Objectives: Hypertonic saline solutions are increasingly used to treat increased intracranial pressure following severe traumatic brain injury. However, whether hypertonic saline provides superior management of intracranial pressure and improves outcome is unclear. We thus conducted a systematic review to evaluate the effect of hypertonic saline in patients with severe traumatic brain injury. Methods: Two researchers independently selected randomized controlled trials studying hypertonic saline in severe traumatic brain injury and collected data using a standardized abstraction form. No language restriction was applied. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and BIOSIS databases. We searched grey literature via OpenGrey and National Technical Information Service databases. We searched the references of included studies and relevant reviews for additional studies.Results: Eleven studies (1,820 patients) were included. Hypertonic saline did not decrease mortality (risk ratio 0.96, 95% confidence interval [CI] 0.83 to 1.11, I 2 = 0%) or improve intracranial pressure control (weighted mean difference −1.25 mm Hg, 95% CI −4.18 to 1.68, I 2 = 78%) as compared to any other solutions. Only one study reported monitoring for adverse events with hypertonic saline, finding no significant differences between comparison groups. Conclusions: We observed no mortality benefit or effect on the control of intracranial pressure with the use of hypertonic saline when compared to other solutions. Based on the current level of evidence pertaining to mortality or control of intracranial pressure, hypertonic saline could thus not be recommended as a first-line agent for managing patients with severe traumatic brain injury. RÉSUMÉObjectifs: Les solutés salés hypertoniques sont de plus en plus utilisés dans le traitement de l'élévation de la pression intracrânienne par suite d'une lésion cérébrale traumatique grave. Toutefois, on ne sait pas avec certitude si les solutés salés hypertoniques sont plus efficaces que d'autres traitements dans l'abaissement de la pression intracrânienne et s'ils donnent de meilleurs résultats. Les auteurs ont donc entrepris une revue systématique de la documentation afin d'évaluer l'effet des solutés salés hypertoniques chez les patients ayant subi une lésion cérébrale traumatique grave. Méthode: Deux chercheurs ont sélectionné chacun de leur côté des essais comparatifs à répartition aléatoire portant sur l'utilisation du soluté salé hypertonique dans le traitement des lésions cérébrales traumatiques graves, et ont recueilli des données sur un formulaire normalisé de résumé analytique. Aucune restriction de langue n'a été appliquée. Des recherches ont été effectuées dans les bases de données Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science et Biosis. Les auteurs ont également consulté la documentation parallèle en passant par les bases de données OpenGrey et National Technical Information Service. Enfi...
Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality.
In the original publication of "Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials," Elyse Berger-Pelletier's name was misspelled. The original has since been corrected.The CJEM editors and Cambridge regret this error.
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