POPULATION OF INTEREST

All patients at a Role 2 surgical capability with an initial GCS ≤ 8 AND diagnosis of traumatic brain injury.

INTENT (EXPECTED OUTCOMES)

1. Cranial procedures will be performed by non-neurosurgeons only when a neurosurgeon is not available within approximately 5 hours.

2. Only patients with following criteria undergo decompressive craniectomy by a non-neurosurgeon:

a. Traumatic brain injury with post-resuscitation GCS <8 AND

b. Lateralizing neurologic signs AND

c. Hemodynamic dysfunction (hypertension, bradycardia, and respiratory variation: i.e., Cushing’s reflex) AND failure of maximal critical care management (new lateralizing cortical finding such as hemiparesis or rapidly expanding pupil, and/or further decline in GCS off of sedation).

3. Non-neurosurgeons will perform emergency life-saving cranial procedures only after teleconsultation with a neurosurgeon. If communications allow real time surgical teleconsultation with a neurosurgeon can augment surgical effectiveness.

4. Non-neurosurgeons will perform emergency life-saving cranial procedures using an electric drill and saw.

PERFORMANCE/ADHERENCE METRICS

1. Number and percentage of patients in the population of interest with documentation of anticipated length of time > 5 hours to arrive at a facility with a neurosurgeon.

2. Number and percentage of patients in the population of interest who have the following indications documented:

a. TBI with post-resuscitation GCS <8 AND

b. Lateralizing neurologic signs AND

c. Hemodynamic dysfunction (hypertension, bradycardia, and respiratory variation: i.e., Cushing’s reflex) AND failure of maximal critical care management (new lateralizing cortical finding such as hemiparesis or rapidly expanding pupil, and/or further decline in GCS off of sedation).

3. Number and percentage of patients in the population of interest who have documentation of teleconsultation with a neurosurgeon.

4. Number and percentage of patients in the population of interest who have documentation of the use of an electric drill and saw for the procedure.

DATA SOURCE

- Patient Record
- DoD Trauma Registry
- ICU flow sheet

SYSTEM REPORTING & FREQUENCY

- The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.
- The system review and data analysis will be performed by the JTS Chief and the JTS PI Branch.

RESPONSIBILITIES

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance, and PI monitoring at the local level with this CPG.

Deploying general surgeons and trauma surgeons should remain current with emergency cranial neurosurgical intervention through attendance at pre-deployment training (Emergency War Surgery course) AND by assisting in cranial procedures at their home institution.