Devastating Brain Injury?

Scenario (Not uncommon)

A patient either post arrest or head injury has a CT demonstrating significant brain injury and Leeds says “No”

What do we do next?

Its not easy; for the family, for us, for the hospital, or the NHS

What do we know? – Neurosurgery get it wrong!

A recent paper from Bristol followed 21 patients with “Devastating  Brain Injury” & a decision to withdraw treatment in ED, that were supported on ICU instead over a 2 year period.

  • 5 had the the decision reversed
    • 3 patients left hospital (2 cognitively intact, 1 still having rehab)
  • 16 patients died
    • All died within 48 hours
    • 13 families approached about organ donation – by donation nurses (12 agreed)
      • 5 patients went on to donate successfully

What don’t we know? – how many similar patients they had over the 2 years that didn’t get admitted to ICU? The real odds for survival is likely much worse than 1:7.

What should we do?

A recently joint college consensus paper has made the following recommendations

  • Prognostication in the ED can be inaccurate
  • A period of physiological stabilisation and observation is recommended to improve the quality of decision making
  • Patients who are intubated will require admission to critical care for this period of observation, [unless the extent of co-morbidity makes continued organ support of no overall benefit]
  • Patients not requiring stabilisation with airway, ventilatory or circulatory support can be observed on a medical ward.
  • During the period of observation the therapeutic aim is to provide cardiorespiratory stability in order to facilitate accurate neurological prognostication.
  • Organ donation should be a routine consideration in end of life care planning.
    (An approach for consent to organ donation should only occur after the family understand and accept the diagnosis of brain death or the reasons for WLST, and then undertaken in collaboration with a specialist nurse for organ donation.)

What considerations should we make?

  • Resource allocation: We need to be pragmatic, ICU beds are limited and at times we may not be able to offer this level of care, any decision to admit or not must be made in conjunction with our ICU colleges.
  • Communication with relatives: This is a very difficult time for relatives, we must ensure that we:
    • Don’t giving conflicting information, if we don’t know say so.
    • Don’t give false hope, the patient will most likely die, however:
      • In ED we can’t confidently predict death with certainty
      • We can ensure the patient is comfortable and well cared for at this time
      • Don’t bring up donation – this is not the primary objective and relieves can be approached if necessary later  in a more appropriate setting my trained staff. However,  if they ask we can let them know that we can put them in touch with the specialist donation team
  • Inform the organ donation team on  – [03000 20 30 40]

 

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