Objective To comprehensively describe the use of dexmedetomidine in a single institutional series of adult ICU patients with severe TBI. We describe the dexmedetomidine dosage and infusion times, as well as the physiological parameters, neurological status, and daily narcotic requirements before, during, and after dexmedetomidine infusion. Methods We identified 85 adult patients with severe TBI who received dexmedetomidine infusions in the Trauma ICU at Vanderbilt University Medical Center between 2006 and 2010. Demographic, hemodynamic, narcotic use, and sedative use data were systematically obtained from the medical record and analyzed for changes associated with dexmedetomidine infusion. Results During infusion with dexmedetomidine, narcotic and sedative use decreased significantly (p<.001 and p<.05). Median MAP, SBP, DBP, and HR also decreased significantly during infusion when compared to pre-infusion values (p<.001). Despite the use of dexmedetomidine, RASS and GCS scores improved from pre-infusion to infusion time periods. Conclusions Our findings demonstrate that initiation of dexmedetomidine infusion is not associated with a decline in neurological functioning in adults with severe TBI. Although there was an observed decrease in hemodynamic parameters during infusion with dexmedetomidine, the change was not clinically significant, and the requirements for narcotics and additional sedatives were minimized.

BACKGROUND With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question: In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (Registration Number: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition. Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE Systematic review, level III.

Objective: The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE). Summary Background Data: Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI. Methods: This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from −1 (worse than death) to 1 (full health), with 0 as reference (death). Results: Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death. Conclusions: In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.

Objective To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. Methods This retrospective cohort study compared adult trauma patients with severe TBI (n=583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest), and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy’s influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3, and 12-months. Results In our multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race, and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR=1.89[95%CI:1.09–3.23]). Mortality was higher in those without tracheostomy placement (HR=4.92[95%CI:3.49–6.93]). Abbreviated injury scale - Head was an independent factor for time to death (HR=2.53[95%CI: 2.00–3.19]), but age, gender, and insurance were not. Conclusions Age and insurance status are independently associated with tracheostomy placement but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.