Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country – a prospective study

Abstract

Background: An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving.Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.

Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation

“…17,28,48,59,63 Some authors have suggested that early tracheostomy decreases ICU mortality rate 23,64,65 and overall in-hospital mortality, 26,66 whereas other studies have reported a mortality rate reduction on a long-term basis, but not on a shortterm basis. 41,55,67 And finally, these observations were not confirmed by other authors who could not demonstrate any significant association between timing of tracheostomy and reduction of mortality rate following surgery, polytrauma, and severe head injury. 19,40,[68][69][70][71] The benefits of early tracheostomy for patients who require extended periods of MV, compared to prolonged translaryngeal intubation have been debated.…”

Impact of Tracheostomy Timing on Outcome After Severe Head Injury

“…Yet, overall rates of pneumonia and mortality were not different between the two groups. On the other hand, in a small prospective study, Chintamani et al found fewer intubation associated complications and improved mortality in patients receiving early tracheostomy as compared to prolonged mechanical ventilation [39]. Despite these multiple studies there remains no consensus to guide timing of tracheostomy these critically ill patients [14,40,41].…”

Optimal timing of tracheostomy after trauma without associated head injury

“…For example, trauma patients with significant head or neck injuries often require tracheostomy for prolonged airway maintenance regardless of whether there is concomitant respiratory failure. This may facilitate the decision for tracheostomy placement earlier in the hospital course [30] and may also result in decreased duration of mechanical ventilation and faster recovery in this subpopulation [14,15]. In contrast, it is more difficult to predict the need for tracheostomy in trauma patients with prolonged respiratory failure without significant head or neck injuries.…”