originally edited by David E. Weissman, M.D. and published in August 2006. Current version re-copy–
edited in April 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Available at:
www.eperc.mcw.edu/fastfact/ff_160.htm
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should
exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other
than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such
product is used.
JOURNAL OF PALLIATIVE MEDICINE
Volume 14, Number 6, 2011
ªMary Ann Liebert, Inc.
DOI: 10.1089/jpm.2011.9683
1
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JPM-2011-9683-Fast Facts And Concepts_1P
References
1. Ely EW, Siegel MD, Inouye SK: Delirium in the intensive care
unit: An under-recognized syndrome of organ dysfunction.
Semin Respir Crit Care Med 2001;22:115–126.
2. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L,
Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus
R: Delirium in mechanically ventilated patients: Validity and
reliability of the Confusion Assessment Method for the In-
tensive Care Unit (CAM-ICU). JAMA 2001;286:2703–2710.
3. Ely EW, Truman B: The Confusion Assessment Method for
the ICU (CAM-ICU) Training Manual. www.icudelirium.org/
delirium/training-pages/CAM-ICU%20trainingman.2005.pdf
(Last accessed April 27, 2009).
4. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R,
Speroff T, Gautam S, Bernard GR, Inouye SK: Evaluation of
delirium in critically ill patients: Validation of the Confusion
Assessment Method for the Intensive Care Unit (CAM-ICU).
Crit Care Med 2001;29:1370–1379.
5. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D,
Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin
WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE,
Nasraway SA Jr, Murray MJ, Peruzzi WT, Lumb PD; Task
Force of the American College of Critical Care Medicine
(ACCM) of the Society of Critical Care Medicine (SCCM),
American Society of Health-System Pharmacists (ASHP),
American College of Chest Physicians: Clinical practice
guidelines for the sustained use of sedatives and analgesics in
the critically ill adult. Crit Care Med 2002;30:119–141.
6. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y: In-
tensive Care Delirium Screening Checklist: Evaluation of a
new screening tool. Intensive Care Med 2001;27:859–864
7. Otter H, Martin J, Basell K, von Heymann C, Hein OV, Bo
¨llert
P, Ja
¨nsch P, Behnisch I, Wernecke KD, Konertz W, Loening S,
Blohmer JU, Spies C: Validity and reliability of the DDS for
severity of delirium in the ICU. Neurocrit Care 2005;2:150–
158.
Address correspondence to:
Robert M. Arnold, M.D.
Division of General Internal Medicine
University of Pittsburgh
200 N Lothrop
MUH 932
Pittsburgh, PA 15213
E-mail: rabob@pitt.edu
DOI: 10.1089/jpm.2011.9682
Prognostication in Severe Traumatic Brain Injury
in Adults #239
Stacy M. Kessler, M.D. and Keith M. Swetz, M.D.
Background
Traumatic brain injury (TBI) is defined as brain injury
caused by an external force, most commonly falls, struck
by/against events, motor vehicle collisions, and assaults. The
vast majority of patients with mild to moderate TBIs have
substantial recoveries; this is not true of severe TBIs. This Fast
Fact discusses prognostication in severe TBI in adults.
Initial TBI Severity
TBI severity is most commonly graded by the initial Glas-
gow Coma Scale (GCS) score. The GCS rates the patient’s best
verbal response, best motor response and the stimulus needed
to elicit eye opening. Scores range from 3–15, with score of 8 or
less representing coma. ‘‘Mild’’ TBI (accounting for approxi-
mately 80% of cases) is manifest by a 30-minute postinjury
GCS of 13–15. ‘‘Moderate’’ TBI consists of immediately altered
or loss of consciousness for more than 30 minutes and 6-hour
postinjury GCS of 9–12. ‘‘Severe TBI’’ involves immediate loss
of consciousness for more than 6 hours with residual GCS of
3–8.
Long-Term Outcomes
The Glasgow Outcome Scale (GOS) is a five-point scale used
widely in brain injury research. An eight-point Extended
Glasgow Outcome Scale (GOS-E) is available with more sen-
sitivity to change in function, but most outcome studies have
referenced only the GOS. The GOS range is (1) death, (2) per-
sistent vegetative state (unconscious and unable to interact), (3)
severe disability (conscious; cannot live independently; re-
quires daily assistance due to physical or mental impairment),
(4) moderate disability (able to live independently; able to work
in a supported environment), and (5) good recovery (minimal
or no deficits; able to work and socialize normally). In addition
to global functional impairments, survivors of severe TBIs of-
ten have impairments in memory, executive functioning, im-
pulse control, sensory processing, and communication skills.
Mental health problems are common.
Predicting Outcomes
Overall 30-day mortality following TBI is estimated to be
20% with the highest mortality corresponding to the worst
JPM-2011-9683-Fast Facts And Concepts_1P.3d 05/03/11 2:00pm Page 2
2 FAST FACTS AND CONCEPTS
initial GCS scores. For patients with reliable initial GCS scores
of 3–5, only 20% will survive and less half of those survi-
vors will have what is often referred to in the research liter-
ature as a ‘‘good outcome’’ (GOS 4–5). Older age, lower initial
GCS score, abnormal initial pupil reactivity, longer length of
coma and duration of posttraumatic amnesia, and certain
computed tomography findings all indicate a smaller chance
of recovery to GOS 4–5. Kothrari proposed the following
prognostic guidelines, based on a comprehensive review of
studies that looked at outcome in adults 6 months or later after
severe TBI:
Favorable outcome (GOS 4–5) likely when the time to
follow commands is less than 2 weeks after injury, and
the duration of posttraumatic amnesia is less than 2
months.
Poor outcome (GOS <4) is likely when the patient is
over 65 years old, the time to follow commands is longer
than 1 month, or the duration of posttraumatic amnesia
is greater than 3 months.
Notably, 10% of patients will not have the outcome
predicted by the guidelines above.
A recent multinational collaborative trial developed a
prognostic model to predict outcomes in TBI. The model uses
age, GCS, pupil reactivity, presence of major extracranial in-
jury, and (optional) computed tomography findings to give
rates of death at 14 days postinjury and GOS at 6 months for
survivors. An online calculator is available.
Helping Families Make Decisions
Families of patients with severe TBIs may be confronted
with decisions about medical care (e.g., gastrostomy tube
placement, chronic ventilatory support, dialysis). Such deci-
sions often depend on a family’s understanding of a patient’s
long-term functional outcome. The abovementioned prog-
nostic indicators can help clinicians provide objective infor-
mation for families about the likelihood of recovery after a
TBI. As with all prognostic tools, however, clinicians can only
predict what would happen to a population of patients with a
similar injury (e.g., ‘‘only 10% of patients would recover such
that they could live independently’’); this is different from
predicting any particular patient’s course. It is important to
communicate the uncertainty that accompanies most prog-
nostic estimations. Counseling families about long-term
functional prognosis, as well as the expected treatment course
(what rehabilitation would involve) is important. While the
research literature often defines a ‘‘good recovery’’ as GOS
4–5, that may not constitute a ‘‘good’’ recovery for an indi-
vidual patient. Clinicians should avoid such language at the
bedside and instead use detailed descriptive language of ex-
pected functional and cognitive outcomes. Early and frequent
family meetings can facilitate communication, built rapport,
and are vital in expectation setting and establishing goals of
care. If life-sustaining treatments are initiated, framing the
treatments in the context of time-limited trials is helpful. This
empowers family members to discontinue certain cares after a
specified period of time if the prognosis remains unchanged
or if the treatment is not meeting the goals of care (e.g.,
helping to restore a patient to a functional status which is
acceptable to the patient). Interdisciplinary team members
including speech, occupational, and physical therapists,
physiatrists, neurologists, palliative care clinicians, and neu-
rosurgeons can be important in letting family members more
fully understand a patient’s likely future. See Fast Fact #226
about helping surrogates make decisions.
References
1. Centers for Disease Control and Prevention: Get the stats on
TBI in the United States. www.cdc.gov/traumaticbraininjury/
factsheets_reports.html (Last accessed November 3, 2010).
2. Carroll LJ, Cassidy JD, Peloso PM, Borg J, von Holst H,
Holm L, Paniak C, Pe
´pin M; WHO Collaborating Centre
Task Force on Mild Traumatic Brain Injury: Prognosis for
mild traumatic brain injury: Results of the WHO Collabor-
ating Centre Task Force on Mild Traumatic Brain Injury. J
Rehabil Med. 2004;43(suppl):S84-S105.
3. Serio CD, Kreutzer JS, Witol AD. Family needs after trau-
matic brain injury: A factor analytic study of the Family
Needs Questionnaire. Brain Injury 1997;11:1–9.
4. Kolakowsky-Hayner SA, Miner KD, Kretuzer JS: Long-term
life quality and family needs after traumatic brain injury. J
Head Trauma Rehabil 2001;16:374–385.
5. Cifu DX, Kreutzer JS, Slater DN, Taylor L: Rehabilitation
after Traumatic Brain Injury. In: Braddom RL, Buschba-
cherRM,ChanL,etal.(eds):Physical Medicine and Re-
habilitation. Philadelphia, PA: Saunders Elsevier, 2007, pp.
1133–1174.
6. National Institute of Neurological Disorders and Stroke.
Traumatic brain injury: Hope through research. Bethesda
(MD): National Institutes of Health; 2002. NIH Publication
No. 02-158. www.ninds.nih.gov/disorders/tbi/detail_tbi
.htm (Last accessed November 3, 2010).
7. Brown AW, Elovic EP, Kothari S, Flanagan SR, Kwasnica C:
Congenital and acquired brain injury. 1. Epidemiology,
pathophysiology, prognostication, innovative treatments,
and prevention. Arch Phys Med Rehabil 2008;89(suppl):
S3–S8.
8. Kothari S: Prognosis after severe TBI: A practical, evidence-
based approach. In: Zasler ND, Katz DI, Zafonte RD (eds):
Brain Injury Medicine: Principles and Practice. New York:
Demos, 2007, pp. 169–199
9. MRC CRASH Trial Collaborators, Perel P, Arango M,
Clayton T, Edwards P, Komolafe E, Poccock S, Roberts I,
Shakur H, Steyerberg E, Yutthakasemsunt S: Predicting
outcome after traumatic brain injury: Practical prognostic
models based on large cohort of international patients. BMJ
2008;336:425–429.
10. Prognostic model for predicting outcome after traumatic
brain injury (online calculator). MRC Crash Trial website.
www.crash2.lshtm.ac.uk/Risk%20calculator/index.html
(Last accessed January 5, 2011).
11. Brain Trauma Foundation-American Association of Neuro-
logical Surgeons-Joint Section on Neurotrauma and Critical
care: Early indicators of prognosis in severe traumatic brain
injury. J Neurotrauma 2000;17:449–627.
Address correspondence to: bAU1
Keith Swetz, M.D.
Mayo Clinic
Rochester, MN
E-mail: Swetz.Keith@mayo.edu
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FAST FACTS AND CONCEPTS 3
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AUTHOR QUERY FOR JPM-2011-9683-FAST FACTS AND CONCEPTS_1P
AU1: Provide complete mailing address.
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... Acute respiratory failure was defined as a condition of respiratory failure requiring intubation and mechanical ventilation for more than 24 hours, regardless of the fraction of inspired oxygen [20]. Coma was defined as a Glasgow Coma Scale score of 3 to 8 [21]. ...
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